Publications by authors named "Khalil Salame"

32 Publications

Resection of Benign Osseous Spine Tumors in Pediatric Patients by Minimally Invasive Techniques.

World Neurosurg 2021 Aug 21;152:e758-e764. Epub 2021 Jun 21.

Department of Neurosurgery, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Objective: Benign osseous tumors of the spine in children are a rare cause for surgery. The aim of this study is to describe our experience with resection of pediatric benign osseous spine tumors using a minimally invasive technique through a variety of surgical approaches.

Methods: A retrospective review of prospectively collected data of pediatric patients who underwent minimally invasive resection of a benign osseous vertebral tumor from May 2013 through November 2018 was performed. Primary outcome measures included the extent of resection and pain resolution. Secondary outcomes included postoperative spinal instability evaluated by standing scoliosis x-rays and tumor recurrence evaluated by periodic follow-up magnetic resonance imaging scans.

Results: Our study group comprised 8 children, 3 males and 5 females, with a mean age of 12.2 years. The average follow-up period was 4.3 years. Complete removal of tumors was achieved in all cases and was verified by follow-up magnetic resonance imaging scans. There were no procedure-related complications. The average duration of surgery was 70 minutes, and the blood loss was less than 20 cc in all cases. The average inpatient length of stay was 1.6 days. Histopathology revealed osteoid osteoma in 6 patients and osteoblastoma in 2 patients. Average improvement of the pain scores was from 8 to 0.8. At the time of this report, no tumor recurrence was evident in all 8 patients and none of the cases developed spinal deformity.

Conclusion: Our limited experience suggests that the minimally invasive technique is a valuable option for the surgical management of selected benign osseous spinal tumors in children.
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http://dx.doi.org/10.1016/j.wneu.2021.06.069DOI Listing
August 2021

Gender differences in multifidus fatty infiltration and sarcopenia and association with preoperative pain and functional disability in patients with lumbar spinal stenosis.

Spine J 2021 Jun 8. Epub 2021 Jun 8.

Spine Surgery Unit, Neurosurgical Department, Tel Aviv Medical Center, Tel Aviv, Israel. Sackler faculty of medicine, Tel-Aviv University. Electronic address:

Background: In patients with lumbar spinal stenosis, female gender has been associated with higher pain and functional disability. Sarcopenia and multifidus atrophy have also been associated with symptomatic severity.

Purpose: The purpose of this study was to determine if gender differences in sarcopenia and multifidus atrophy are associated with gender disparities in disease symptomatology.

Study Design: Prospectively collected medical records and imaging studies were retrospectively reviewed.

Patient Sample: We retrospectively reviewed medical records and imaging studies for 63 patients with clinically and radiologically defined lumbar spinal stenosis at L3/4 or L4/5 who underwent minimally invasive decompression.

Outcome Measures: Pain and functional disability were measured using the Oswestry Disability Index (ODI) and visual analogue scores for back pain (VASB) and leg pain (VASL).

Methods: Multifidus total cross sectional area (tCSA), multifidus functional cross sectional area (fnCSA), multifidus fatty infiltration (FI), psoas tCSA, and psoas relative cross sectional area (rCSA) were evaluated by univariable and multivariable regression to identify gender linked and gender independent predictors of higher ODI, VASB, and VASL.

Results: Female gender was significantly associated with lower multifidus fnCSA (p < .001), higher multifidus FI (p < .001), lower psoas tCSA (p < .001), lower psoas rCSA (p = .002), and higher preoperative ODI (p = .008). Lower psoas rCSA (p = .044) and psoas tCSA in the lowest sex specific quartile (p = .034) were significantly associated with higher preoperative VASB and psoas rCSA less than the sex specific median (p = .050) was significantly associated with higher preoperative VASL after controlling for age and gender. Multifidus FI was significantly associated with preoperative ODI after adjusting for age (p = .048) but not after controlling additionally for gender (p = .651).

Conclusions: Female patients with lumbar spinal stenosis may develop more severe and functionally significant multifidus atrophy, resulting in a more severe clinical course with higher functional disability. Sarcopenia was significantly associated with higher preoperative back pain and leg pain in both male and female patients with lumbar spinal stenosis.
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http://dx.doi.org/10.1016/j.spinee.2021.06.007DOI Listing
June 2021

Surgical Management of "Kissing" Spinal Plexiform Neurofibromas in Neurofibromatosis Type 1 Patients.

World Neurosurg 2020 Feb 28;134:e1143-e1147. Epub 2019 Nov 28.

