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Background and Context: Satisfaction is a key indicator of how health care has met patient expectations., Purpose: To examine relationship between clinical and functional outcome and patient satisfaction., Study Design/setting: Prospective analysis of outcomes., Patient Sample: A total of 428 patients undergoing cervical spine surgery consecutively enrolled at 23 nationwide sites., Outcome Measures: Cervical Spine Outcomes Questionnaire (CSOQ)., Methods: We used the CSOQ to evaluate 428 patients undergoing cervical spine surgery at 23 nationwide sites. Satisfaction was assessed at 3 months by self-report. Clinical improvement was defined at 3 months as decreased postoperative CSOQ domain scores. Principal components analysis (PCA) was used to demonstrate adherence of the CSOQ to domains of clinical and functional recovery and to identify items measuring patient satisfaction. Psychometric properties of items measuring patient satisfaction were examined. The association between patient satisfaction and 3 month clinical and functional outcome was tested., Results: On repeat administration in a subset of 50 patients, these four items demonstrated good test-retest reliability (Cronbach's alpha=0.784). PCA extracted factors adhering to the domain structure of the CSOQ. A unique factor was characterized by the following: recommend to friend (loading=0.658), compare favorably with others (loading=0.525) and with expectations (loading=0.701), and show overall satisfaction (loading=0.513). Structural equation models revealed influence of CSOQ domain scores and socioeconomic status on patient satisfaction. All reported comparisons were significant at p<.001., Conclusions: Satisfaction is unobservable, but can be assessed through self-report. Clinical improvement, especially in neck pain, after surgery is associated with improved patient satisfaction.

Objective: Spinal cord compression secondary to a subluxation of one vertebral body over another can be achieved with reduction of the translational deformity. Intraoperative reduction of C1-C2 subluxations can be technically challenging when one uses traditional techniques (e.g., wiring and transarticular screw fixation). The popularization of C1 lateral mass and C2 pedicle screws has allowed surgeons to achieve a more complex realignment at this region of the spine. Control of both C1 and C2 with independent fixation can be used to obtain reduction. In certain instances, placement of C2 pedicle screws is not possible. The use of C2 translaminar screws (if the C2 lamina is present and suitable) is an alternative method of fixation in C2 and can be used for intraoperative reduction., Clinical Presentation: A 15-year-old boy with juvenile rheumatoid arthritis presented with spinal cord compression secondary to a C1-C2 subluxation. The C2 pedicle anatomy precluded safe placement of C2 pedicle screws. An alternative method of fixation with the use of C2 translaminar screws and reduction was performed to obtain proper alignment and decompress the spinal cord., Technique: C1 lateral mass screws and C2 translaminar screws are inserted in the usual fashion. Two contoured rods, two rod holders, and two distractors, combined with C1 lateral mass screws and C2 translaminar screws, were used to achieve reduction. Concomitant distraction between the C2 translaminar screw head and the rod holder resulted in ventral translation of C2 on C1, decompressing the spinal cord. The reduction was maintained by tightening the C2 locking nut onto the rod., Conclusion: The use of C2 translaminar screws (if the C2 lamina is present and suitable) is an alternative method of fixation in C2. C1 lateral mass and C2 translaminar screw fixation provide a powerful means of reducing C1-C2 subluxations and maintaining alignment, achieving indirect decompression of the spinal cord.

Background: The Cervical Spine Outcomes Questionnaire (CSOQ), a disease-specific outcomes instrument, has not been systematically compared with the Short Form-36 (SF-36) or the Neck Disability Index (NDI)., Purpose: To examine the psychometric properties of the CSOQ and to compare them with those of the SF-36 and NDI., Study Design: Prospective analysis of outcomes data in patients undergoing surgery., Methods: We used telephone surveys (CSOQ) and clinical assessments (SF-36 and NDI) to evaluate 534 patients undergoing anterior cervical decompression and fusion at 23 nationwide sites. The psychometric properties of the CSOQ were analyzed for floor/ceiling effect, internal consistency of items within the CSOQ, and concurrent validity with the SF-36 and NDI., Results: The CSOQ domain scores showed good psychometric properties (Cronbach's alpha >0.70). Only physical symptoms (other than pain) showed a ceiling effect. The CSOQ domain scores had good concurrent validity (Spearman rank correlation coefficient >0.70) with the mental health score of the SF-36 and the total disability score of NDI., Conclusions: The CSOQ domain scores provide a disease-specific assessment of functional limitations resulting from cervical spine disorders. The domain scores for functional disability and psychological distress provide similar information to that provided by the NDI and SF-36. The CSOQ domain scores for pain severity provide information that is more specific to cervical disc disease than does the physical health score of the SF-36.

