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Biomedical subjects

J M Cotler

Publications and source records attributed to J M Cotler.

At least 19 recordsLinked to original sources
PubMed1992

Value of polydirectional tomography in the assessment of the postoperative spine after anterior decompression and vertebral body autografting.

With the growing number of orthopedic reconstructive spinal procedures, the use of bone grafting has steadily increased in the past decade. An understanding of the biology of bone grafting is essential for both the clinician and radiologist. Despite the advent of computed tomography and magnetic resonance imaging, conventional polydirectional tomography remains an important tool in the evaluation of vertebral body autografts. Trispiral or hypocycloidal tomography plays a valuable role in the assessment of bone graft fusion and possible complications, especially in the presence of metallic fixation devices. We present our imaging experience derived from 375 patients with cervical, thoracic, or lumbar anterior spinal fusion. True graft complications occurred in 27 patients (7%) and consisted of fracture (4%), malpositioning (3%), and infection (less than 1%).

Adult↗
PubMed1992

Noncontiguous injuries of the spine.

A total of 372 consecutive spinal injury patients were evaluated at the Regional Spinal Cord Injury Center of Delaware Valley. Of these, 39 patients (10.5%) were found to have noncontiguous spinal column injuries. Fewer than half of the patients in our series could be classified into previous classification systems (Calenoff, Gupta) of noncontiguous spinal fractures. Fifteen fractures in 12 patients were missed on presentation on admission and 25% of these patients had a progressive neurologic deficit as a result of improper initial immobilization. The location of missed fractures were found to be primarily at the extremes or junctures of the spine (i.e., cervicothoracic, thoracolumbar). Complete spinal roentgenographic evaluation is recommended in the workup of suspected spinal column injury patients, and additional imaging modalities (i.e., tomograms, computed tomography scans, and magnetic resonance imaging) may be necessary in those areas of the spine difficult to visualize.

Adolescent↗
PubMed1991

Intervertebral disc injury complicating cervical spine trauma.

The incidence of acute herniated nucleus pulposus was determined in 55 patients with cervical spine trauma. A standardized protocol and a 1.5-T magnetic resonance image scanner was used to document a 42% incidence of acute herniated nucleus pulposus in patients studied within 72 hours of injury. The incidence of herniated nucleus pulposus was correlated with the patients' presenting neurologic status and mechanism of injury. The incidence of herniated nucleus pulposus was highest in patients with bilateral facet dislocations (80%) and anterior cord syndromes (100%). There was no statistically significant correlation between the incidence of herniated nucleus pulposus and patients' age or sex.

Adult↗
PubMed1991

Gastrointestinal complications in spinal cord injury.

Fifty-nine patients were identified with 70 gastrointestinal tract complications from a review of 950 spinal cord injury patients admitted during a 10-year period (prevalence 6.2%). When compared to a random spinal-cord-injured noncomplication control group (N = 31 patients), there was no difference in the percentage of low-dose steroids (dexamethasone 40 mg/day) given or in the percentage of patients receiving ulcer prophylaxis. All but two patients in the complication group received ulcer prophylaxis. Although an increase in the percentage of cervical and complete lesions was seen in the bleeding complications group, this increase was not statistically significant. The low complication rate (6.2%) seen in this study probably reflects the global use of ulcer prophylaxis and heightened awareness at a regional spinal cord injury center.

Female↗
PubMed1991

Differentiation between spinal tumors and infections with magnetic resonance imaging.