The Gilbert Israeli Neurofibromatosis Center, Tel-Aviv Medical Center, and Tel-Aviv University, Tel-Aviv, Israel; Department of Pediatric Neurosurgery, Tel-Aviv Medical Center, and Tel-Aviv University, Tel-Aviv, Israel. Electronic address:

Background: "Kissing" neurofibromas (KNs) are a unique group of spinal tumors found in neurofibromatosis type 1 (NF1) patients. These are bilateral neurofibromas that approximate each other at the same level, with significant impingement compression of the cord or thecal sac. The best management options and surgical strategies for NF1 patients with KN have not been standardized.

Methods: We conducted a retrospective study evaluating adult NF1 patients with KN. All patients are followed routinely at the Gilbert Israeli NF Center. Patients' files were reviewed for natural history, imaging features, surgical technique, and surgical outcome.

Results: Twelve patients with at least 1 pair of KN were identified (6 females). Median age at spinal presentation was 24 (range 17-48). KNSs were located at the cervical (n = 8) and lumbar (n = 8) region, with no thoracic involvement. Seven of the 12 patients were operated; all underwent surgery due to cervical compression with progressive myelopathy. Four patients remained asymptomatic during the follow-up period. Three patients underwent multiple operations. Operative outcome was favorable in 71% of patients, with marked overall motor improvement or stabilization of neurologic deterioration. Two patients who entered surgery with a low functional reserve deteriorated after surgery.

Conclusions: In our series, KN caused progressive cord compression in 7 of the 8 patients with cervical tumors. No intervention was needed for lumbar tumors. Cervical tumors should be followed closely, with a low threshold for intervention. NF1 patients harboring KN should be followed both clinically and radiologically for life.
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http://dx.doi.org/10.1016/j.wneu.2019.11.124DOI Listing
February 2020

Use of 3-Dimensional Printing Technology in Complex Spine Surgeries.

World Neurosurg 2020 Jan 11;133:e327-e341. Epub 2019 Sep 11.

Spine Surgery Unit, Neurosurgical Department, Tel-Aviv Medical Center, Tel-Aviv, Israel.

Background: Medical implications of 3-dimensional (3D) printing technology have evolved and are increasingly used. Surgical spine oncology involves at times complex resection using various surgical approaches and unique spinal reconstruction. As high general complication rates, including hardware failure, are reported, careful preoperative planning and optimized fixation techniques should be performed. 3D printing technology allows the improvement of preoperative planning, practice and exploration of various surgical approaches, and designing customized surgical tools and patient specific implants.

Objective: To investigate the use of 3D printing technology in complex spine surgeries.

Methods: Between 2015 and 2018, all complex spine oncological cases were evaluated and assessed for the possible benefit of use of 3D printing technology. Following high-quality imaging, a computerized integrated 3D model was created. Based on the planned procedure considering the various surgical steps, a customized 3D model was planned and printed, and in select cases a 3D custom-made implant was designed and printed in various sizes with matching trials.

Results: A total of 7 cases were selected for the use of a 3D printing technology. For all, a custom-made model was created. In 3 of these cases, a customized 3D-printed implant was used. Special customized intraoperative instruments were made for 2 cases, and a simulated surgical approach was performed in 5 cases. In 2 cases, pre-bent rods were made based on the model created and were used in surgery later on.

Conclusions: For complex spine oncology cases, the use of 3D printing allowed better preoperative planning, simplified the operative procedure, and enabled improved reconstruction.
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http://dx.doi.org/10.1016/j.wneu.2019.09.002DOI Listing
January 2020

Acute Presentation of Cervical Myelopathy Following Manipulation Therapy.

Isr Med Assoc J 2019 Aug;21(8):542-545

Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.

Background: Spinal manipulation therapy (SMT) is commonly used as an effective therapeutic modality for a range of cervical symptoms. However, in rare cases, cervical manipulation may be associated with complications. In this review we present a series of cases with cervical spine injury and myelopathy following therapeutic manipulation of the neck, and examine their clinical course and neurological outcome. We conducted a search for patients who developed neurological symptoms due to cervical spinal cord injury following neck SMT in the database of a spinal unit in a tertiary hospital between the years 2008 and 2018. Patients were assessed for the clinical course and deterioration, type of manipulation used and subsequent management. A total of four patients were identified, two men and two women, aged 32-66 years. In three patients neurological deterioration appeared after chiropractic adjustment and in one patient after tuina therapy. Three patients were managed with anterior cervical discectomy and fusion while one patient declined surgical treatment. Assessment for subjective and objective evidence of cervical myelopathy should be performed prior to cervical manipulation, and suspected myelopathic patients should be sent for further workup by a specialist familiar with cervical myelopathy (such as a neurologist, a neurosurgeon or orthopedic surgeon who specializes in spinal surgery). Nevertheless, manipulation therapy remains an important and generally safe treatment modality for a variety of cervical complaints. This review does not intend to discard the role of SMT as a significant part in the management of patients with neck related symptoms, rather it is meant to draw attention to the need for careful clinical and imaging investigation before treatment.
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August 2019

Osteophytes in the Cervical Vertebral Bodies (C3-C7)-Demographical Perspectives.

