Faculty Bibliography

Metameric lesions of the spine are rare. The authors present a case of patient with a complex metameric vascular lesion of the thoracic spine and describe a management strategy for this entity

BACKGROUND: C1-C2 fusion has significantly advanced from predominantly wiring/cable modalities to more biomechanically stable screw-rod techniques. Minimally invasive surgical techniques represents the most recent modification of atlantoaxial fixation. The indications, rationale, and surgical technique of this novel procedure are described. METHODS: Six patients requiring C1-C2 fusion (5 type II odontoid fractures and 1 os odontoideum) underwent minimally invasive C1-C2 fusion over a 2-year period. The cohort consisted of 5 men and 1 woman with a mean age of 51 years (age range, 39-64 y). All 6 patients underwent bilateral segmental atlantoaxial fixation using an expandable tubular retractor. RESULTS: The mean follow-up time was 32 months (age range, 24-46 mo) There were no intraoperative complications, and the mean estimated blood loss was 100 mL. Solid fusion was achieved in all 6 patients, without pathological motion on dynamic studies. Postoperative computed tomographic images showed no hardware malposition in the scanned patients (4 of the 6 patients). CONCLUSIONS: Placement of C1 and C2 instrumentation using minimally invasive techniques is technically feasible. Because the instrumentation and the means of obtaining arthrodesis do not differ substantively from the standard approach, we would not anticipate long-term results to be different from those of an open procedure, apart from the approach-related morbidity.

Anteriorly located Type IV thoracic arteriovenous malformations (AVMs) are difficult to treat surgically. Although high-flow fistula subtypes are amenable to treatment using endovascular techniques, low-flow fistulas should be treated surgically. There are few reports discussing the diagnosis, behavior, and treatment of these spinal fistulas due to their low incidence. Posterior surgical approaches to Type IV spinal AVMs reported in the literature have been associated with high morbidity rates or aborted procedures. The authors report the successful management of a T-12 Type IV spinal AVM with an emphasis on approach, interoperative angiography, and the use of modern instrumentation. To the authors' knowledge, this is also the first reported case of multiple arterial-side aneurysms in a Type IV AVM of the anterior spinal artery

OBJECTIVE AND IMPORTANCE: Posterior C1-C2 fusion with polyaxial screw and rod fixation has become an accepted means of atlanto-axial stabilization. We describe a novel technique for minimally invasive placement of C1 lateral mass screws and C2 pedicle screws for polyaxial screw-rod stabilization. CLINICAL PRESENTATION: The patient presented with a history of chronic neck pain, as well as a 6-month history of weakness and paresthesias involving her left hand. An Os Odontoideum was present on computed tomographic imaging of the cervical spine. Significant instability was noted on flexion-extension imaging, and magnetic resonance imaging demonstrated mild T2 signal change within the spinal cord. TECHNIQUE: Under fluoroscopic guidance, serial dilators were passed through a 2.5 cm paramedian skin incision to allow placement of an expandable tubular retractor. The exposure was centered on the C2 lateral mass. After expansion of the retractor and further subperiosteal dissection, the C1 and C2 lateral masses were visible permitting placement of a polyaxial screw rod construct. This procedure was carried out bilaterally. CONCLUSION: Placement of C1 lateral mass and C2 pedicle screws using minimally invasive techniques is technically feasible

OBJECTIVE: Disc herniations at the C7-T1 level are unusual (4% of all herniated cervical discs) and are often incorrectly diagnosed because of unusual neurological findings and suboptimal imaging studies. Furthermore, the anterior approach may be problematic because the manubrium and slope of the vertebral bodies away from the surgeon obscures the end plates. The recurrent laryngeal nerve and the thoracic duct may be injured by respective right- or left-sided approaches. A posterior approach to this level has, therefore, been advocated, but results of C7-T1 herniations treated anteriorly have not been specifically addressed in the literature. We, therefore, reviewed our experience in the operative management of patients undergoing single level anterior cervical discectomy and fusion at the C7-T1 interspace for the 10 years ending June 2004 with regard to clinical presentation, imaging, problems of operative exposure, and neurological outcome. METHODS: Of 268 patients with single level anterior cervical discectomy and fusions (ACDFs), 10 (3.7%) had C7-T1 disc herniations. We retrospectively reviewed the medical records, operative reports, and imaging studies of these 10 patients. RESULTS: All patients presented with C8 motor deficit without myelopathy. The operation was carried out through an anterior approach with a skin incision 3 cm above the clavicle. Visualization of the C7-T1 disc space was achieved in all without difficulty. Eight of 10 patients are neurologically intact. CONCLUSION: The C7-T1 disc herniates laterally because of the absence of Luschka joints at this level. Central herniation with myelopathy is rare. An anterior approach was easily accomplished in all patients. Recovery of motor function was related to duration and severity of preoperative deficit

We describe the anesthetic management difficulties of a man with mucopolysaccharidosis I. We also briefly review the anesthesia literature related to this disease

Intestinal injury is a rare complication of lumbar disc surgery, resulting from inadvertent penetration of the anterior annulus fibrosus and anterior longitudinal ligament. Patients typically complain of abdominal pain and distention developing over the course of several days. Imaging with plain upright chest radiographs or abdominal computed tomography may demonstrate free air in the abdominal cavity. We report a case of intestinal perforation after microscopic lumbar discectomy and present the diagnostic postoperative imaging. In addition, we review the relevant literature and discuss techniques that may be employed to avoid this complication