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Adjacent segment disease (ASD) in the lumbar spine is a possible consequence in segments adjacent to a fusion. As the number of lumbar fusions in the United States increases, the rates of ASD will continue to climb. There are several treatment options for ASD with open decompression and extension of the fusion being common. However, need for exposure and removal of existing instrumentation can lead to increased operative times resulting in increasing blood loss and infection risk. The purpose of this paper is to describe a case report for unilateral cortical trajectory screw instrumentation, allowing for posterior instrumentation without having to remove the existing pedicle screws in the setting of ASD. Our technique can be done with standard c-arm fluoroscopy without the need for navigation.

Anterior interbody fusions are commonly used in the treatment of adult spinal deformity. The addition of anterior fusions to posterior constructs offers increased construct stability, improved fusion rates, and better lordosis restoration. The anterior column is most commonly accessed by the anterior retroperitoneal approach, in which the anterior longitudinal ligament is resected, or by the lateral transpsoas approach, which offers the ability to either leave the anterior longitudinal ligament intact or resect it as part of anterior column realignment. Complications are mostly approach-related and include vascular, visceral, and neurological injury.

Cadaveric biomechanical study.To determine the degree of segmental correction that can be achieved through lateral transpsoas approach by varying cage angle and adding anterior longitudinal ligament (ALL) release and posterior element resection.Lordotic cage insertion through the lateral transpsoas approach is being used increasingly for restoration of sagittal alignment. However, the degree of correction achieved by varying cage angle and ALL release and posterior element resection is not well defined.Thirteen lumbar motion segments between L1 and L5 were dissected into single motion segments. Segmental angles and disk heights were measured under both 50 N and 500 N compressive loads under the following conditions: intact specimen, discectomy (collapsed disk simulation), insertion of parallel cage, 10° cage, 30° cage with ALL release, 30° cage with ALL release and spinous process (SP) resection, 30° cage with ALL release, SP resection, facetectomy, and compression with pedicle screws.Segmental lordosis was not increased by either parallel or 10° cages as compared with intact disks, and contributed small amounts of lordosis when compared with the collapsed disk condition. Placement of 30° cages with ALL release increased segmental lordosis by 10.5°. Adding SP resection increased lordosis to 12.4°. Facetectomy and compression with pedicle screws further increased lordosis to approximately 26°. No interventions resulted in a decrease in either anterior or posterior disk height.Insertion of a parallel or 10° cage has little effect on lordosis. A 30° cage insertion with ALL release resulted in a modest increase in lordosis (10.5°). The addition of SP resection and facetectomy was needed to obtain a larger amount of correction (26°). None of the cages, including the 30° lordotic cage, caused a decrease in posterior disk height suggesting hyperlordotic cages do not cause foraminal stenosis.N/A.

Scheuermann kyphosis is a structural hyperkyphosis defined radiographically as anterior wedging of ≥5° of at least three consecutive vertebral bodies. Typically, the disease develops during adolescence but may not present until adulthood. The etiology remains unknown. Indications for management include progressive deformity, pain, cosmesis, neurologic deficit, and cardiopulmonary compromise. Surgical intervention is indicated in patients with persistent pain and unacceptable deformity caused by significant kyphosis. Surgery can be performed through posterior-only, anterior-only, or combined anterior-posterior approaches. Correction should include the entire length of the kyphosis and should not exceed 50% of the original deformity. The most common postoperative complications are wound infection and loss of correction.

Background The aims of this study were to determine how often fracture reduction alone restored pulses and vascular perfusion in displaced supracondylar humerus fractures with absent distal pulses on presentation, and whether any preoperative factors were associated with the need for vascular repair and vascular complications. Methods We reviewed 1255 supracondylar humerus fractures in children treated operatively over 12 years at one institution. We identified 33 patients who presented with displaced supracondylar humerus fractures and absent distal pulses. We reviewed the management and outcome of these injuries. Results Thirty-three (of 1255) patients presented with a pulseless supracondylar humerus fracture (2.6%). The patients were divided into 2 groups: those at presentation whose hand was well perfused (n=24) or poorly perfused (9). None (0 of 24) of the well-perfused patients underwent vascular repair; 3 had open reduction. Of the 21 well-perfused patients undergoing closed reduction and pinning, 11 (of 21) had a palpable pulse after surgery and 10 (of 21) remained pulseless but well perfused; all did well clinically. Of the 9 patients in the poorly perfused group, 4 underwent vascular repair, and compartment syndrome developed in 2 during the postoperative period. In just over half of patients with a poorly perfused hand (5 of 9), fracture reduction alone was the definitive treatment. Conclusions In the largest series of children with pulseless displaced supracondylar humerus fractures in the literature, we identify 2 distinct populations, with the perfusion status of the hand at time of presentation correlating significantly with the ultimate need for vascular repair. In patients presenting with a well-perfused hand, fracture reduction alone was sufficient treatment in all 24 (of 24) cases, and no patients developed compartment syndrome. Nearly half of these patients still had an absent palpable pulse but well-perfused hand after closed reduction, yet did well clinically. Patients presenting with a poorly perfused hand are at high risk for vascular repair and compartment syndrome.