Anat Rec (Hoboken) 2019 02 9;302(2):226-231. Epub 2018 Nov 9.

Department of Anatomy and Anthropology, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel.

Vertebral osteophytes are an age-dependent manifestation of degenerative changes in the spine. We aimed to determine the prevalence and severity of cervical osteophytosis in a large study population. To do so, we developed a grading system for osteophytosis, enabling the assessment of their presence and severity in the cervical spine, and applied it to the analysis of dried cervical vertebral bodies (C3-C7) from 273 individuals. Statistical analyses were carried out per motion segment, while testing for the effect of age, sex, and ethnicity. The highest prevalence of osteophytes was found in motion segment C5/C6 (48.2%), followed by C4/C5 (44.1%), and last C6/C7 and C3/C4 (40.5%). Severe osteophytes are most commonly seen in motion segment C5/C6. In all motion segments, the inferior discal surface of the upper vertebra manifests more osteophytes than the superior discal surface of the lower one. Osteophytes prevalence is sex-dependent only in the upper cervical vertebrae (C3-C4), and age- and ethnicity-dependent for all vertebrae. Anat Rec, 302:226-231, 2019. © 2018 Wiley Periodicals, Inc.
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http://dx.doi.org/10.1002/ar.23901DOI Listing
February 2019

The torg ratio of C3-C7 in African Americans and European Americans: A skeletal study.

Clin Anat 2019 Jan;32(1):84-89

Department of Anatomy and Anthropology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

The ratio between the sagittal diameter of the spinal canal and the sagittal diameter of the vertebral body, known as the "Torg ratio", is often used to test for spinal canal narrowing. Here, we investigate this ratio in a large population, consisting of two ethnicities, both sexes and three age groups. Measurements were taken on the dry cervical verterbrae (C3-C7) of 277 individuals using a digital apparatus allowing for the recording of 3D coordinates of a set of landmarks on the vertebral body. Vertebral body and vertebral foramen lengths were compared across the different subgroups. Vertebral body and vertebral foramen lengths differ significantly between males and females and between African Americans and European Americans. With age, the vertebral body length increases while the foramen length does not undergo significant changes. These anatomical differences are reflected in differences in the Torg ratio calculated for the different subgroups. In conclusion, our findings suggest that a hard cutoff on the Torg ratio used to define a pathological narrowing of the cervical spine should be adapted to the population the patients come from. Clin. Anat. 32: 84-89, 2019. © 2018 Wiley Periodicals, Inc.
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http://dx.doi.org/10.1002/ca.23269DOI Listing
January 2019

Continuous mapping of the corticospinal tracts in intramedullary spinal cord tumor surgery using an electrified ultrasonic aspirator.

J Neurosurg Spine 2017 Aug 19;27(2):161-168. Epub 2017 May 19.

Department of Neurosurgery, Tel Aviv, "Sourasky" Medical Center, Tel Aviv University; and.

Intramedullary spinal cord tumors (IMSCTs) represent a rare entity, accounting for 4%-10% of all central nervous system tumors. Microsurgical resection of IMSCTs is currently considered the primary treatment modality. Intraoperative neurophysiological monitoring (IONM) has been shown to aid in maximizing tumor resection and minimizing neurological morbidity, consequently improving patient outcome. The gold standard for IONM to date is multimodality monitoring, consisting of both somatosensory evoked potentials, as well as muscle-based transcranial electric motor evoked potentials (tcMEPs). Monitoring of tcMEPs is optimal when combining transcranial electrically stimulated muscle tcMEPs with D-wave monitoring. Despite continuous monitoring of these modalities, when classic monitoring techniques are used, there can be an inherent delay in time between actual structural or vascular-based injury to the corticospinal tracts (CSTs) and its revelation. Often, tcMEP stimulation is precluded by the surgeon's preference that the patient not twitch, especially at the most crucial times during resection. In addition, D-wave monitoring may require a few seconds of averaging until updating, and can be somewhat indiscriminate to laterality. Therefore, a method that will provide immediate information regarding the vulnerability of the CSTs is still needed. The authors performed a retrospective series review of resection of IMSCTs using the tip of an ultrasonic aspirator for continuous proximity mapping of the motor fibers within the spinal cord, along with classic muscle-based tcMEP and D-wave monitoring. The authors present their preliminary experience with 6 patients who underwent resection of an IMSCT using the tip of an ultrasonic aspirator for continuous proximity mapping of the motor fibers within the spinal cord, together with classic muscle-based tcMEP and D-wave monitoring. This fusion of technologies can potentially assist in optimizing resection while preserving neurological function in these challenging surgeries.
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http://dx.doi.org/10.3171/2016.12.SPINE16985DOI Listing
August 2017

