Proceedings of the NASS 20th Annual Meet

CONCLUSIONS: Distractive PLIF and posterior fixation in compressionis an efficient technique for decompression and stabilization, with an optimal98.3% fusion rate. The absence of degenerative lesions at the level abovethe instrumentation after long-term follow-up over 8 years in 96% ofthe patients gives evidence of the reliability of the semi-rigid system andevidence of efficiency of the transitional non-fused intervertebral zonecreated between the rigid fused segment and the hypersolicitated levelabove the instrumentation. Fusion with cages, restoration of lumbar lordosis,semi-rigid fixation for protection of pathological adjacent disc, and avoid-ance of postoperative corset collectively meet all the requirements not onlyfor pain relief but also for definitive stabilization without iatrogenic spinalcomplication or further adjacent degeneration.DISCLOSURES: FDA device/drug: ISOBAR TTL Semi-rigid system.Status: Investigational/not approved.CONFLICT OF INTEREST: Author (GP) Consultant: The author is thepromotor of the semi-rigid Isobar TTL System introduced by Scient’Xcompany, Paris, France.

doi: 10.1016/j.spinee.2005.05.178

6:06177. Wartime management of spinal cord and spinal columninjuries from IraqTimothy Kuklo, MD, Adam Groth, MA, MD, Christopher Neal,Michael Rosner, MD; Walter Reed Army Medical Center,Washington, DC, USA

BACKGROUND CONTEXT: Walter Reed Army Medical Center hasbeen a long standing tertiary center for soldiers returning to the UnitedStates from overseas conflicts.PURPOSE: To review the wartime management and medical evacuationof spinal column and spinal cord injuries from Operation Iraqi Freedomto Walter Reed Army Medical Center, the treatment algorithms, prognosisfor neurologic change, and ultimate outcome.STUDY DESIGN/SETTING: Walter Reed Army Medical Center, Wash-ington, DC.PATIENT SAMPLE: 4,042 medical evacuations to Walter Reed ArmyMedical Center, Washington, DC.OUTCOME MEASURES: A retrospective review of surgical versus non-surgical management, as well as evacuation level of surgical inter-vention, were also analyzed to determine outcome.METHODS: To date, there have been over 4,042 medical evacuations toWRAMC, of which 84 (80M, 4F, 48%) were considered to have a severespinal cord or column injury and were primarily evacuated from the theatre ofwar to WRAMC for definitive treatment. Thirty-six (42%) were secondaryto penetrating trauma. Mechanism of injury, associated injuries, initialneurologic status/injury evaluation, neurologic status on arrival toWRAMC, and final neurologic status were reviewed to determine func-tional outcomes.RESULTS: The average age was 28.6 years (range, 20–59), arriving atWRAMC at an average of 8.7 days � 5.6 days (range, 2–33) post-injury.Of these, there were 36 cervical (18 penetrating), 19 thoracic (6 penetrating),21 lumbar (8 penetrating) and 8 sacral (4 penetrating); with 37 multi-level (2–7 levels), and 6 non-contiguous injuries. 22 were complete or partial spinalcord injuries, one incomplete SCI which had neurologic deterioration duringmedical evacuation (penetrating GSW at L1), with 11 incomplete SCIdemonstrating some improvement. High-dose steroids were used sparingly(5 pts) due to timing and availability, and did not appear to affect outcome.63 were treated surgically, non-electively (7 revisions from combat hospitalor evacuation hospital), with improvement in neurologic status in 10 patients(1-level improvement in neurologic grade). There were 4 postoperativeinfections (6.3%) despite the high incidence of concomitant bacterial coloni-zation and/or infection of the extremity injuries.CONCLUSIONS: The present evacuation system satisfactorily cares forspinal cord and column injuries, as noted by the low incidence of neurologicdeterioration during evacuation (1/84 pts. —1.2%). Surgical managementappears to be best performed at the highest echelon of care (tertiary referral

Friday, September 30, 20056:00–7:00 PM

SIPP 3: Salvage

6:00176. Salvage posterolateral fusion for failed anterior interbodyfusion with titanium and bone cagesJames Reynolds, MD1*, Paul Slosar, Jr., MD2, Brian Steinke, MD3,Derek Snook, MD1, Jerome Schofferman, MD2; 1SpineCare MedicalGroup, Daly City, CA, USA; 2San Francisco Spine Institute, Daly City,CA, USA; 3Daly City, CA, USA

BACKGROUND CONTEXT: Some patients who undergo stand-aloneanterior lumbar interbody fusion (ALIF) with bone or titanium cages failto improve. One cause of clinical failure is pseudarthrosis, which may ormay not be apparent on radiographs. Posterolateral fusion (PLF) withtranspedicular instrumentation may be an effective salvage surgery forthese patients.PURPOSE: To assess the outcome on pain and function of salvage PLFpatients who failed to improve after stand-alone ALIF with bone or tita-nium cages.STUDY DESIGN/SETTING: Retrospective chart identification, prospec-tive data collection, and chart review in a tertiary care private practice.PATIENT SAMPLE: All patients in one practice who underwent PLFwith transpedicular instrumentation because of poor clinical response toALIF with bone or titanium cages.OUTCOME MEASURES: Pain was measured using an 11-point numeri-cal rating scale (NRS). Function was measured using the Oswestry LowBack Disability Index (OSI).METHODS: Salvage surgery included PLF with transpedicular instrumen-tation. Decompression and foraminotomy were performed when necessary.At the time of revision surgery, fusion status was determined by manu-ally stressing the spinal segments. Gross motion at the was used to indicatea pseudarthrosis. X-rays were reviewed blindly by two authors.RESULTS: There were 40 patients with failed ALIF with cages, 10 ofwhom were excluded due to inadequate data or short follow-up. There were13 men and 17 women. Mean age at revision was 42 years (26–71). Meanduration between ALIF and salvage surgery was 24 months (5–57). AnMDII bone prosthesis was used at 23 levels in 15 patients, BAK cageswere used at 21 levels in 13 patients, and Ray cages were used at 2 levels in2 patients. Mean duration of follow-up was 48 months (24–69). There waspseudarthrosis in 22 patients (73%) at 26 levels observed at surgery. TheNRS improved from a mean of 6.9 (3–10) before salvage surgery to amean of 4.5 (0–8) after surgery (p�.0001), and 16 (53%) improved by

ing / The Spine Journal 5 (2005) 1S–189S 91S

3 NRS points. The mean OSI improved from 58 (9–84) before salvagesurgery to a mean of 51 (0–89) after surgery (p�.02). There was poorcorrelation between radiographic appearance of fusion and outcome ofsalvage surgery. There was no difference in eventual outcome betweenbone dowel and titanium cages. 19/30 of patients underwent 22 subsequentprocedures including hardware removal (17), placement of spinal cordstimulators (3) or extension/revision of PLF (2).CONCLUSIONS: Stand-alone ALIF with bone or titanium cages is oftenused to treat discogenic low back pain. In patients who did not improve, weperformed salvage PLF with transpedicular instrumentation, and observedstatistically significant improvement in both pain and function. PreoperativeX-rays were not predictive of eventual outcome.DISCLOSURES: FDA device/drug: transpedicular instrumentation.Status: Approved for this indication.CONFLICT OF INTEREST: Author (JR) Consultant: Medtronic SofamorDanek; Author (JR) Grant Research Support: Medtronic Sofamor Danek.

doi: 10.1016/j.spinee.2005.05.179