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.
Over a 13-year period extending from 1980 to 1993, 27 children less than 3 years of age underwent operation for removal of an intramedullary spinal cord tumor (IMSCT). The majority (18 of 27) of children had undergone surgery before being referred to New York University (NYU) Medical Center. The most common reasons for radiological investigation were pain (42%), motor regression (36%), gait abnormalities (27%), torticollis (27%), and progressive kyphoscoliosis (24%). Forty procedures were performed in 27 children. Nine children underwent two operations and two children underwent three procedures. A gross-total resection was achieved in 72% of the procedures. There was no surgical mortality. A comparison of the preoperative and 3-month postoperative functional grades for the first NYU procedure (NYU-1) yielded the following findings: 20 patients' conditions remained the same, five patients improved, and two patients deteriorated. The functional outcomes of a second operation (NYU-2) were similar. The majority of the children (24 of 27, 89%) had histologically determined low-grade lesions. There were 12 patients with low-grade astrocytomas (Grades I-III), eight with gangliogliomas, two with ganglioglioneurocytomas, one with a glioneurofibroma, and one child with a mixed astro/oligodendroglioma. Two children had anaplastic astrocytomas (Grades II-III) and one child had a glioblastoma multiforme. In a median follow-up review of 76 months, two patients died and two patients were lost to follow up. The 3- and 5-year progression-free survival (PFS) rates were 81.7% (standard error of the mean (SEM) 0.083) and 76.2% (SEM 0.094), respectively. Eight of 24 patients suffered a recurrence within a mean time of 45.4 +/- 28.9 months. All were treated with surgery (NYU-2). Lesions recurred in three of 12 children with low-grade astrocytomas, two of eight children with gangliogliomas, one child with an anaplastic astrocytoma, one child with a ganglioglioneurocytoma, and one child with a glioblastoma multiforme. At follow-up review, most of these children were doing well. Sixteen are in functional Grades I or II and 18 children attend a normal school system. The authors conclude that surgery for the removal of IMSCTs in children less than 3 years of age can be performed radically and safely. The postoperative functional performance is determined by the degree of the preoperative deficit. It is, therefore, of utmost importance to diagnose and treat these children as early as possible. Spinal cord tumors should be recognized as potentially excisable lesions on their initial presentation and when they recur. The optimum treatment for malignant lesions is still to be determined.
Herniated discs at the L1-L2 or L2-L3 level are different entities from those at lower levels of the lumbar spine. The surgical outcome in terms of postoperative back and radicular pain is worse for herniated discs at L1-L2 and L2-L3 compared with those treated at L3-L4. Our patients with L1-L2 or L2-L3 surgically treated herniated discs were more likely to have had previous lumbar surgery and required a fusion more often than their counterparts with L3-L4 herniated discs.
Multilevel laminectomy and instrumentation with lateral mass plates is associated with minimal morbidity, provides excellent decompression of the spinal cord (as visualized on MRI), produces immediate stability of the cervical spine, prevents kyphotic deformity, and precludes further development of spondylosis at fused levels. Neurological outcome is equal or superior to multilevel anterior procedures and prevents spinal deformity associated with laminoplasty or noninstrumented laminectomy.
Percutaneous pedicle screw placement with the O-arm Multidimensional Intraoperative Imaging System is a safe and effective technique and provided improved overall accuracy and reduced operative time compared with conventional fluoroscopic techniques.
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