Jacob M Buchowski

Washington University in St. Louis, San Luis, Missouri, United States

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Publications (112)251.8 Total impact

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    ABSTRACT: Retrospective analysis of inpatient and outpatient data from a single academic trauma center. To test the effectiveness of a conservative treatment algorithm for civilian spinal gunshot wounds (CSGSWs) by comprehensively evaluating neurological status and recovery, fracture type, concomitant injuries, indications for surgery, and complications. Few large studies exist to guide treatment of CSGSWs, and none have been published in nearly 20 years. A search of International Classification of Diseases, Ninth Revision (ICD-9) codes was performed for all hospital patients treated from 2003 to 2011 by either neurosurgery or orthopedic surgery to identify 159 consecutive patients who sustained CSGSWs. Mean follow-up was 13.6 months. American Spinal Injury Association grading was used to assess neurological injury. Fifty percent of patients had neurological deficits from CSGSW. Complete spinal injury was the most common injury grade; thoracic injuries had the most risk of complete injury (P < 0.001). Nearly 80% of patients had concomitant injuries to other organs. Operative treatment was more likely in patients with severe neurological injuries (P = 0.008) but was not associated with improved neurological outcomes (P = 1.00). Nonoperative treatment did not lead to any cases of late spinal instability or neurological deterioration. Overall, 31% of patients had an improvement of at least 1 American Spinal Injury Association grade by final follow-up. Nearly half of patients experienced at least 1 GSW-related complication; risk of complications was associated with neurological injury grade (P < 0.001) and operative treatment (P = 0.04). The vast majority of CSGSWs should be managed nonoperatively, regardless of neurological grade or number of spinal columns injured. Indications for surgery include spinal infection and persistent cerebrospinal fluid leaks. 3.
    Spine 04/2015; 40(7):450-461. DOI:10.1097/BRS.0000000000000797 · 2.45 Impact Factor
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    ABSTRACT: The skeletal system is the third most common site of metastases after the lung and liver. Within the skeletal system, the vertebral column is the most common site of metastases, and 8% to 15% of vertebral metastases are in the cervical spine, consisting, anatomically and biomechanically, of the occipitocervical junction, subaxial spine, and cervicothoracic junction. The vertebral body is more commonly affected than the posterior elements. Nonsurgical management techniques include radiation therapy (stereotactic and conventional), bracing, and chemotherapy. Surgical techniques include percutaneous methods, such as vertebroplasty, and palliative methods, such as decompression and stabilization. Surgical approach depends on the location of the tumor and the goals of the surgery. Appropriate patient selection can lead to successful surgical outcomes by restoring spinal stability and improving quality of life. Copyright 2014 by the American Academy of Orthopaedic Surgeons.
    The Journal of the American Academy of Orthopaedic Surgeons 01/2015; 23(1):38-46. DOI:10.5435/JAAOS-23-01-38 · 2.40 Impact Factor
  • The Spine Journal 10/2014; DOI:10.1016/j.spinee.2014.08.035 · 2.80 Impact Factor
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    ABSTRACT: Study Design. Retrospective. Objective. The purpose of this study was to report the prevalence of abnormal neurological findings detected by physical examination in Scheuermann kyphosis and to correlate it to radiographs, magnetic resonance imaging (MRI) findings, and results of operative treatment. Summary of Background Data. There have been sporadic reports about abnormal neurological findings in patients with Scheuermann kyphosis. Methods. Among 82 patients with Scheuermann kyphosis who underwent corrective surgery, 69 primary cases were selected. Patients' charts were reviewed retrospectively in terms of pre and postoperative neurological examinations. Sensory or motor change was defined as an abnormal neurological examination. Their duration, associated problems, and various parameters on preoperative radiographs and MRI examinations were also measured to search for any atypical findings associated with an abnormal neurological examination. Results. There were 6 cases (9%) (group AbN), with an abnormal neurological examination ranging from severe myelopathy to a subtle change (e.g., sensory paresthesias on trunk). Five patients recovered to a normal neurological examination after corrective surgery. The remaining 1 patient with severe myelopathy also showed marked improvement and was ambulatory unassisted by 2-year follow-up. In patients with a normal neurological examination (group N, n = 63), only 1 patient had neurological sequelae because of anterior spinal artery syndrome after combined anterior-posterior correction. No preoperative radiographical parameters were significantly different between groups. Average age was 21.3 (AbN) and 18.6 (N) years (P = 0.55). Average preoperative T5-12 kyphosis was 69.0 degrees (AbN) and 72.5 degrees (N) (P = 0.61). Forty-two magnetic resonance images were obtained and all showed typical findings of Scheuermann kyphosis. Five patients in the AbN group (1 patient underwent computed tomography/myelography) and 37 patients in the N group underwent an MRI. Conclusion. The prevalence of abnormal neurological findings in Scheuermann kyphosis was 9%, emphasizing the importance of performing a detailed preoperative neurological examination. If congenital stenosis or a herniated thoracic disc is present, myelopathy can occur. No radiographical findings correlated with the abnormal preoperative neurological examinations. A normal MRI can exist in the face of an abnormal neurological examination, and conversely, a normal neurological examination can be seen with an abnormal MRI. Surgery was successful in alleviating abnormal neurological issues.