Demographic aspects in cervical vertebral bodies' size and shape (C3-C7): a skeletal study.

Spine J 2017 01 17;17(1):135-142. Epub 2016 Aug 17.

Department of Anatomy and Anthropology, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv 6997801, Israel. Electronic address:

Background Context: This cross-sectional study was conducted on the skeletal remains of individuals of known sex, age, and ethnic origin. The vertebral bodies of levels C3-C7 were measured and analyzed. Whereas many studies were performed on the size and shape of the vertebral bodies in the thoracic and lumbar spines, few have focused on the cervical vertebral bodies. Thus, there is insufficient data in the literature on the anatomy of the cervical spine, especially based on large study populations.

Purpose: To establish a large database on cervical vertebral bodies' size and shape and analyze their association with demographic parameters.

Study Design: The population studied was composed of 277 individuals, adult males and females of African American (AA) and European American (EA) origin. The skeletal remains are housed at the Hamman-Todd Osteological collection (Cleveland Museum of Natural History, Cleveland, OH).

Methods: A 3-D digitizer was used to measure the size and shape of the C3-C7 vertebral bodies. Descriptive statistics were carried out for all measurements. t Test and one-way analysis of variance were performed to assess differences in vertebral bodies' size and shape between different demographical groups (by age, sex, and ethnicity).

Results: The vertebral bodies and foramina are significantly wider, more elongated, and higher in males compared to females. AA females and males manifest significantly greater vertebral bodies (width and length) in the upper and midcervical region (vertebrae C3-C5) than EA females and males. Nevertheless, the heights of the C3 and C4 vertebral bodies are significantly smaller among the AA population, regardless of sex. The vertebral foramina's width does not differ significantly between the two ethnic groups, independent of sex, whereas they tend to be elongated in the EA group (significant for C3, C5, C7). For most vertebrae, no significant differences were found in the superior facets' length between AA and EA males and females. Cervical vertebral bodies become wider and more elongated with age, although the changes in the latter dimension are much more pronounced than in the former. Notably, the body shape of the cervical vertebrae changes gradually from a more round shape (C3 length/width index=0.84) to a more oval one (C7 length/width index =0.65). This is due to the fact that the width dimensions increase by almost 40% from C3 to C7, whereas the length dimensions increase only by approximately 10%. Furthermore, there is a significant reduction in body height with age in C3-C6. In contrast, no significant changes in vertebral foramen size with age were found.

Conclusions: The cervical vertebral bodies' shape and size are sex-dependent phenomena, that is, in all parameters studied, the dimensions were greater in males than in females. For the midcervical level, there is a difference in body shape between individuals of different ethnic origins. The cervical vertebral bodies also exhibit considerable size and shape changes with age, that is, they become more elongated (oval shaped), wider, and shorter. In contrast, vertebral foramen size is age independent.
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http://dx.doi.org/10.1016/j.spinee.2016.08.022DOI Listing
January 2017

Electrophysiological monitoring during preoperative angiography to guide decisions regarding permanent occlusion of major radicular arteries in patients undergoing total en bloc spondylectomy.

Neurosurg Focus 2016 Aug;41(2):E19

Department of Neurosurgery, The Spine Unit, Tel Aviv Medical Center;