Objective: Delayed cerebral vasospasm is an under-recognized complication of meningitis. This case report is important because it is the first to definitively associate vasospasm with meningitis using catheter angiography. Furthermore, it is the first to correlate the time course of delayed cerebral vasospasm with meningitis., Clinical Presentation: We present a patient who developed a partial expressive aphasia 9 days after developing meningitis, consistent with cerebral vasospasm, after lumbosacral spinal surgery., Intervention: Vasospasm was confirmed by angiography and transcranial Doppler sonography, and symptoms responded to hypervolemia, hypertension, and hemodilution therapy., Conclusion: If a patient develops neurological symptoms consistent with a timeline of delayed cerebral vasospasm in the setting of meningitis, angiographic evaluation and appropriate therapy should be pursued.

Magnetic resonance imaging (MRI) is the best imaging modality for evaluating most spinal tumors. In this review, we describe the MRI appearance of extradural, intradural-extramedullary, and intradural-intramedullary tumors as well as the image interpretation techniques that permit identification of the compartment in which a lesion is located. In addition, we review the literature and our experience in using an anatomic classification system to narrow the differential diagnosis for patients with spine tumors. This method permits successful identification of a narrow differential diagnosis, which can be used to guide additional evaluation and treatment.

Objective: Although the majority of human epidural spinal metastases originate in the vertebral body, current animal models of spinal epidural tumors are limited to extraosseous tumor placement. We investigated the onset of paraparesis, radiographic changes (magnetic resonance imaging [MRI] and computed tomographic [CT] scans), and histopathological findings after intraosseous injection of VX2 carcinoma cells into the lower thoracic vertebrae of rabbits., Methods: New Zealand white rabbits (n = 23) were injected with a 15-mul suspension containing 300,000 VX2 carcinoma cells in the lowest thoracic vertebral body. Lower extremity motor function was assessed daily. For the first 3 animals, MRI scans (T2-weighted and T1-weighted +/- gadolinium) were acquired at postoperative day (POD) 14 and at the onset of paraparesis. Noncontrast CT scans were obtained on POD 7 and at the time of paraparesis. At the onset of paraparesis, the animals ware killed and the spines were dissected. After demineralization, hematoxylin and eosin cross sections were obtained., Results: Before the onset of paraparesis, the CT and MRI scans revealed no gross tumor. At the onset of paraparesis, CT scans demonstrated an osteolytic tumor centered at the junction of the left pedicle and vertebral body, and MRI scans demonstrated epidural tumor arising from the body and compressing the spinal cord. Histopathological examination confirmed carcinoma arising from the body and extending into the canal, with widespread osteolytic activity. By POD 28, 72% of the animals had become paraparetic, and by the termination of the experiment on POD 120, 89% had become paraparetic., Conclusion: We established a novel intraosseous intravertebral tumor model in rabbits and characterized it with respect to onset of paraparesis, imaging features, and histopathological findings.

Background Context: Neurologic deterioration after immobilization of traumatic spondylolisthesis of the axis rarely occurs because of the decompressive nature of the injury itself and the large amount of space available for the cord in the upper cervical spine., Purpose: To document neurologic deterioration after reduction (without the use of traction) and halo immobilization of a Type IIA traumatic spondylolisthesis of the axis (hangman's fracture) secondary to an epidural hematoma., Study Design/setting: Case report. PATIENT SAMPLE AND OUTCOME MEASURES: The patient population consisted of one patient; no outcome measures were used., Methods: The medical record and radiographic studies of a 27-year-old patient involved in a motor vehicle crash that resulted in a traumatic spondylolisthesis of the axis were retrospectively reviewed, and a review of the English literature was performed., Results: Upon evaluation, the patient was found to have, in addition to other injuries, a Type IIA hangman's fracture of the C2 vertebra, which was stabilized in a halo. Shortly thereafter, the patient developed a gradual progressive neurologic deficit. Magnetic resonance imaging revealed the presence of a large epidural hematoma with cord compression treated with posterior laminectomy and transdural decompression of an anterior hematoma. Postoperatively, the patient's neurologic examination improved and returned to normal within 6 months., Conclusion: An epidural hematoma can occur after traumatic spondylolisthesis of the axis, but its symptoms may not present until after the spondylolisthesis is treated.

Background and Purpose: Concern exists that vertebral bodies augmented with cement placed laterally may be at risk of collapse on the nonaugmented side. The purpose of the current study was to determine if placing the cement laterally rather than centrally resulted in risk of collapse on the nonaugmented side., Methods: Vertebral bodies (L2-L5) were harvested from eight osteoporotic female cadaver spines. Simulated vertebral-body compression fractures were created and stabilized by injecting 3.5 or 7.0 mL of cement centrally or laterally. Vertebral bodies were recrushed to measure their augmented strength and stiffness. Anterior, posterior, left, and right lateral heights were measured initially, after augmentation, and after recompression., Results: Lateral and central 3.5-mL injections of cement restored strength, whereas 7.0-mL injections significantly increased strength compared with initial values. The stiffness of vertebral bodies receiving central 3.5-mL injections was significantly less than it was initially, although the stiffness of bodies receiving 3.5-mL laterally was not significantly different from initial values. Initial and posttreatment stiffness values did not significantly differ in vertebral bodies receiving 7.0-mL, lateral or central injections. Vertebral heights did not significantly differ between the augmented and the final compression states in any location. Height loss between central and lateral injections did not differ significantly., Conclusion: Vertebral bodies in which cement is placed laterally do not appear to be at risk for collapse on the unaugmented side.