    Spine 10/2014; 39(21):1771-1776. DOI:10.1097/BRS.0000000000000519 · 2.45 Impact Factor
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    ABSTRACT: While interspinous motion analysis is commonly used to determine the status of an anterior cervical fusion, the accuracy of this technique is unclear. We believed that three questions needed to be answered. What degree of image magnification is ideal? How much motion should be considered "adequate" for making dynamic radiographs? What is the optimal amount of interspinous motion for detecting pseudarthrosis? We performed a retrospective study of 125 patients (109 fused segments and 153 pseudarthrotic segments) who had undergone reexploration with confirmation of fusion status. Interspinous motion at each operatively treated level and one superjacent level was measured by two independent investigators twice. Reliabilities of interspinous motion analysis at different magnification rates (25%, 100%, 150%, and 200%) were evaluated for fifty randomly selected segments to determine the optimal magnification, which we used for the remainder of the measurements. Fusion status was also determined on computed tomography (CT) by two other raters. We compared the intraoperative findings with those based on dynamic radiographs (with use of cutoff values of 1 and 2 mm of interspinous motion as the indication of pseudarthrosis) and CT. On radiographs, both 150% and 200% magnification yielded higher interobserver and intraobserver reliabilities compared with 25% and 100% magnification, and the reliabilities at 150% and 200% were similar to each other, so subsequent measurements were made at 150%. The cutoff value of interspinous motion for detecting pseudarthrosis was 0.9 mm as determined with receiver operating characteristic curve analysis. Compared with CT, interspinous motion of ≥1 mm showed relatively low sensitivity (79.5%) and negative predictive value (77.1%) and similar specificity (97.0%) and positive predictive value (97.4%). Using interspinous motion of ≥2 mm as the cutoff decreased the sensitivity and negative predictive value to 46.6% and 56.8%, respectively. Our evaluation of what constituted adequate dynamic motion for making the radiographs showed that, with use of interspinous motion of ≥1 mm as the cutoff for detecting pseudarthrosis, superjacent interspinous motion of ≥4 mm increased the sensitivity and negative predictive value (86.3% and 83.4%) compared with those associated with alternative cutoffs of superjacent interspinous motion (≥3.5, ≥5, and ≥6 mm), and the specificity (96.1%) and positive predictive value (96.9%) were reasonable. Use of interspinous motion of ≥1 mm as the cutoff for detection of anterior cervical pseudarthrosis on radiographs magnified 150% and made with superjacent interspinous motion of ≥4 mm yielded accuracies comparable with those of CT. Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.
    The Journal of Bone and Joint Surgery 04/2014; 96(7):557-63. DOI:10.2106/JBJS.M.00167 · 4.31 Impact Factor
  • Jeffrey L Gum, Jacob M Buchowski
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    ABSTRACT: Gruskay JA, Webb ML, Grauer JN. Methods of evaluating lumbar and cervical fusion. Spine J 2014;14:531-9 (in this issue).