OBJECTIVE Preoperative embolization is performed before spine tumor surgery when significant intraoperative hemorrhage is anticipated. Occlusion of radicular and segmental arteries may result in spinal ischemia. The goal of this study was to check whether neurophysiological monitoring during preoperative angiography in patients scheduled for total en bloc spondylectomy (TES) of spine tumors improves the safety of vessel occlusion. METHODS This was a case series study of patients who underwent tumor embolization under somatosensory evoked potential (SSEP) and motor evoked potential (MEP) monitoring in preparation for TES in treating spine tumors. The angiography findings, the embolized vessels, and the results are presented. RESULTS Five patients whose ages ranged from 33 to 75 years and who had thoracic spine tumors are reported. Four patients suffered from primary tumor and 1 patient had a metastatic tumor. Radicular arteries at the tumor level, 1 level above, and 1 level below were permanently occluded when SSEPs and MEPs were preserved during temporary occlusion. No complications were encountered during or after the angiography procedure and embolization. CONCLUSIONS Temporary occlusion with electrophysiological monitoring during preoperative angiography may improve the safety of permanent radicular artery occlusion, including the artery of Adamkiewicz in patients undergoing TES for the treatment of spine tumors.
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http://dx.doi.org/10.3171/2016.5.FOCUS16140DOI Listing
August 2016

A Comparison of Different Minimally Invasive and Open Posterior Spinal Procedures Using Volumetric Measurements of the Surgical Exposures.

Clin Spine Surg 2017 Nov;30(9):425-428

Departments of *Neurosurgery †Center for Minimally Invasive Spine Surgery, Spine Institute of San Diego, San Diego, CA ‡Orthopaedic Surgery, Tel-Aviv Sourasky Medical Center, Israel.

Study Design: A Prospective observational study.

Summary Of The Background Data: Minimally invasive (MI) spine surgery techniques strive to minimize the damage to paraspinal soft tissues. Previous studies used only the length of the surgical incision to quantify the invasiveness of certain MI procedures. However, this method does not take into account the volume of muscle tissue that is dissected and retracted from the spine to achieve sufficient exposure. To date, no simple method has been reported to measure the volume of the surgical exposure and to quantify the degree of surgery invasiveness.

Study Objectives: To obtain and compare volumetric measures of various MI and open posterior-approached spinal surgical exposures.

Methods: The length, the depth, and the volume of the surgical exposure were obtained from 57 patients who underwent either open or MI posterior lumbar surgery. MI procedures included the following: tubular discectomy, laminotomy, and transforaminal interbody fusion. Open procedures included the following: discectomy, laminectomy, transforaminal interbody fusion, or posterior-lateral instrumented fusion. Four attending spine surgeons at our unit performed the surgeries. To reduce variability, only single-level procedures performed between L4 and S1 vertebrae were used. The volume of exposure was obtained by measuring the amount of saline needed to fill the surgical wound completely once the surgical retractors were deployed and opened.

Results: The average volumes in mililiters of exposure for a single-level MI procedure ranged from 9.8±2.8 to 75±11.7 mL and were significantly smaller than the average volumes of exposure for a single level open procedures that ranged from 44± 21 to 277±47.9 P<0.001. The average skin-incision lengths for single-level MI procedures ranged from 1.7±0.2 to 7.7±1.6 cm and were significantly smaller than the average skin-incision lengths for open procedures [5.2±1.4 (Table 3) to 11.3±2 cm, P<0.001]. The measured surgical depths were similar in MI and open groups (P=0.138). MI decompression and posterior fusion procedures yielded 92% and 73% reductions in the volumes of exposure, respectively. However, absolute differences in exposure volumes were larger for fusion (202 mL) compared with decompression alone (110.7 mL).

Conclusions: Direct volumetric measurement of the surgical exposure is obtained easily by measuring the amount of saline needed to fill the exposed cavity. Using this method, the needed surgical exposure of different spinal procedures can be quantified and compared. This volumetric measurement combined with the measure of retraction force, the duration of retraction, and the impact on soft tissue vascularity can help build a model that assesses the relative invasiveness of different spinal procedures.
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http://dx.doi.org/10.1097/BSD.0000000000000390DOI Listing
November 2017

Minimally Invasive Spinal Decompression in Patients Older Than 75 Years of Age: Perioperative Risks, Complications, and Clinical Outcomes Compared with Patients Younger Than 45 Years of Age.

World Neurosurg 2016 May 12;89:337-42. Epub 2016 Feb 12.

Department of Neurosurgery, The Spine Surgery Unit, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel; Department of Orthopaedic Surgery, The Spine Surgery Unit, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel. Electronic address:

Objective: Minimally invasive spinal decompression for the treatment of spinal stenosis or disk herniation is often indicated if conservative management fails. However, the influence of old age on the risk of postoperative complications and clinical outcome is not well understood. We therefore sought to compare complication rates and outcomes after minimally invasive surgery decompression and discectomy in elderly patients with a cohort of younger patients undergoing similar procedures.

Methods: We evaluated medical records of 61 patients older than 75 years and 69 patients younger than 45 years that underwent minimally invasive lumbar decompression between April 2009 and July 2013 at our institute. Medical history, American Society of Anesthesiologists score, perioperative mortality, complications, and revision surgery rates were analyzed. Patient outcomes included visual analog scale and EuroQol-5 Dimension scores.