Percutaneous vertebroplasty is an effective treatment for aggressive vertebral hemangiomas, osteoporotic vertebral compression fractures, spinal metastases, and myelomas. As percutaneous vertebroplasty is more commonly performed to treat various forms of back pain, new or modified cements are being used. This review examines the physiochemical and biomechanical properties of various bone cements and additives.

Low back pain in athletes can result from a wide variety of conditions. A detailed history and physical examination supplemented by appropriate imaging studies can lead to an accurate diagnosis. The majority of cases will be self-limiting and resolve within 6 weeks regardless of treatment, but it is important to be able to identify conditions that require specific treatment. The decision of when an athlete can return to active competition is determined by the specific condition, associated symptoms, and treatment provided. Most athletes can return to full unrestricted play after sufficient resolution of pain and restoration of range of motion. Athletes undergoing spinal fusion are typically restricted from full-contact sports.

Study Design: Biomechanical flexibility tests were performed using calf and human cadaveric lumbar spine models to investigate the effect of anatomic differences., Objectives: The purpose is to determine if differences exist in biomechanical flexibility testing results between calf and human cadaveric spines when using identical methods and instrumentation., Summary of Background Data: Calf spines are commonly used in biomechanical research as a substitute for human cadaveric spines in an attempt to reduce expense and specimen variability. Despite widespread use, the validity of this model has not been thoroughly investigated., Methods: Five fresh calf spines and five human cadaveric spines (L2-L5) were used for nondestructive biomechanical flexibility testing. Maximum moments of 6.4 Nm were achieved in five increments of 1.6 Nm. The rotations of L3 with respect to L4 were measured in 5 cases: 1) intact; 2) following partial discectomy, including partial laminectomy and partial facetectomy; 3) partial discectomy with pedicle screw instrumentation; 4) total discectomy with pedicle screw instrumentation; and 5) pedicle screw instrumentation with interbody graft. Rotational angles were normalized to the intact case to determine the stabilizing effect during each testing case. Data were analyzed using analysis of variance to determine if significant differences existed between the calf spine results and the human cadaveric spine results., Results: In both models, motion increased following discectomy, decreased with instrumentation, and increased with total discectomy. Placement of the interbody graft decreased motion during axial rotation, flexion, and extension but increased lateral bending motion. A two-way analysis of variance revealed no significant differences in the two models during flexion or extension (P > 0.05), but significant differences were discovered in axial rotation and lateral bending (P < 0.05)., Conclusions: Significant differences were identified in flexibility testing between calf and human cadaveric specimens. The calf spine model overestimated the stabilizing effect of instrumentation during lateral bending and underestimated stability during axial rotation. The extrapolation of calf spine data to the in vivo case, especially during axial rotation and lateral bending, should carefully consider the variation between these two models.

Background and Purpose: Vertebroplasty is now a widely accepted image-guided intervention in patients with compression fracture. The purpose of this report is to look specifically at the male population undergoing vertebroplasty and identfy the management considerations distinct to men., Methods: The hospital medical records and radiographic studies of 24 men treated with vertebroplasty between February 1999 and November 2000 were retrospectively reviewed., Results: Five patients presented with idiopathic or secondary osteoporosis. In two of these five men, malignancies were discovered by core biopsies taken at the time of vertebroplasty. Thirteen patients (54%) had secondary osteoporosis. Of this group, 10 patients (42%) were steroid dependent and three (13%) were hypogonadal. Five patients (21%) had traumatic events leading to fracture. One presented with known metastases., Conclusion: Primary osteoporosis in men is unusual. In male patients without a definable cause of osteoporosis, known metastatic disease, or a significant history of trauma, the routine performance of a vertebral biopsy through the vertebroplasty needle before the injection of bone cement is indicated to identify unexpected neoplasm.

Computer-assisted pedicle screw insertion is feasible but has proved to be problematic. The purpose of this study was to detail the accuracy of registration techniques and pedicle screw insertion using a frameless stereotactic system. Two registration techniques were evaluated on a model spine. The frameless stereotactic system was then used to insert 26 pedicle and 8 lateral mass screws in human cadavers. For posterior vertebral elements, trajectory accuracy was 2.5 +/- 1.0 mm between T12 and L5 and 2.2 +/- 0.9 mm between C2 and T1. Registration of the anterior elements, however, was less accurate. Despite this flaw, all screws were inserted without penetrating the cortex. Screw trajectory was accurate to 2 degrees. The main limitation of frameless stereotactic surgery in the spine stems from the fact that only the posterior vertebral elements are used during registration. Despite this flaw, the system placed all screws correctly. Given these limitations, we believe that this system is most useful for locating the screw insertion point and providing a trajectory in the pedicle.