Distinction between spinal tumors and infections is a frequent clinical dilemma. To assess the accuracy of magnetic resonance imaging in distinguishing between spinal tumors and spinal infections, 30 patients with proven spinal tumors or infections were studied. Magnetic resonance imaging correctly diagnosed spinal tumors and infections in 29 of 30 cases (97%): 21 of 22 tumors were correctly diagnosed, and 8 of 8 infections were correctly diagnosed. The following points were learned: 1) The most consistent finding of vertebral osteomyelitis was the involvement of the disc space and adjacent vertebral body with decreased signal intensity on the T1-weighted images and increased signal intensity on the T2-weighted images. On the contrary, the disc spaces in tumor cases were uninvolved and demonstrated normal intensities on both T1- and T2-weighted images. 2) Loss of definition of the vertebral endplate was more common with infection than with tumor. 3) Contiguous vertebral involvement was seen more frequently in infections than in tumors. 4) Soft tissue changes were quite helpful: fat planes were obscured diffusely due to edema in infection, whereas fat planes were frequently intact, or obscured only focally, in tumors. 5) Cord compression was accurately diagnosed by magnetic resonance imaging in both tumors and infections. Magnetic resonance imaging was found to be superior to other imaging modalities in its ability to detect tumors or infections early and in providing information on the bone, disc, soft tissue, and neural structures.

Adult↗
PubMed1991

Low lumbar burst fractures. Comparison among body cast, Harrington rod, Luque rod, and Steffee plate.

Burst fracture of the low lumbar spine are rare and have not been well delineated in the literature. Thirty-one low lumbar burst fractures (L3-L5) were treated from 1981 through 1989. Average follow-up for 27 of the 31 patients was 46 months. Persistent complaints of back pain seemed to be found more in patients with long instrumentation and fusion and in patients with loss of lordosis. Conservative treatment of low lumbar burst fractures with body cast is a viable option in the neurologically intact patients with minimal height loss and minor angulation. If surgery is chosen, short rigid instrumentation (eg, transpedicular device) is best in accomplishing shorter fusion, maintaining vertebral height, and restoring lumbar lordosis. Harrington distraction rods improve vertebral height but produce loss of lumbar lordosis. Luque rods do not restore vertebral height and are only moderately effective in restoring lumbar lordosis. If patients are neurologically impaired in association with low lumbar burst fractures, posterior decompression by laminotomy or a transpedicular approach is generally effective. Maintaining vertebral height and restoring lumbar lordosis may be important in the prevention of disability from back pain.

Back Pain↗
PubMed1990

The medical and economic impact of closed cervical spine dislocations.

The current study examined the medical and economic impact of various treatment modalities of unstable cervical spine dislocations. Thirty-five patients with dislocations of the cervical spine were reviewed retrospectively from two large university hospitals. There were 23 unilateral and 12 bilateral facet dislocations. Fourteen patients were treated nonoperatively and 21 patients were treated with early surgery. Nine of the 14 patients treated nonoperatively redisplaced their dislocations while in an orthosis and required late surgery. Analysis of variance shows that it is the amount of injury (unilateral versus bilateral) that results in statistically significant difference in the injury severity score, Glasgow coma scale, trauma motor index, and the number of complications. Of the treatment groups (operative versus nonoperative), the operative group showed a statistically significant difference in the length of hospital stay. Also noted in the operative group was less traction time, earlier erect physical therapy, an average financial savings of $18,407.00, and equal morbidity or mortality to the nonoperative treatment group. Based on this limited experience, it would appear that "diagnosis related groups" are not capable of supporting traumatic spinal care and, if adopted by other states and third party payers, the concept of trauma and/or spinal cord injury centers may be in jeopardy.

Adult↗
PubMed1990

Gunshot wounds to the cervical spine.

A retrospective review was performed on 28 patients with low-velocity gunshot wounds to the cervical spine. These composed 31% of all spinal gunshot wounds seen during the study period between 1979 and 1988. Surgical decompression did not seem to improve neurologic recovery in either the incomplete or complete patients. Neurologic recovery also appeared to be unaffected by the presence of retained intracanal bullet fragments. The authors found no advantage to routine neck exploration of this penetrating injury. Complications were seen in 93% of the patients. Most complications were thromboembolic, pulmonary, and urinary tract infections. No cases of instability occurred as a direct result of the gunshot wound. No deaths occurred in this series. Two cases of posttraumatic syrinxes were diagnosed. The authors' current treatment recommendations for these patients include selective wound management and observation of retained intracanal bullet fragments in patients with complete lesions. Surgical decompression after this injury is not recommended.