    The spine journal: official journal of the North American Spine Society 03/2014; 14(3):540-1. DOI:10.1016/j.spinee.2013.09.041 · 2.80 Impact Factor
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    ABSTRACT: Pulmonary cement embolization after vertebroplasty is a well-known complication but typically presents with minimal respiratory symptoms. Although this rare complication has been reported, the current literature does not address the need for awareness of symptoms of potentially devastating respiratory compromise. We present the case of a 29-year-old man who underwent T11 vertebroplasty and subsequently had chest pain develop several days later. His right lower lung lobe had infarcted owing to massive cement embolization to his pulmonary arterial circulation. Open pulmonary wedge resection and embolectomy were performed. The patient recovered from the embolectomy but had chronic, persistent respiratory symptoms after surgery. Operative management of vertebral compression fractures has included percutaneous vertebroplasty for the past 25 years. The reported incidence of pulmonary cement emboli after vertebroplasty ranges from 2.1% to 26% with much of this variation resulting from which radiographic technique is used to detect embolization. Symptoms of pulmonary cement embolism can occur during the procedure, but more commonly begin days to weeks, even months, after vertebroplasty. At least six deaths from cement embolization after vertebroplasty have been reported. Most cases of pulmonary cement emboli with cardiovascular and pulmonary complications are treated nonoperatively with anticoagulation. Endovascular removal of large cement emboli from the pulmonary arteries is not without risk and sometimes requires open surgery for complete removal of cement pieces. Pulmonary cement embolism is a potentially serious complication of vertebroplasty. If a patient has chest pain or respiratory difficulty after the procedure, chest radiography and possibly advanced chest imaging studies should be performed immediately.
    Clinical Orthopaedics and Related Research 02/2014; 472(5). DOI:10.1007/s11999-014-3506-0 · 2.88 Impact Factor
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    ABSTRACT: Study Design Retrospective review. Objective The objective of this study is to describe the natural history of neurologic recovery after anterior cervical discectomy and fusion (ACDF). Methods Patients between 18 and 80 years of age, diagnosed with cervical radiculopathy, who underwent single-level ACDF and were followed for a minimum of 2 years were identified from a single-center database. Sensory and motor deficits were documented and graded based on physical examination findings at preoperative and postoperative visits, and used to calculate deficit rates. Results One hundred eighteen patients were included in the study. Mean age was 46 ± 9.2 years and mean follow-up time was 3.8 ± 2.1 years. At the time of surgery, 66% had a sensory deficit. Recovery of sensory function was seen in 85% of patients within 1 year. At final follow-up, new sensory deficits had developed in 30% of patients, 60% of whom had adjacent-level sensory deficits. Patients with preoperative sensory deficits tended to be more likely to develop a new deficit postoperatively (p = 0.05). At the time of surgery, 55% had a motor deficit. Recovery of motor function was seen in 95% of patients within 1 year, and 14% developed new postoperative motor deficits by final follow-up. Of those patients who developed a new motor deficit postoperatively, 76% did so at an adjacent level. Conclusions In our series, a high percentage of patients recovered neurologic function during the first year after ACDF. Adjacent-level and remote-level degeneration were large contributors to neurologic deficits that occurred in subsequent years.
    02/2014; 4(1):41-6. DOI:10.1055/s-0033-1360723
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    ABSTRACT: Study Design Single-center, retrospective study. Objective Suboptimal concentrations of vitamin D have been linked to hip and knee osteoarthritis in large, population-based cohort studies. We sought to examine the association of vitamin D levels with intervertebral disk disease. Methods From January 2010 through May 2011, 91 consecutive, eligible adult spine surgery patients who had undergone cervical magnetic resonance imaging (MRI) and preoperative serum 25-hydroxyvitamin D (s25D) measurement were retrospectively included. MRI was read for C2-T1 disk herniation and degeneration (grades I to V). Logistic regressions were performed. Results Compared with the 384 disks of nondeficient patients, 162 disks of vitamin D-deficient (< 20 ng/mL) patients were more frequently herniated (40% versus 27%, p = 0.004); deficiency was not predictive of individual disk grade (unadjusted odds ratio [uOR] = 0.98, p = 0.817). On regression analysis, deficiency was associated with increased number of herniations per patient (uOR = 2.17, 95% confidence interval [CI] = 1.22 to 3.87, p = 0.009; adjusted odds ratio [aOR] = 2.12, 95% CI = 1.11 to 4.03, p = 0.023). When disks were analyzed individually, and levels (e.g., C5 to C6), additionally controlled for, deficiency correlated with greater likelihood of herniation per disk (uOR = 1.81, 95% CI = 1.22 to 2.66, p = 0.003; aOR = 2.06, 95% CI = 1.25 to 3.41, p = 0.005). Conclusion Among adults undergoing spine surgery at our institution, vitamin D deficiency was associated with cervical disk herniation. Considering the current epidemics of vitamin D insufficiency and neck pain, further investigation is warranted, as these data were retrospectively collected and subject to sampling bias.
