Faculty Bibliography

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

OBJECTIVE: We describe a series of seven consecutive patients treated with endoscopically assisted transoral surgery for decompression of high cervical and clival abnormalities. METHODS: Seven endoscopically assisted transoral procedures were performed at the University of Florida from September 1999 to April 2000 for irreducible compression at the cervicomedullary junction. The abnormalities encountered were primary basilar invagination from congenital craniovertebral junction malformation (two cases), irreducible rheumatoid cranial settling (one case), secondary basilar invagination caused by migration of odontoid fracture fragments (one case), pseudogout granulation mass (one case), clivus chordoma (one case), and Chiari malformation with associated basilar invagination (one case). RESULTS: Successful decompression was achieved in all seven patients. There were no adverse neurological sequelae. One patient died from a perioperative myocardial infarction. At a mean clinical follow-up of 6.16 months, neurological status was noted to be stable or improved in all remaining patients. CONCLUSION: Endoscopically assisted transoral surgery represents an emerging alternative to standard microsurgical techniques for transoral approaches to the anterior cervicomedullary junction. Used in conjunction with intraoperative fluoroscopy, it provides a safe method for anterior decompression of the cervicomedullary junction without the need for extensive soft palate splitting, hard palate resection, or extended maxillotomy. Experience is required with greater numbers of patients and long-term follow-up to further validate this promising technique

Swallowing difficulties and dysphonia may occur in patients undergoing anterior cervical discectomy and fusion. The etiology and incidence of these abnormalities, however, are not well defined. In view of this, we performed a prospective, objective analysis of swallowing function and vocal cord approximation in patients undergoing anterior cervical discectomy and fusion. Twenty-three consecutive patients (22 male and one female, mean age 59 years) undergoing anterior cervical discectomy and fusion had standardized modified barium swallow study and videolaryngoendoscopy performed preoperatively and again at 1 week and 1 month postoperatively. Eleven patients (48%) had radiographic evidence of preoperative swallowing abnormalities. The majority of these patients had myelopathic rather than radicular findings (p = 0.03). None, however, had symptoms of swallowing dysfunction. Among these patients, one had worse function postoperatively, three had improvement, and function remained unchanged in seven. The preoperative swallowing assessment was normal in 12 patients (52%). Postoperative radiographic swallowing abnormalities were demonstrated in eight of these patients (67%). Preoperative vocal cord movement was normal in all patients. Postoperatively, vocal cord paresis was detected in two patients. The paresis was transient in one and permanent in the other. Age, previous medical history, operation duration, and spinal level decompressed were not significantly associated with the incidence of swallowing dysfunction. There was, however, a tendency for patients undergoing multilevel surgery to demonstrate an increased incidence of swallowing abnormalities on postoperative radiographic studies. In addition, soft tissue swelling was more frequent in patients whose swallowing function was worse postoperatively (p = 0.007). Postoperative voice and swallowing dysfunction are common complications of anterior cervical discectomy and fusion, although in the majority of patients these abnormalities are not symptomatic. Patients undergoing multilevel procedures are at an increased risk for these complications, in part because of soft tissue swelling in the neck