Adolescent↗
PubMed1990

Immediate closed reduction of cervical spine dislocations using traction.

Cervical facet dislocations may be reduced rapidly and effectively using axial traction with weights applied at over the traditional 45-pound limit. Fifty-three sequential patients with cervical facet dislocations were reviewed. Thirty-nine patients required more than 50 pounds of traction to achieve rapid reduction. Sixty-eight percent of the entire series showed significant improvement in neurologic function. There were no cases of significant loss of function. A cadaver study confirmed that the cranial tongs could support over 100 pounds of traction. Careful application of up to 100 pounds seems to be associated with a low risk of neurologic compromise or tong failure, but results in effective reduction of dislocations.

Aged↗
PubMed1990

Spinal cord injury: a ten-year report.

In the past 10 years, the RSCICDV has had a unique opportunity to serve and expand the bounds of knowledge regarding this most devastating injury. The RSCICDV has collaborated with other model SCI systems in research regarding the incidence of respiratory complications, the value of removing bullet fragments lodged within the spinal canal, the survival/cause of death following spinal cord injury, the cost of spinal cord injury care, and the recovery of motor strength after quadriplegia. Key on-site research efforts have focused on preventing deep vein thrombosis and in documenting the course of motor recovery after spinal cord injury. The identification of electrical stimulation plus low dose heparin as a prophylaxis has been a major breakthrough in the prevention of deep vein thrombosis. The documentation of motor recovery after injury has led to the designation of Thomas Jefferson University as a federally-funded National Rehabilitation Research and Training Center in Neural Recovery and Functional Enhancement (1988-1993). It cannot be stressed enough, however, that the accomplishments of the Regional Spinal Cord Injury Center of Delaware Valley would have been quite impossible without the cooperation and support of the many physicians who have referred their patients to this regional center program. Continuing and expanding this cooperative effort should result in even greater achievements for persons with spinal cord injury in the years to come.

Accidental Falls↗
PubMed1987

Biomechanical analysis of cervical distraction.

A biomechanical analysis of cervical distraction is presented, and a model comparing closed reduction of cervical spine dislocations to spring mechanics is developed. Behavior of a spring may be described as F = k delta x where F = distraction force; delta x = elongation of the spring; and k = spring constant. The records and roentgenograms of 24 cervical spine dislocations were reviewed retrospectively. Evaluation of cervical distraction vs traction weight indicates that Ftraction = kneck delta x; where F = traction weight and x = distraction at the injured level. The constant, kneck, is different for bilateral and unilateral dislocations (P less than .001) and is a function of magnitude of injury and neck morphology. As determined in this study, traction weight needed for reduction of facet dislocations may be estimated using the formulae: Ftx = 107.1 lbs/cm (x) unilateral, and Ftx = 76.4 lbs/cm (x) bilateral.

Adult↗
PubMed1987

Closed reduction of cervical spine dislocations.

Between July 1979 and July 1983, 24 patients with cervical facet dislocations were treated. There were 11 unilateral and 13 bilateral facet dislocations. The treatment consisted of axial skeletal tractions, Stryker frame, Gardner-Wells tongs, and judicious manipulation. Cadaver studies were important for learning the anatomy and principles of cervical manipulation. Seventeen (71%) of the 24 patients were reduced successfully by a closed method without any progression of neurologic deficit or facet fracture. Seven (29%) of the 24 patients could not be reduced closed. Ninety percent (9 of 10) of incomplete spinal cord injuries improved when evaluated by the Frankel classification at least one grade. The program of treatment proved to be safe and effective in achieving closed reduction of either unilateral or bilateral facet dislocations.

Adolescent↗
PubMed1986

The use of Harrington rods in thoracolumbar fractures.

