Biomedical subjects

C A Dickman

Publications and source records attributed to C A Dickman.

At least 19 recordsLinked to original sources

PubMed1996

Threaded steinmann pin fusion of the craniovertebral junction.

STUDY DESIGN: In a clinical retrospective study, the authors review long-term results of occipitocervical fusion using a wide diameter, contoured, threaded Steinmann pin. OBJECTIVES: To evaluate the clinical and radiographic results of occipitocervical fusion using this technique in a variety of abnormalities including rheumatoid arthritis. SUMMARY OF BACKGROUND DATA. The various surgical techniques and hardware developed for occipitocervical fusion have been associated with mixed results, particularly in patients with rheumatoid arthritis or basilar invagination. METHODS: Thirty-nine patients with occipitocervical instability were internally fixed with a wide diameter, contoured, threaded Steinmann pin wired to the occiput and cervical laminae or facets. Fusion was facilitated using autologous iliac crest bone graft and a cervical orthosis. Instability resulted from rheumatoid arthritis (n = 12), congenital anomalies (n = 12), trauma (n = 10), tumor (n = 4), or osteogenesis imperfecta (n = 1). Fifteen patients had radiographic evidence of basilar invagination. Long-term outcome (mean follow-up period, 38.9 months; range, 12-78 months) was based on clinical and radiographic review. RESULTS: Thirty-seven patients (97%) had a stable postoperative occipitocervical construct: there were 35 osseous unions, two fibrous unions, and one nonunion. There was on postoperative death from pulmonary complications. No patient developed evidence of new, recurrent, or progressive basilar invagination. CONCLUSION: The authors concluded that rigid segmental fixation of the craniovertebral junction using a wide diameter, contoured, threaded Steinmann pin and supplemental autograft creates excellent fusion with minimal complications. This technique is appropriate for a variety of abnormalities including rheumatoid arthritis.

Adolescent↗

PubMed1996

Injuries involving the transverse atlantal ligament: classification and treatment guidelines based upon experience with 39 injuries.

Comprehensive anatomic and clinical analyses of 39 patients with injuries involving the transverse atlantal ligament or its osseous insertions were performed to assess the morphology of the injured ligaments and the patients' capacity to heal. Injuries of the upper cervical spine were screened with plain radiographs, thin-section computed tomography, and magnetic resonance imaging studies. The injuries were classified as disruptions of the substance of the ligament (Type I injuries, n = 16) or as fractures and avulsions involving the tubercle for insertion of the transverse ligament on the C1 lateral mass (Type II injuries, n = 23). These two types of injuries had distinctly different clinical characteristics that were useful for determining treatment. Type I injuries were incapable of healing satisfactorily without internal fixation; they should be treated with early surgery. Type II injuries, which rendered the transverse ligament physiologically incompetent even though the ligament substance was not torn, should be treated initially with a rigid cervical orthosis, because they had a 74% success rate nonoperatively. Surgery should be reserved for patients with Type II injuries that have nonunion with persistent instability after 3 to 4 months of immobilization. Type II injuries had a 26% rate of failure of immobilization; therefore, close monitoring is needed to detect patients who will require delayed operative intervention.

Adolescent↗

PubMed1996

Thoracic vertebrectomy and reconstruction using a microsurgical thoracoscopic approach.

A video-assisted thoracoscopic microsurgical approach was developed in the laboratory and subsequently used clinically to resect abnormalities of the thoracic vertebrae, to decompress the thoracic spinal cord, and to reconstruct the thoracic vertebral bodies. This report describes the development of the clinical operative techniques for microsurgical thoracoscopic vertebrectomy, neural decompression, and spinal reconstruction. This minimally incisional approach was clinically used in 17 patients to treat vertebral osteomyelitis, tumors, and compression fractures. Microsurgical thoracoscopic techniques were performed using several narrow, flexible, working portals placed in small incisions in the intercostal spaces. Access to the thoracic spine was achieved through the pleural cavity after temporary deflation of one lung using a double-lumen endotracheal tube. The parietal pleura, segmental vessels, and rib heads were dissected off the surfaces of the involved vertebrae to expose the region of interest. Long narrow spine dissection tools were used to perform the spinal decommpression and reconstruction. This technique achieved the same amount of spinal dissection as that achieved with conventional open spinal procedures and used microsurgical visualization techniques. The small incisions with reduced soft tissue dissection may reduce postoperative pain, shorten the length of hospitalization, and have cosmetic and functional advantages. Thoracoscopic vertebrectomies and reconstruction of the spine were technically feasilble procedures that were performed with excellent clinical results. This minimally incisional technique provides a viable alternative to thoracotomy or to posterolateral approaches for thoracic vertebrectomy and vertebral body reconstruction.