    12/2013; 3(4):231-6. DOI:10.1055/s-0033-1354252
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    ABSTRACT: Study Design. Comparative case series. Data prospectively entered and retrospectively analyzed.Objective. To evaluate the need for distal lumbar interbody fusion when sufficient recombinant human bone morphogenetic protein-2 (rhBMP-2) is used posterolaterally at L5-S1 in long spinal constructs for adult deformity via costs and radiographic and patient-reported outcome comparisons.Summary of Background Data. Many authors and investigators have suggested that an interbody fusion is mandatory at L5-S1 with long fusion to the sacrum with sacropelvic fixation. Past studies have shown competitive fusion rates using rhBMP-2 vs. iliac crest bone graft for long fusions. There are various advocates for anterior lumbar interbody fusion (ALIF) vs. posterior lumbar interbody fusion (PLIF) vs. transforaminal lumbar interbody fusion (TLIF). The optimal strategy remains elusive.Methods. Fifty-seven patients were studied at one institution. Thirty-one patients had no interbody fusion (NI group) with 20mg bone morphogenetic protein (rhBMP-2) posterolaterally on 10 cc carrier and 26 patients had TLIF at L5-S1 (TLIF group) with 6mg rhBMP-2 in the interbody space along with local bone graft and 6mg rhBMP-2 on carrier posterolaterally at L5-S1. Patients were followed for 24-87 months (mean follow-up 3.92 years). Demographics of the two groups were similar.Results. There were no detected nonunions at L5-S1 in either group. By our limited cost analysis, the expense of performing a TLIF at L5-S1 is higher than that of using extra rhBMP-2 posterolaterally at that segment. Improvement in outcomes scores, namely Scoliosis Research Society (SRS)-22 and Oswestry Disability Index (ODI), were the same statistically in both groups. Blood loss was greater in the TLIF group than the NI group. There were no identified rhBMP-2 adverse events in either group.Conclusion. Utilization of 20mg rhBMP-2 at L5-S1 has the potential to be less expensive than an interbody fusion in most patients having a primary long fusion for adult spinal deformity. The apparent fusion rates at L5-S1 were identical in both groups. Both strategies were successful in regards to improving patient outcomes and achieving apparent solid arthrodesis at the lumbosacral junction, which was the focus of this study.
    Spine 10/2013; 38(26). DOI:10.1097/BRS.0000000000000045 · 2.45 Impact Factor
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    ABSTRACT: Study Design. Retrospective analysis of a prospectively collected database.Objective. To determine the overall incidence, location, and type of disc herniations in professional football players in order to target treatment issues and prevention.Summary of Background Data. Disc herniations represent a common and debilitating injury to the professional athlete. The National Football League's (NFL) Sports Injury Monitoring System is a surveillance database created to monitor the league for all injuries, including injuries to the cervical, thoracic, and lumbar spine.Methods. A retrospective analysis was performed on all disc herniations to the cervical, thoracic, and lumbar spine over a twelve-season period (2000-2012) using the NFL's surveillance database. The primary data points included the location of the injury, player position, activity at time of injury, and playing time lost due to injury.Results. Over the 12 seasons, 275 disc herniations occurred in the spine. In regard to location, 76% occurred in the lumbar spine and most frequently affected the L5-S1 disc. The offensive linemen were most frequently injured. As expected, blocking was the activity causing most injuries. Lumbar disk herniations rose in prevalence and had a mean loss of playing time of more than half the season (11.5 games). Thoracic disc herniations led to the largest mean number of days lost overall, whereas players with cervical disc herniations missed the most practices.Conclusions. Disc herniations represent a significant cause of morbidity in the NFL. While much attention is placed on spinal cord injuries, preventive measures targeting the cervical, thoracic, and lumbar spine may help to reduce the overall incidence of these debilitating injuries.