Background context Spinal epidural abscess (SEA) is a serious condition that can lead to significant morbidity and mortality if not expeditiously diagnosed and appropriately treated. However, the nonspecific findings that accompany SEAs often make its diagnosis difficult. Concurrent noncontiguous SEAs are even more challenging to diagnose because whole-spine imaging is not routinely performed unless the patient demonstrates neurologic findings that are inconsistent with the identified lesion. Failure to recognize a separate SEA can subject patients to a second operation, continued sepsis, paralysis, or even death. Purpose To formulate a set of clinical and laboratory predictors for identifying patients with concurrent noncontiguous SEAs. Study design A retrospective, case-control study. Patient sample Patients aged 18 years or older admitted to our institution during the study period who underwent entire spinal imaging and were diagnosed with one or more SEAs. Outcome measures The presence or absence of concurrent noncontiguous SEAs on magnetic resonance imaging or computed tomography (CT)-myelogram. Methods A retrospective review was performed on 233 adults with SEAs who presented to our health-care system from 1993 to 2011 and underwent entire spinal imaging. The clinical and radiographic features of patients with concurrent noncontiguous SEAs, defined as at least two lesions in different anatomical regions of the spine (ie, cervical, thoracic, or lumbar), were compared with those with a single SEA. Multivariate logistic regression identified independent predictors for the presence of a skip SEA, and a prediction algorithm based on these independent predictors was constructed. Institutional review board committee approval was obtained before initiating the study. Results Univariate and multivariate analyses comparing patients with skip SEA lesions (n=22) with those with single lesions (n=211) demonstrated significant differences in three factors: delay in presentation (defined as symptoms for ≥7 days), a concomitant area of infection outside the spine and paraspinal region, and an erythrocyte sedimentation rate of >95 mm/h at presentation. The predicted probability for the presence of a skip lesion was 73% for patients possessing all three predictors, 13% for two, 2% for one, and 0% for zero predictors. Receiver operating characteristic curve analysis, used to evaluate the predictive accuracy of the model, revealed a steep shoulder with an area under the curve of 0.936 (p Conclusions The proposed set of three predictors may be a useful tool in predicting the risk of a skip SEA lesion and, consequently, which patients would benefit from entire spinal imaging.

Background context The notion that all patients with spinal epidural abscess (SEA) require surgical decompression has been recently challenged by reports of successful medical management of select patients with SEA. Purpose The purpose of this study was to identify the independent variables that determine success or failure of medical management of SEA. Study design/setting This was a retrospective, case-control study. Patient sample Patients 18 years or older with diagnosis of SEA admitted to our institution during the study period were included in the sample. Outcome measures The outcome measure was successful management of SEA by eradication of the infection without worsening of neurologic deficits. Methods All patients admitted to our health-care system with a diagnosis of SEA from 1993 to 2011 were identified and the data were retrospectively collected. Patients 18 years or older diagnosed with SEA were included. Excluded were those with postsurgical SEA or phlegmon without an abscess and those with a complete spinal cord injury from SEA for longer than 48 hours. Results A total of 355 patients with average age of 60 years met our inclusion criteria. Of the patients who initially underwent nonoperative treatment, 54 patients failed medical management and 73 patients were successfully treated without surgery. Univariate and multivariate analysis identified incomplete or complete spinal cord deficits as the most significant risk factor for failure of medical management. Age older than 65 years, diabetes, and methicillin-resistant Staphylococcus aureus (MRSA) were also independent risk factors for failure. An algorithm for probability of failed antibiotic management of spinal epidural abscess predicted 99% probability of failure for patients with all four of these risk factors. Conclusions SEA treated with medical management alone has a very high risk for failure if the patient is older than 65 years with diabetes, MRSA infection, or neurologic compromise. In the absence of these risk factors, nonoperative management of spinal epidural abscess may be considered as the initial line of treatment with close monitoring.

IntroductionLordotic cage insertion through lateral transpsoas approach is being used increasingly for restoration of sagittal alignment. However, the degree of correction achieved by varying cage ...