Results: The average age was 78.66 ± 4.42 years in the elderly group and 33.59 ± 6.7 years in the younger group. No major postoperative complications were recorded in either group, and all recruited patients were still alive at the time of the last follow-up. No statistically significant difference existed in the surgical revision rate between the groups. Both groups showed significant improvement in their outcome scores after surgery.

Conclusions: Our results indicate that minimally invasive decompressive surgery is a safe and effective treatment for elderly patients and does not pose an increased risk of complications. Future prospective studies are necessary to validate the specific advantages of the minimally invasive techniques in the elderly population.
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http://dx.doi.org/10.1016/j.wneu.2016.02.018DOI Listing
May 2016

Effect of Fibromyalgia Symptoms on Outcome of Spinal Surgery.

Pain Med 2017 04;18(4):773-780

Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.

Objectives: To evaluate the effect of presurgical symptoms characteristic of fibromyalgia on the postsurgical outcome of patients undergoing spinal surgery.

Methods: In this observational cohort study, participants were patients scheduled for spinal surgery, including cervical or lumbar laminectomy and foraminectomy. Presurgical evaluation included physical examination and manual dolorimetry. Questionnaires included the widespread pain index (WPI), symptom severity scale (SSS), and SF-36. Postsurgical evaluation performed at 10-12 weeks included questionnaires, physical examination, and dolorimetry.

Results: Forty patients (21 male, 19 female) were recruited. Four patients (10%) fulfilled American College of Rheumatology (ACR) 1990 fibromyalgia; nine patients fulfilled 2010 criteria (22.5%). Overall, a significant 34% reduction in WPI was observed postsurgically ( P  < 0.01), but no significant change was observed in SSS. Comparing outcomes for patients fulfilling and not fulfilling fibromyalgia criteria, fibromyalgia syndrome (FMS)-negative patients experienced highly significant reductions of both SSS and WPI (-50.1% and -42.9%, respectively, P  < 0.01), while FMS-positive patients experienced no reduction of SSS symptoms and only a marginally significant reduction in WPI (-20.3%, P  = 0.04). A significant negative correlation was observed between results of presurgical WPI and change in physical role functioning SF-36 component postsurgically. A significant negative correlation was observed between presurgical SSS and change in composite physical functioning SF-36 component. Regression analysis demonstrated a difference in trend between FMS-positive and FMS-negative patients regarding postop changes in SSS, as well as a difference in trend regarding the general health role limitation due to emotional problems and pain components of the SF-36.

Conclusions: Fibromyalgia symptoms were highly prevalent among patients scheduled for spinal surgery. A negative correlation was observed between presurgical severity of fibromyalgia symptoms and components of postsurgical SF-36. Patients with symptoms typical of fibromyalgia may have a less favorable outcome after spinal surgery. The clinical utility of surgical intervention in such patients should be carefully evaluated, and treatment specific for fibromyalgia might be considered before embarking on a surgical course.
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http://dx.doi.org/10.1093/pm/pnw232DOI Listing
April 2017

Total en bloc spondylectomy for vertebral tumors.

Isr Med Assoc J 2015 Jan;17(1):37-41

Background: Most spine tumors are resistant to radiation and chemotherapy. Complete surgical removal provides the best chance for long-term control of the tumor. Total en bloc spondylectomy (TES) is a radical new technique that entails total removal of the tumor and affected vertebras with clean margins.

Objectives: To review our initial experience with TES, focusing on feasibility, surgical challenges and the short-term outcome.

Methods: We retrospectively reviewed the hospitalization charts and follow-up data of all patients treated with TES for spine tumors in the spine unit at Tel Aviv Medical Center.

Results: TES was performed in 12 patients aged 13-78 years. Nine patients had primary spinal tumors and three had metastasis. Total en bloc removal was achieved in all cases with spondylectomy of one to three affected vertebras. There was no perioperative mortality and only one major intraoperative complication of injury to a major blood vessel. Late complications were mainly related to hardware failure.

Conclusions: Total en bloc spondylectomy is feasible and effective for the management of selected patients with extradural spinal tumors. Since the surgical procedure is demanding and carries significant risk, careful preoperative evaluation and collaboration with colleagues from other specialties are crucial.
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January 2015

Delayed diagnosis of cervical spondylotic myelopathy by primary care physicians.

Neurosurg Focus 2013 Jul;35(1):E1

The Spine Unit, Queen's Medical Centre, Nottingham, England.