    Spine 09/2013; DOI:10.1097/BRS.0b013e3182a67678 · 2.45 Impact Factor
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    ABSTRACT: Use of recombinant human bone morphogenetic protein-2 (rhBMP-2) has increased considerably since its introduction in 2002. The complications associated with high-dose rhBMP-2 (≥40 mg) are unknown. The purpose of our study was to determine outcomes and medical and surgical complications associated with high-dose rhBMP-2 at short-term and long-term follow-up evaluations. Five hundred and two consecutive adult patients who had received high-dose rhBMP-2 as a part of spinal surgery from 2002 to 2009 at one institution were enrolled. Data were entered prospectively and studied and analyzed retrospectively. Surgical procedures in the thoracic and lumbar spine were included. Major and minor complications were documented intraoperatively, perioperatively, and at the latest follow-up examination. Complications potentially associated with rhBMP-2 use were evaluated for correlation with rhBMP-2 dose. Scoliosis Research Society (SRS) and Oswestry Disability Index (ODI) outcome measures were obtained before and after surgery. On average, 115 mg (range, 40 to 351 mg) of rhBMP-2 was used. The average age of the patients (410 women and ninety-two men) at the time of the index procedure was 52.4 years (range, eighteen to eighty years). There were 265 primary and 237 revision procedures, and 261 patients had interbody fusion. An average of 11.5 vertebrae were instrumented. The average duration of follow-up was forty-two months (range, fourteen to ninety-two months). The diagnoses included idiopathic scoliosis (41%), degenerative scoliosis (31%), fixed sagittal imbalance (18%), and other diagnoses (10%). The rate of intraoperative complications was 8.2%. The rate of perioperative major surgical complications was 11.6%. The rate of perioperative major medical complications was 11.6%. Minor medical complications occurred in 18.9% of the cases, and minor surgical complications occurred in 2.6%. Logistic regression analysis and Pearson correlation did not identify a significant correlation between rhBMP-2 dosage and radiculopathy (r = -0.006), seroma (r = -0.003), or cancer (r = -0.05). Significant improvements in the ODI score (from a mean of 41 points to a mean of 26 points; p < 0.001) and the SRS total score (from a mean of 3.0 points to a mean of 3.7 points; p < 0.001) were noted at the latest follow-up evaluation. This is the largest study of which we are aware that examines complications associated with high-dose rhBMP-2. Major surgical complications occurred in 11.6% of patients, and 11.6% experienced major medical complications. There was a cancer prevalence of 3.4%, but no correlation between increasing rhBMP-2 dosage and cancer, radiculopathy (seen in 1% of the patients), or seroma (seen in 0.6%) was found. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
    The Journal of Bone and Joint Surgery 09/2013; 95(17):1546-53. DOI:10.2106/JBJS.L.01730 · 4.31 Impact Factor
  • The Spine Journal 09/2013; 13(9):S8-S9. DOI:10.1016/j.spinee.2013.07.050 · 2.80 Impact Factor
  • The Spine Journal 09/2013; 13(9):S141-S142. DOI:10.1016/j.spinee.2013.07.363 · 2.80 Impact Factor
  • The Spine Journal 09/2013; 13(9):S42. DOI:10.1016/j.spinee.2013.07.132 · 2.80 Impact Factor
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    ABSTRACT: Introduction There is increasing awareness of adult degenerative or de novo scoliosis, and its surgical treatment when indicated can be challenging and resource intense. Surgical randomized controlled trials are rare, and observational studies pose limitations because of the heterogeneity of surgical practices, techniques, and patient populations. Pooled analysis of current literature may identify effective treatment strategies and guide future efforts at prospective clinical research. This study aimed to synthesize existing data on the outcomes of surgical intervention for adult degenerative scoliosis. Methods PubMed, Medline, Cochrane, and Web of Science databases were searched using key words and were limited to the English language. Spine surgeons reviewed abstracts and evaluated whether they contained surgically treated cohorts of adults (more than 18 years of age) with degenerative scoliosis. Full-text articles were reviewed in detail and data were abstracted. All meta-analyses were conducted using random effects models and heterogeneity was estimated with I2. Random-effects