The spine journal : official journal of the North American Spine Society
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Cervical spine fusion is performed for various indications in patient populations ranging from young and healthy to aged and frail. The choice of surgical approach is affected not only by disease pathoanatomy, but also by age, medical comorbidities, and the number of involved levels. Anterior fusion is more common for single-level pathology in relatively young, healthy patients; and posterior fusion is typically performed on older, more comorbid patients with multilevel disease. Consequently, retrospective comparisons of surgical approaches for cervical fusion will be impacted by this bias, and the optimal management of multilevel cervical spine pathology remains ambiguous with surgeon preference and experience playing a significant role in choice of procedures. ⋯ This nationwide study defines the incidence of mortality and the frequency of inpatient complications encountered during multilevel cervical fusion. The results suggest that immediate morbidity from anterior approaches is less than those undergoing posterior fusion. Prospective analysis is required to evaluate if these findings remain significant in a randomized study population. Further, these results represent only perioperative complications. However, based on the data presented herein, when confronted with the patient requiring a four-level cervical fusion, the anterior approach may offer a less risky and less costly option.
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Case Reports
Traumatic spondyloptosis resulting from high-energy trauma concurrent with a tonic-clonic seizure.
Traumatic lumbosacral dislocation injuries are rare, high-energy injuries that are challenging to surgically manage. ⋯ The injury pattern described is quite rare. This case of multilevel, bilateral pedicle fracture with traumatic L5-S1 spondyloptosis was successfully treated by circumferential reduction and arthrodesis without neurological injury.
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Ewing's sarcoma is the most common childhood malignancy of bone, but it rarely occurs as a primary extraosseous epidural tumor. ⋯ Ewing's sarcoma of the epidural space should be considered in the differential diagnosis of epidural mass lesions. Because wide surgical margins cannot be obtained, close follow-up with a low threshold for reoperation is mandatory.
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Vertebral artery (VA) injury can be a catastrophic iatrogenic complication of cervical spine surgery. Although the incidence is rare, it has serious consequences including fistulas, pseudoaneurysm, cerebral ischemia, and death. It is therefore imperative to be familiar with the anatomy and the instrumentation techniques when performing anterior or posterior cervical spine surgeries. ⋯ VA injury during cervical spine surgery is a rare but serious complication. It can be prevented by careful review of preoperative imaging studies, having a sound anatomical knowledge and paying attention to surgical landmarks intraoperatively. When a VA injury occurs, prompt recognition and management are important.
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Multicenter Study
Physical demand levels in individuals completing a sports performance-based work conditioning/hardening program after lumbar fusion.
Pain and disability after lumbar fusion surgery contributes to the over $20 billion dollars spent in health-care costs and estimated $28 billion in lost wages annually. With the goal of returning to work, an intensive program designed to build functional strength may be used. Previous interventions for this subgroup report the outcome measure of return to work (RTW), but do not account for the physical demand of the job to which they are returning. This may account for varying RTW and re-injury rates. ⋯ Post-lumbar spinal fusion patients are typically at the light PDL (<20lb occasionally) on completion of traditional physical therapy program. After an SPWC/H program, significant increase strength of deadlift and overhead lift volume and one repetition maximum demonstrated a median three-level increase in classification of PDL. We were also able to determine that there was no difference in strength outcome between those with a single- vs. multiple-level fusion surgery. Although the vast majority of individuals entered the program at the lowest PDL (20lb or less occasionally), more than 80% of patients completed the program at PDL of medium (50lb occasionally) or above, and 37% of patients achieved the maximum PDL (over 100lb occasionally). Future studies are needed to determine if increases in strength determined by PDL classification such as these relates to increased RTW rates and decreased re-injury rates.