Object: A retrospective study analyzing medical files of patients who had undergone surgical management for cervical spondylotic myelopathy (CSM) at a single tertiary hospital was performed to determine the time needed by community care physicians to reach a diagnosis of CSM in patients presenting with typical myelopathic signs and symptoms, and to establish the reasons for the delayed diagnosis when present. Previous studies have documented that early diagnosis and surgical treatment of CSM may improve patients' neurological as well as general outcome. However, patients complaining of symptoms compatible with CSM may undergo lengthy medical investigations and treatments by community-based physicians before a correct diagnosis is made. The authors have found no published data on the process and time frame involved in attaining a diagnosis of CSM in the community setting.

Methods: The medical records of 42 patients were retrospectively reviewed for demographic data, symptoms, time to diagnosis, physician specialty, number of visits involved in the diagnostic process, and neurological status prior to surgery.

Results: The mean time delay from initiation of symptoms to diagnosis of CSM was 2.2 ± 2.3 years. The majority of symptomatic patients (90.4%) initially presented to a family practitioner (69%) or an orthopedic surgeon (21.4%), with fewer patients (9.6%) referring to other disciplines (for example, the emergency department) for initial care. In contrast, the diagnosis of CSM was most often made by neurosurgeons (38.1%) and neurologists (28.6%), and less frequently by orthopedic surgeons (19%) or family physicians (4.8%).

Conclusions: The diagnosis of CSM in the community is frequently delayed, leading to late referral for surgery. A higher index of suspicion for this debilitating entity is required from family practitioners and community-based orthopedic surgeons to prevent neurological sequelae.
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http://dx.doi.org/10.3171/2013.3.FOCUS1374DOI Listing
July 2013

Minimally invasive transforaminal, thoracic microscopic discectomy: technical report and preliminary results and complications.

Spine J 2012 Jul;12(7):570-6

Spine Surgery Unit, Department of Neurosurgery, Tel-Aviv Sourasky Medical Center, 6 Weitzman St., Tel Aviv 64239, Israel.

Background Context: Surgical decompression of thoracic disc herniations is technically challenging because retraction of the thecal sac in this area must be avoided. Standard open thoracic discectomy procedures require fairly extensive soft tissue dissection and vertebral resection to provide safe decompression of the spinal cord.

Purpose: To describe our experience using a minimally invasive, transforaminal thoracic discectomy (MITTD) technique for the treatment of thoracic disc herniation.

Study Design: Technical report and preliminary results and complications.

Methods: Twelve patients undergoing MITTD were evaluated preoperatively and postoperatively at 1-, 3-, and 6-month intervals with neurologic examination, and were graded using the American Spinal Injury Association (ASIA) impairment scale and a pain visual analog scale (VAS). Thoracic instability and bony fusion were assessed clinically and radiographically with plain radiographs and computed tomography (CT) scans. Surgical time, blood loss, complications, and hospital length of stay were recorded.

Results: Twelve patients (seven men and five women) underwent MITTD. The median surgical time was 128 (80 to 185) minutes, the median estimated blood loss was 100 (30 to 250) mL, and the median hospital stay was 2 (1 to 4) nights. All discs were successfully removed, and a CT or magnetic resonance imaging confirmed adequate cord decompression in all cases. All patients reported easing of neurologic symptoms and improved walking ability. The median VAS scores improved from 4.5 to 2 for back pain. The ASIA score improved from D to E in the two patients who suffered from motor weakness. Preoperative sensory deficit was reduced in three of the five patients. Patients who suffered from sexual and urinary disturbances did not report improvement. Serious systemic or local complications and neurologic deterioration were not reported.

Conclusions: The transforaminal approach enabled sufficient access to the midline of the spinal canal without extensive resection of the facet joint or the adjacent pedicle. Because most of the osseous and ligamentous structures were preserved, additional instrumentation was not required to prevent postoperative instability. Our early results suggested that minimally invasive thoracic discectomy by transforaminal microscopic technique is a valuable choice in the management of thoracic disc herniation.
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http://dx.doi.org/10.1016/j.spinee.2012.07.001DOI Listing
July 2012

Intervertebral disc height changes after weight reduction in morbidly obese patients and its effect on quality of life and radicular and low back pain.

Spine (Phila Pa 1976) 2012 Nov;37(23):1947-52

Spine Program, Department of Neurosurgery and Orthopedic, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.

Study Design: Prospective study in a morbidly obese population after bariatric surgery.

Objective: To document the effect of significant weight reduction on intervertebral disc space height, axial back pain, radicular leg pain, and quality of life.