Adult↗

PubMed1996

Multilevel anterior thoracic discectomies and anterior interbody fusion using a microsurgical thoracoscopic approach. Case report.

A video-assisted thoracoscopic microsurgical approach was performed to treat a myelopathic patient with a severe kyphotic deformity caused by chronic nonunion of compression fractures of the T7-9 vertebrae. The kyphotic deformity was treated by combined operative procedures. First, an anterior release was performed using a thoracoscopic technique, sectioning the anterior longitudinal ligament and performing multilevel thoracic discectomies. Next, a posterior reduction and internal fixation of the deformity was achieved using hook-rod instrumentation. Finally, bone graft harvested during the posterior approach was used for interbody fusion via a thoracoscopic approach. Microsurgical thoracoscopic techniques potentially can be used in a variety of spinal surgeries. Compared to transthoracic and posterolateral approaches, this technique presents distinct advantages to treatment of anterior spinal pathology. The small incisions made into the intercostal spaces without retracting the ribs may reduce postoperative pain, shorten the length of hospitalization, and allow early return to activity. The operative techniques used in this case are described in detail. This report demonstrates that thoracoscopic discectomies and interbody fusion are technically feasible and can be effectively performed with acceptable results.

Adolescent↗

PubMed1996

Radiographic and clinical follow-up review of Caspar plates in 49 patients.

Although they are excellent clinical tools, Caspar anterior cervical plates have not been studied closely with regard to their mechanisms of failure. As more extensive operations are contemplated on older, sicker patients, it is imperative to know when a plating system might be prone to failure and what the mechanism of that failure might be. Therefore, the authors reviewed 49 patients undergoing Caspar plate placement in whom sufficient radiographs were obtained to determine if the fate of the hardware was related to the patient's age, type of operation, and the length of construct. Eleven of 49 patients suffered hardware failure, defined as any amount of screw backout or breakage, plate pullout, or pseudarthrosis. Four patients underwent hardware removal; one underwent posterior fusion for pseudarthrosis. Only two required treatment in a halo brace. There was an eventual fusion rate of 100%, including one fibrous union, and one of the patients who underwent repeat surgery was lost to follow-up review. No graft extrusions or new neurological deficits were incurred as a result of hardware failure. Plate length predicted plate failure in a statistically significant manner. Increasing age and reoperation correlated with plate failure but were not statistically significant in this small number of patients. Telescoping of the bone graft and vertebral bodies, with concomitant migration of the plate and slippage of the screws, was common. However, telescoping was more profound in the group in which the plates failed. The authors conclude that Caspar plate failures are more likely to occur in the elderly and in patients who need longer constructs. Bone fusion can be expected even when the hardware loosens.

Adult↗

PubMed1996

The anatomical suitability of the C1-2 complex for transarticular screw fixation.

Posterior transarticular screw fixation of the C1-2 complex has become an accepted method of rigid internal fixation for patients requiring posterior C1-2 fusion. The principal limitation of this procedure is the location of the vertebral artery, because an anomalous position may prohibit screw placement. In this study, a consecutive series of computerized tomography (CT) scans was reviewed, and the suitability of each patient for transarticular screw fixation was evaluated. All of the fine-slice axial C1-2 CT scans and reconstructions performed on a spiral scanner over 2 years were reviewed. A novel screw trajectory reconstruction was designed to visualize the potential path of a transarticular screw in the plane of the reconstruction. Scans were reviewed for bone anatomy and the position of the transverse foramen. Seventeen (18%) of 94 patients had a high-riding transverse foramen on at least one side of the C-2 vertebra that would prohibit the placement of transarticular screws. The left side was involved in nine patients and the right in five. Three patients had bilateral anomalies. The mean age of the group with anomalies (35.9 years, range 10-76) was not significantly different from the overall mean age (35.7 years, range 6-94). An additional five patients (5%) were considered to have anatomy in which screw placement was feasible but risky. On the basis of these data, it is postulated that 18% to 23% of patients may not be suitable candidates for posterior C1-2 transarticular screw fixation on at least one side.

