Journal of neurosurgery. Spine
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OBJECT Extradural decompression is a minimally invasive technique for treating Chiari malformation Type I (CM-I) that avoids the complications of dural opening. While there is no agreement on which surgical method is optimal, mounting evidence demonstrates that extradural decompression effectively treats clinical symptoms, with a minimal reoperation rate. Neurological symptoms such as headache may be related to obstructed flow of CSF, and one aspect of successful extradural decompression is improved CSF dynamics. ⋯ CONCLUSIONS Extradural decompression has the potential to be the first-line treatment for CM-I but has been lacking an objective measure by which to assess surgical success as well as the need for reoperation. An increase in the CSF spaces and improved CSF dynamics may be associated with resolution of clinical symptoms. Including cine imaging as part of routine pre- and postoperative evaluation can help identify which patients are most likely to benefit from surgery.
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Multicenter Study
Cervical compensatory alignment changes following correction of adult thoracic deformity: a multicenter experience in 57 patients with a 2-year follow-up.
OBJECT Alignment changes in the cervical spine that occur following surgical correction for thoracic deformity remain poorly understood. The purpose of this study was to evaluate such changes in a cohort of adults with thoracic deformity treated surgically. METHODS The authors conducted a multicenter retrospective analysis of consecutive patients with thoracic deformity. ⋯ CONCLUSION Increased CL is common in adult spinal deformity patients with thoracic deformities and, unlike after lumbar corrective surgery, does not appear to normalize after thoracic corrective surgery. Cervical sagittal malalignment (C2-7 SVA) also increases postoperatively. Surgeons should be aware that spontaneous cervical alignment normalization might not occur following thoracic deformity correction.
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OBJECT The purpose of this study was to explore the use of super-resolution tract density images derived from probabilistic diffusion tensor imaging (DTI) tractography of the spinal cord as an imaging surrogate for microstructural integrity and functional impairment in patients with cervical spondylosis. METHODS Structural MRI and DTI images were collected for 27 patients with cervical spondylosis with (n= 21) and without (n= 6) functional impairment as defined by the modified Japanese Orthopaedic Association Scale (mJOA). DTI was performed axially through the site of compression in a total of 20 directions with 10 averages. ⋯ A ratio of maximum fiber tract density at the site of compression to fiber tract density at C-2 greater than 1.45 had 82% sensitivity and 70% specificity for identifying patients with moderate to severe impairment (ROC AUC= 0.8882, p= 0.0009). CONCLUSIONS These results support the use of DTI as a surrogate for determining spinal cord integrity in patients with cervical spondylosis. Probabilistic tractography provides spinal cord microstructural information that can help discern clinical status in cervical spondylosis patients with varying degrees of neurological impairment.
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OBJECT In this study the authors' aim was to describe their experience with total en bloc sacrectomy using a posterioronly approach and to assess the outcome of patients with malignant sacral tumors who underwent this procedure at their center. METHODS The authors identified and retrospectively reviewed the records of 10 patients with malignant sacral tumors who underwent a total en bloc sacrectomy via a single posterior approach at their center. The pathological diagnosis was chordoma in 4 patients, chondrosarcoma in 1, osteosarcoma in 1, malignant schwannoma in 1, malignant giant cell tumor in 1, and Ewing's sarcoma in 2. ⋯ The total complication rate was 40% (4 of 10). Wound complications (deep infection and wound healing problems) occurred in 3 patients, and a distal deep vein thrombosis occurred in 1 patient. CONCLUSIONS Total en bloc sacrectomy using a posterior-only approach is feasible and safe in selected patients and is an important procedure for the treatment of primary malignant tumor involving the entire sacrum or only the top portion.
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OBJECT Total en bloc sacrectomy is a dramatic procedure that results in extensive sacral defects. The authors present a series of patients who underwent flap reconstruction after total sacrectomy, report clinical outcomes, and provide a treatment algorithm to guide surgical care of this unique patient population. METHODS After institutional review board approval, data were collected for all patients who underwent total sacrectomy between 2002 and 2012 at The Johns Hopkins Hospital. ⋯ CONCLUSIONS The authors' experience suggests that the GM and pedicled VRAM flaps are reliable options for softtissue reconstruction of total sacrectomy defects. For posterior-only operations, GM flaps with or without a prosthetic rectal sling are generally used. For multistage operations including a laparotomy, the authors consider the pedicled VRAM flap to be the gold standard for simultaneous reconstruction of the pelvic diaphragm and obliteration of dead space.