meta-regression models were used to investigate the association of treatment effects with baseline levels of each outcome. Results Of 482 articles, 24 (n = 805) met inclusion criteria Available outcomes included Cobb angle correction, coronal and sagittal balance, visual analog scale for pain (VAS), and Oswestry Disability Index. Despite significant heterogeneity among studies, random-effects meta-analysis showed significant improvements in Cobb angle (−11.1°; 95% confidence interval [CI], −13.86° to −8.40°), coronal balance (7.674 mm; 95% CI, −10.5 to −4.9), VAS (−3.24; 95% CI, −4.5 to −1.98), and Oswestry Disability Index (−27.18%; 95% CI, −34.22 to −20.15) postoperative treatment (p < .001). Meta-regression models showed that preoperative values for Cobb angle, coronal balance, and VAS were significantly associated with surgical treatment effect (p < .05). Changes in sagittal balance did not reach statistical significance although only 6 articles were included. Conclusions Exhaustive literature review yielded 24 studies reporting preoperative and postoperative data regarding the surgical treatment of adult degenerative scoliosis. No randomized clinical trials (RCTs) were identified. Despite heterogeneity, a limited meta-analysis showed significant improvement in Cobb angle, coronal balance, and VAS after surgical treatment of adult degenerative scoliosis.
    07/2013; 1(4):248–258. DOI:10.1016/j.jspd.2013.05.001
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    ABSTRACT: BACKGROUND CONTEXT: Although routine transection of the C2 nerve root during atlantoaxial segmental screw fixation has been recommended by some surgeons, it remains controversial and to our knowledge no comparative studies have been performed to determine whether transection or preservation of the C2 nerve root affects patient-derived sensory outcomes. PURPOSE: The purpose of this study is to specifically analyze patient-derived sensory outcomes over time in patients with intentional C2 nerve root transection during atlantoaxial segmental screw fixation compared with those without transection. STUDY DESIGN: This is a post-hoc comparative analysis of prospectively collected patient-derived outcome data. PATIENT SAMPLE: The sample consists of 24 consecutive patients who underwent intentional bilateral transection of the C2 nerve root during posterior atlantoaxial segmental screw fixation (transection group) and subsequent 41 consecutive patients without transection (preservation group). OUTCOME MEASURES: A visual analog scale (VAS) score was used for occipital neuralgia as the primary outcome measure and VAS score for neck pain, neck disability index score and Japanese Orthopedic Association score for cervical myelopathy and recovery rate, with bone union rate as the secondary outcome measure. METHODS: Patient-derived outcomes including change in VAS score for occipital neuralgia over time were statistically compared between the two groups. This study was not supported by any financial sources and there is no topic-specific conflict of interest related to the authors of this study. RESULTS: Seven (29%) of the 24 patients in the transection group experienced increased neuralgic pain at 1 month after surgery either because of newly developed occipital neuralgia or aggravation of preexisting occipital neuralgia. Four of the seven patients required almost daily medication even at the final follow-up (44 and 80 months). On the other hand, only four (10%) of 41 patients in the preservation group had increased neuralgic pain at 1 month after surgery, and at ≥1 year, no patients had increased neuralgic pain. The difference in the prevalence of increased neuralgic pain between the two groups was statistically significant at all time points (3, 6, 12, and 24 months postoperatively) except at 1 month postoperatively. The intensity of neuralgic pain, which preoperatively had not been significantly different between the two groups, was significantly higher in the transection group at the final follow-up. CONCLUSIONS: C2 nerve root transection is not a benign procedure and, in our experience, more than a quarter of the patients experience increased neuralgic pain following C2 nerve root transection. Because the prevalence and intensity of postoperative neuralgia was significantly higher with C2 nerve root transection than with its preservation, we recommend against routine C2 nerve root transection when performing atlantoaxial segmental screw fixation.