Adolescent↗

PubMed1996

Biomechanical characteristics of C1-2 cable fixations.

The biomechanical characteristics of four different methods of C1-2 cable fixation were studied to assess the effectiveness of each technique in restoring atlantoaxial stability. Biomechanical testing was performed on the upper cervical spines of four human cadaveric specimens. Physiological range loading was applied to the atlantoaxial specimens and three-dimensional motion was analyzed with stereophotogrammetry. The load-deformation relationships and kinematics were measured, including the stiffness, the angular ranges of motion, the linear ranges of motion, and the axes of rotation. Specimens were nondestructively tested in the intact state, after surgical destabilization, and after each of four different methods of cable fixation. Cable fixation techniques included the interspinous technique, the Brooks technique, and two variants of the Gallie technique. All specimens were tested immediately after fixation and again after the specimen was fatigued with 6000 cycles of physiological range torsional loading. All four cable fixation methods were moderately flexible immediately; the different cable fixations allowed between 5 degrees and 40 degrees of rotational motion and between 0.6 and 7 mm of translational motion to occur at C1-2. The Brooks and interspinous methods controlled C1-2 motion significantly better than both of the Gallie techniques. The motion allowed by one of the Gallie techniques did not differ significantly from the motion of the unfixed destabilized specimens. All cable fixation techniques loosened after cyclic loading and demonstrated significant increases in C1-2 rotational and translational motions. The bone grafts shifted during cyclic loading, which reduced the effectiveness of the fixation. The locations of the axes of rotation, which were unconstrained and mobile in the destabilized specimens, became altered with cable fixation. The C1-2 cables constrained motion by shifting the axes of rotation so that C-1 rotated around the fixed cable and graft site. After the specimen was fatigued, the axes of rotation became more widely dispersed but were usually still localized near the cable and graft site. Adequate healing requires satisfactory control of C1-2 motion. Therefore, some adjunctive fixation is advocated to supplement the control of motion after C1-2 cable fixation (that is, a cervical collar, a halo brace, or rigid internal fixation with transarticular screws).

Aged↗

PubMed1996

Thoracic disc.

Explore the source record for details and available documents.

Humans↗

PubMed1996

Comparison of initial injury features in cervical spine trauma of C3-C7: predictive outcome with halo-vest management.

The purpose of this retrospective study was to examine specific patient variables and fracture morphologies to further elucidate the predictors of successful halo-vest treatment for cervical spine fractures (C3-C7). Eighty-seven cases of acute cervical spine injuries treated with halo-vest management were reviewed to assess initial injury features and radiographic outcomes by measuring (a) subluxation and direction, (b) angulation, (c) facet abnormalities, and (d) vertebral body fracture patterns on plain radiographs and computed tomography scans. The cases were divided into three groups: facet subluxations with fractures, facet subluxation without fractures, and fractures with no subluxation. Patients with facet subluxation and advance-staged compression-flexion fractures (stages 4 or 5) were a distinct group when treated conservatively with a halo. Despite anatomic reduction, facet subluxations associated with advance-staged compression-flexion fractures (stages 4-5), might be best treated surgically. Risk factors for late halo failure should include subluxations with advance-staged compression-flexion fractures when treated conservatively.

Adolescent↗

PubMed1995

An apparatus for applying pure nonconstraining moments to spine segments in vitro.

STUDY DESIGN: This article reports on the design and use of a new apparatus for creating and monitoring pure, relatively nonconstraining moments to induce flexion/extension, lateral bending, and axial rotation in cadaveric spine segments of two or more vertebrae. OBJECTIVE: The apparatus was designed to take advantage of the precision and control available in a servo-hydraulic testing frame to efficiently create and monitor testing moments. SUMMARY OF BACKGROUND DATA: Other laboratories have reported methods of flexibility testing that also use cables and pulleys. However, instead of loading the cables and pulleys using a mechanical testing frame, previous systems have used pneumatic actuators or dead weights. METHODS: Force from a uniaxial mechanical testing frame is converted to torque applied to the specimen through a system of cables and pulleys. The cable orientation is monitored to ensure that pure moments are created. Applied moments are recorded using one or two load cells. RESULTS: Sketches of the apparatus are presented and its operation is described. CONCLUSION: Because the materials required to build this apparatus are inexpensive and the equipment needed for its operation is common in mechanical testing labs, this design may be useful for researchers interested in beginning in vitro spine flexibility testing with minimal expenditure.