It would appear that in carefully preselected circumstances, dual Harrington distraction rods may be successfully utilized in a large percentage of thoracolumbar fractures. Mechanistic classification of these fractures offers insight into the extent of soft-tissue disruption. As the circumferential soft-tissue damage increases, the degree of spinal stability obtained with distraction fixation decreases. This is especially true when considering the anterior longitudinal ligament. In compression flexion and vertical compression, the anterior structures are predominantly intact, and thus distraction fixation offers excellent stability. Utmost care must be offered to hook placement and stability, particularly in the proximal area. In the torsional flexion and lateral flexion groups, complex mechanisms of soft-tissue disruption require special consideration when distraction rods are to be employed. Likewise, analysis of soft-tissue and bony disruption in the distractive extension, distractive flexion, and translation injury groups suggests that serious consideration be given to spinal stability prior to the routine use of distraction rods in these patients. Surgically, the posterior approach does not preclude removal of bony fragments from the canal, either by rod distraction and reduction alone or via canal exploration. Below L1, laminectomy with direct access to the fragments is possible. Above L1, pedicle resection and costotransversectomy have been eminently successful procedures in fractures less than 3 weeks old. None of these surgical procedures preclude a subsequent anterior approach if necessary. In no instance was a patient neurally damaged in our series by this surgical protocol. We are loath to allow only internal support during the fusion maturation period and strongly urge external support during this phase. Removal of the rods prior to solid fusion is to be discouraged, as this may predispose to persistent pain and return of deformity. CT scan appears to represent an essential tool preoperatively and postoperatively, particularly in complete neural lesions. We have gleaned some presumptive evidence relative to posterior superior body fragment position, pedicle integrity and position, and possible posterior longitudinal ligament integrity. With the information available through radiographs and CT, we are in the process of attempting to determine prospectively where posterior distraction rods alone may suffice. Thus, we would hope to circumvent the concomitant need for laminotomy, pedicle resection and fragment removal, or reduction or anterior corpectomy. It is hoped that this information will be available soon.

Adolescent↗
PubMed1985

The use of autografts for vertebral body replacement of the thoracic and lumbar spine.

Thirty-seven patients with fractures of the thoracic or lumbar spine underwent anterior corpectomy (partial or complete) and vertebral body replacement for either destructive lesions from tumor or infection (13 patients) or trauma (24 patients). The vertebral bodies were replaced using either rib (12 patients) or tricortical iliac crest (25 patients) autografts. The Dunn device was utilized in conjunction with the autografts in 19 patients. Posterior stabilization was used in five patients; three prior to anterior stabilization and two after anterior stabilization. Within 2 weeks of the operative procedure, all patients began walking or sitting. Of the 37 patients, 21 with incomplete neurologic deficits improved, and 10 of those went onto complete recovery. Of the 27 patients who have been followed for a minimum of 1 year, 25 have obtained solid fusions, one developed a pseudarthrosis that required regrafting, and one had a delayed union prior to death from metastatic disease. There were two deaths in the immediate postoperative period and three deaths in the first six postoperative wounds due to metastatic disease. The purpose of this study is to present a consecutive series of patients who have undergone corpectomy and vertebral body replacement as well as to define the adequacy of stabilization.

Adolescent↗
PubMed1985

Management of lumbar translocation injuries: case reports.

Lumbar translocation (complete lumbar dislocation) injuries constitute a severe and highly unstable form of thoraco-lumbar spinal injury and are uncommon. Adequate management of such injuries includes removing the neural tissue compression and realigning and stabilizing the spine. Computerized axial tomographic scans of the spine are very dramatic in demonstrating encroachment on the spinal canal by bony fragments. We report two cases of lumbar translocation injuries with favorable outcomes. The patients were initially managed with halo-femoral traction, resulting in spinal reduction and eliminating the need for acute surgical intervention, and subsequently underwent posterior fusion for stability. Anterior decompression was done at a later date as computed tomography showed retropulsed intracanalicular bone fragments. The use of Harrington rod instrumentation and realignment of the spine did not free the canal of bony fragments and, hence, decompression was required.

Adolescent↗