    The spine journal: official journal of the North American Spine Society 05/2013; 13(7). DOI:10.1016/j.spinee.2013.04.006 · 2.80 Impact Factor
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    ABSTRACT: BACKGROUND CONTEXT: To our knowledge, no large series comparing the risk of vertebral artery injury by C1-C2 transarticular screw versus C2 pedicle screw have been published. In addition, no comparative studies have been performed on those with a high-riding vertebral artery and/or a narrow pedicle who are thought to be at higher risk than those with normal anatomy. PURPOSE: To compare the risk of vertebral artery injury by C1-C2 transarticular screw versus C2 pedicle screw in an overall patient population and subsets of patients with a high-riding vertebral artery and a narrow pedicle using computed tomography (CT) scan images and three-dimensional (3D) screw trajectory software. STUDY DESIGN: Radiographic analysis using CT scans. PATIENT SAMPLE: Computed tomography scans of 269 consecutive patients, for a total of 538 potential screw insertion sites for each type of screw. OUTCOME MEASURES: Cortical perforation into the vertebral artery groove of C2 by a screw. METHODS: We simulated the placement of 4.0 mm transarticular and pedicle screws using 1-mm-sliced CT scans and 3D screw trajectory software. We then compared the frequency of C2 vertebral artery groove violation by the two different fixation methods. This was done in the overall patient population, in the subset of those with a high-riding vertebral artery (defined as an isthmus height ≤5 mm or internal height ≤2 mm on sagittal images) and with a narrow pedicle (defined as a pedicle width ≤4 mm on axial images). RESULTS: There were 78 high-riding vertebral arteries (14.5%) and 51 narrow pedicles (9.5%). Most (82%) of the narrow pedicles had a concurrent high-riding vertebral artery, whereas only 54% of the high-riding vertebral arteries had a concurrent narrow pedicle. Overall, 9.5% of transarticular and 8.0% of pedicle screws violated the C2 vertebral artery groove without a significant difference between the two types of screws (p=.17). Among those with a high-riding vertebral artery, vertebral artery groove violation was significantly lower (p=.02) with pedicle (49%) than with transarticular (63%) screws. Among those with a narrow pedicle, vertebral artery groove violation was high in both groups (71% with transarticular and 76% with pedicle screws) but without a significant difference between the two groups (p=.55). CONCLUSIONS: Overall, neither technique has more inherent anatomic risk of vertebral artery injury. However, in the presence of a high-riding vertebral artery, placement of a pedicle screw is significantly safer than the placement of a transarticular screw. Narrow pedicles, which might be anticipated to lead to higher risk for a pedicle screw than a transarticular screw, did not result in a significant difference because most patients (82%) with narrow pedicles had a concurrent high-riding vertebral artery that also increased the risk with a transarticular screw. Except in case of a high-riding vertebral artery, our results suggest that the surgeon can opt for either technique and expect similar anatomic risks of vertebral artery injury.
    The spine journal: official journal of the North American Spine Society 05/2013; 13(7). DOI:10.1016/j.spinee.2013.04.005 · 2.80 Impact Factor

Publication Stats

1k Citations
251.80 Total Impact Points

Institutions

  • 2006–2014
    • Washington University in St. Louis
      • Department of Orthopaedic Surgery
      San Luis, Missouri, United States
  • 2012
    • Rush University Medical Center
      • Department of Orthopaedic Surgery
      Chicago, IL, United States
    • American Academy of Orthopaedic Surgeons
      Роземонт, Illinois, United States
  • 2011
    • University of Missouri - St. Louis
      Saint Louis, Michigan, United States
    • Seoul National University Hospital
      • Department of Orthopedic Surgery
      Seoul, Seoul, South Korea
  • 2010
    • Seoul National University Bundang Hospital
      • Department of Orthopaedic Surgery
      Seoul, Seoul, South Korea
  • 2009
    • Saint Louis University
      • Department of Orthopaedic Surgery
      Saint Louis, MI, United States
    • Seoul National University
      • Department of Orthopaedic Surgery
      Seoul, Seoul, South Korea
  • 2008
    • Walter Reed National Military Medical Center
      Washington, Washington, D.C., United States
  • 2000–2007
    • Johns Hopkins University
      • Department of Orthopaedic Surgery
      Baltimore, MD, United States
  • 2001–2006
    • Johns Hopkins Medicine
      • Department of Orthopaedic Surgery
      Baltimore, MD, United States