Biomechanical Phenomena↗

PubMed1995

Comparative anatomy of the baboon and the human cervical spine.

STUDY DESIGN: The anatomy of baboon and human cervical spines were compared by measuring adult, cadaveric specimens. OBJECTIVE: The objective of the study was to compare human and baboon cervical motion segments to determine whether the baboon provides a suitable model for spinal research. SUMMARY OF BACKGROUND DATA: Several studies have examined the quantitative anatomy of the human cervical bones and ligaments. Several animal species have been used for cervical spine research; however, no studies have validated whether the animal models resemble the human cervical spine closely enough to provide generalizable data. METHODS: Multiple morphologic parameters were measured directly from nine baboon and six human adult cadaveric cervical spine specimens. The bone structure and geometry of each of the seven cervical vertebrae were analyzed; the structure and histology of the ligaments were measured; and histomorphometry of the vertebrae was performed. RESULTS: The architectural composition and geometry of individual cervical vertebrae of baboons and humans were similar at each level. The proportional relationship of bone and ligament structures in the two species was almost identical. There were, however, several differences: 1) The baboon spine was about half the size of the human spine; 2) its vertebral arteries were encased fully within the C1 lateral mass; 3) its uncovertebral joints were more prominent; 4) its vertebral endplates were more concave; 5) its pedicles were thinner; 6) its transverse processes were longer; and 7) its spinous processes were horizontal and nonbifid. CONCLUSIONS: The geometry and anatomy of the baboon cervical spine closely resemble that of the human cervical spine. It therefore provides an excellent model for in vivo and in vitro research.

Adult↗

PubMed1995

Anterior communicating artery aneurysm paraparesis syndrome: clinical manifestations and pathologic correlates.

OBJECTIVE: Clinicopathologic evaluation of patients with lower extremity paraparesis/-plegia following rupture and repair of anterior communicating artery (ACoA) aneurysms. DESIGN: Institution-based retrospective review. SETTING: A tertiary neurologic referral center. PATIENTS, PARTICIPANTS: Seven of 101 patients with subarachnoid hemorrhage from ruptured ACoA aneurysms treated between January 1987 and December 1992. MAIN OUTCOME MEASURES: Neurologic status at latest follow-up examination. RESULTS: All patients presented with severe hemorrhage, poor clinical grade, and intracranial hypertension. Motor deficits developed within 7 days of aneurysm rupture and persisted for a mean duration of 39 days. Angiographic evidence of vasospasm in the anterior cerebral artery (ACA) distribution was documented in all cases, and paraparesis persisted beyond the angiographic resolution of vasospasm. All patients had evidence of frontal lobe dysfunction throughout their postoperative courses, and deep venous thrombosis and pulmonary emboli were common causes of morbidity and mortality. Autopsy data supported regional microvascular ischemia within the ACA distribution as the etiology of these motor deficits. CONCLUSIONS: The combination of vasospasm in the ACA distribution and lower extremity weakness associated with cognitive and affective impairment that resolves with time is common in patients with ACoA aneurysms. We propose that this constellation of clinical, radiographic, and pathologic findings be referred to as the "ACoA aneurysm paraparesis syndrome."

Aged↗

PubMed1995

Biomechanical effects of transoral odontoidectomy.

The acute biomechanical effects of transoral odontoidectomy were studied by using qualitative and quantitative methods to assess atlantoaxial motion. In vitro biomechanical testing was performed on the upper cervical spines of eight baboon and five human cadaveric specimens. Using an unconstrained testing apparatus, we performed a flexibility method of testing. Physiological range loading was applied to atlantoaxial specimens, and three-dimensional motion was analyzed with stereophotogrammetry. Force-deformation relationships were delineated in intact specimens and again after surgical removal of the anterior C1 arch, odontoid process, and transverse atlantal ligament. We studied the total range of rotational and linear motions, the behavior of the neutral zone and elastic zone, the flexibility coefficients, and the instantaneous axes of rotation during flexion, extension, bilateral lateral bending, and bilateral axial rotation. Odontoidectomy produced several distinct alterations in motion and in force-deformation responses at C1-C2 that were almost identical in the baboon and human specimens. After odontoidectomy, the atlas developed significantly increased translational movements, which were most prominent in the anteroposterior direction. The total angular range of motion increased significantly during flexion, extension, and lateral bending but not during axial rotation. When the total range of motion was altered, the neutral zone was affected selectively and the elastic zone was spared. Surgery produced mobile, widely spread, unconstrained instantaneous axes of rotation that were in a constrained, fixed position in intact specimens. Clinically, transoral odontoidectomy may predispose patients to spinal instability. Even if acute spinal instability is not apparent, the patients may be susceptible to the delayed effects of the surgery because of the altered anatomy and biomechanical responses.

Aged↗

PubMed1995

Surgical management of spinal epidural hematoma: relationship between surgical timing and neurological outcome.

Thirty patients were treated surgically for spinal epidural hematoma (SEH). Twelve of these cases resulted from spinal surgery, seven from epidural catheters, four from vascular lesions, three from anticoagulation medications, two from trauma, and two from spontaneous causes. Pain was the predominant initial symptom, and all patients developed neurological deficits. Eight patients had complete motor and sensory loss (Frankel Grade A); six had complete motor loss but some sensation preserved (Frankel Grade B); and 16 had incomplete loss of motor function (10 patients Frankel Grade C and six patients Frankel Grade D). The average interval from onset of initial symptom to maximum neurological deficit was 13 hours, and the average interval from onset of symptom to surgery was 23 hours. Surgical evacuation of the hematoma was performed in all patients; 26 of these improved; four remained unchanged, and no patients worsened (mean follow up 11 months). Complete recovery (Frankel Grade E) was observed in 43% of the patients and functional recovery (Frankel Grades D or E) was observed in 87%. One postoperative death occurred from a pulmonary embolus (surgical mortality 3%). Preoperative neurological status correlated with outcome; 83% of Frankel Grade D patients recovered completely compared to 25% of Frankel Grade A patients. The rapidity of surgical intervention also correlated with outcome; greater neurological recovery occurred as the interval from symptom onset to surgery decreased. Patients taken to surgery within 12 hours had better neurological outcomes than patients with identical preoperative Frankel grades whose surgery was delayed beyond 12 hours. This large series of SEH demonstrates that rapid diagnosis and emergency surgical treatment maximize neurological recovery. However, patients with complete neurological lesions or long-standing compression can improve substantially with surgery.

Adolescent↗

PubMed1995

Surgical management of atlantoaxial nonunions.

Sixteen patients referred for atlantoaxial fixation failures were treated surgically with revision procedures during the past decade. Of these 16 patients, atlantoaxial instability occurred because of rheumatoid arthritis in five, as odontoideum in seven, transverse ligament disruption in two, and odontoid fracture nonunion in two. The 16 individuals (10 men, six women; mean age 43.7 years; age range 20-77 years) had undergone a total of 20 C1-2 internal fixation procedures that failed. Surgical strategies for definitive revision of the nonunions in these 16 subjects included 10 rigid internal fixations with transarticular screws, three revised C1-2 fixations with autogenous bone struts and wire or cables, and three extended fixations with occipitocervical instrumentation. Autogenous grafts were used in all revisions. A postoperative halo brace was used in five individuals with osteoporotic bone; all patients wore a restrictive postoperative cervical orthosis. Postoperatively, 15 patients (94%) had a stable construct (mean follow up 35 months; range 12-79 months), which included 13 osseous unions and two stable fibrous unions. One patient had nonunion; he fractured his anterior C1-2 transarticular screws 2 years postoperatively. He had occipital radicular pain without myelopathy but refused further surgery. Atlantoaxial pseudarthroses were effectively treated by addressing the pathological, biomechanical, and technical reasons for failed fusion. Successful fusion after reoperation was improved by using autologous bone grafts, adequately controlling atlantoaxial motion (with rigid transarticular screws internally or externally with a halo vest), compressing the bone grafts between the arches of C-1 and C-2 with wire cables, meticulously preparing the fusion bed, and by optimizing the pharmacological and clinical parameters to promote bone healing.

Adult↗

PubMed1995

Cannulated screws for odontoid screw fixation and atlantoaxial transarticular screw fixation. Technical note.

Cannulated screw systems use thin Kirschner wires (K-wires) that have been drilled into the bone to direct screw trajectories accurately into small bone fragments. Use of the K-wires avoids overdrilling the pilot holes and allows fixation of adjacent bone fragments during screw insertion. Hollow tools and hollow screws are inserted into the bone over the K-wires. Cannulated screw fixation is useful in the cervical spine to stabilize odontoid fractures and to treat atlantoaxial instability. This report describes techniques for successful cannulated screw insertion and methods to minimize complications. Cannulated screws have several distinct advantages compared to noncannulated screws: 1) the K-wires guide the screw position into the bone; 2) the K-wire trajectory can be repositioned easily if the original trajectory was not ideal; 3) the K-wires allow continuous fixation of adjacent unstable bone fragments; and 4) the K-wires prevent migration of unstable bone fragments during screw insertion. Complications associated with the K-wire (breakage, repositioning, and advancement) can be minimized using precise operative techniques, a specialized tool system, and intraoperative fluoroscopic monitoring. A unique cannulated screw tool system was developed specifically for upper cervical fixation to allow percutaneous drilling using long tunneling devices, tissue sheaths, drill guides, and long K-wires. These tools allow delivery of cannulated fracture-fixation screws at a low angle to the spine through long soft-tissue trajectories. Cannulated screws have significant advantages compared to noncannulated screws for fixation of the unstable cervical spine.

Bone Screws↗

PubMed1994

Morphology and kinematics of the baboon upper cervical spine. A model of the atlantoaxial complex.

STUDY DESIGN: Quantitative and qualitative analyses were performed to compare the anatomy and biomechanics of baboon and human upper cervical spines. OBJECTIVES: This study examined the baboon as a potential model for in vivo and in vitro atlantoaxial research. SUMMARY OF BACKGROUND DATA: A variety of animal models have been used for spine research; however, no species have been used for C1-C2 research. Most species have remarkably different C1-C2 morphology compared with that of humans. METHODS: Twenty baboon and seven human normal adult cadaveric upper cervical spines were studied morphologically. C1-C2 motion segments were analyzed biomechanically using a flexibility method of testing with physiologic range, nondestructive loading. Motion and load-deformation relationships were studied during flexion, extension, bilateral lateral bending, and bilateral axial rotation. RESULTS: The bones and ligaments of the baboon and human upper cervical vertebrae have similarly proportioned structures, identical individual components, and similar geometric configurations. The average size of the baboon vertebrae was 50% to 60% of the human specimens. There were several minor anatomical differences. Baboons had more horizontal C2-C3 facet joints and more vertical C1-C2 articular surfaces; the vertebral arteries were encased in a continuous bony canal in C1. Biomechanical testing demonstrated that baboons and humans had similarly proportioned neutral zones and elastic zones. Compared with humans, baboons had a 2 degrees to 9 degrees wider range of motion in all directions. CONCLUSIONS: The baboon and human upper cervical anatomy and biomechanics are similar. The baboon may be useful to study atlantoaxial biomechanics and pathology.

Adult↗

PubMed1994

Repair of vertebral artery injury during anterior cervical decompression.

METHODS: Vertebral artery injury is a rarely described complication of anterior cervical decompression. The authors performed a retrospective review of their operative database for the purposes of defining the optimal management of this complication and its avoidance. RESULTS: Four of 1,215 (0.3%) patients undergoing anterior cervical operation sustained arterial injuries. In three cases, primary repair of the artery was successful; in one case, the artery was exposed and ligated. There were no postoperative ischemic complications. Artery laceration occurred during decompression (n = 2), screw tapping (n = 1), and during soft tissue retraction (n = 1). CONCLUSIONS: Injury to the vertebral artery during anterior approaches can be avoided by preoperative identification of anomalous arteries and by intraoperative attention to the midline. When the artery is injured, primary repair may be the optimal management strategy.

Cervical Vertebrae↗