Summary Of Background Data: Low back pain is a common complaint in obese patients, and weight loss is found to improve low back pain and quality of life. The mechanism by which obesity causes low back pain is not fully understood. On acute axial loading and offloading, intervertebral disc changes its height; there are no data on intervertebral disc height changes after significant weight reduction.

Methods: Thirty morbidly obese adults who underwent bariatric surgery for weight reduction were enrolled in the study. Disc space height was measured before and 1 year after surgery. Visual analogue scale was used to evaluate axial and radicular pain. The 36-Item Short Form Health Survey and Moorehead-Ardelt questionnaires were used to evaluate changes in quality of life.

Results: Body weight decreased at 1 year after surgery from an average of 119.6 ± 20.7 kg to 82.9 ± 14.0 kg corresponding to an average reduction in body mass index of 42.8 ± 4.8 kg/m(2) to 29.7 ± 3.4 kg/m(2) (P < 0.001). The L4-L5 disc space height increased from 6 ± 1.3 mm, presurgery to 8 ± 1.5 mm 1 year postsurgery (P < 0.001). Both axial and radicular back pain decreased markedly after surgery (P < 0.001). Patients' Moorehead-Ardelt score significantly improved after surgery (P < 0.001). Although the 36-Item Short Form Health Survey score did not show any statistically significant improvement after surgery, the physical component of the questionnaire showed a positive trend for improvement. No correlation was noted between the amount of weight reduction and the increment in disc space height or back pain improvement.

Conclusion: Bariatric surgery, resulting in significant weight reduction, was associated with a significant decrease in low back and radicular pain as well as a marked increase in the L4-L5 intervertebral disc height. Reduction in body weight after bariatric surgery in morbidly obese patients is associated with a significant radiographical increase in the L4-L5 disc space height as well as a significant clinical improvement in axial back and radicular leg pain.
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http://dx.doi.org/10.1097/BRS.0b013e31825fab16DOI Listing
November 2012

Absorbable anterior cervical plate for corpectomy and fusion in a 2-year-old child with neurofibromatosis. Technical note.

J Neurosurg Pediatr 2012 Apr;9(4):442-6

Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Postlaminectomy cervical kyphosis is one of the most challenging entities in spine surgery. Correction of this deformity usually requires anterior fusion with plating and a strut graft or interbody cage and posterior fusion with screws and rods. The situation is more complicated in the young child because fusion may affect future growth of the cervical spine. There is also a paucity of adequate instrumentation for the small bony structures. Some authors have reported utilization of absorbable cervical plates for fusion in pediatric patients with favorable results. The authors present a modified surgical technique that was used for circumferential fusion in a 2-year-old girl with cervical kyphosis and recurrent neurofibroma. Anterior fusion was performed using an autologous rib graft and an absorbable cervical plate. This was followed by posterior fusion using rib bone and cables. Previous reports on the use of absorbable cervical plates are reviewed and the advantages of the current technique are discussed.
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http://dx.doi.org/10.3171/2011.12.PEDS11264DOI Listing
April 2012

Minimally invasive posterior cervical discectomy for cervical radiculopathy: technique and clinical results.

J Spinal Disord Tech 2011 Dec;24(8):521-4

Spine Unit, Department of Neurosurgery, Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Study Design: Retrospective analysis of data of all patients treated by minimally invasive posterior discectomy for cervical radiculopathy between January 2004 and February 2008.

Objective: To describe our technique and report the outcome of minimally invasive posterior cervical discectomy using the MetRx tubular retractor system and surgical microscope.

Summary Of Background Data: Although several studies have been published on posterior minimally invasive approaches to cervical radiculopathy, most have focused on decompression of the nerve root by laminoforaminotomy only without the removal of the offending disc.

Methods: The hospital charts, magnetic resonance imaging studies, and follow-up records of all the patients were reviewed. Outcome was assessed by neurological status, visual analog scale (VAS) for neck and arm pain, and by the short form-36 health survey questionnaire.

Results: Thirty-two patients were included in this study. The follow-up time was 20 to 67 months (mean, 39 mo). Muscle weakness improved in all patients; sensory deficits resolved in 21 patients and improved in 7 patients. Analysis of the mean VAS for radicular pain, VAS for neck pain, and all 8 domains of the short form-36 health survey questionnaire showed significant improvement. Complications included 1 case of incidental dural tear without postoperative cerebrospinal fluid leakage and 1 case of longstanding neck pain.

Conclusion: Minimally invasive posterior cervical discectomy is safe and effective in the management of lateral cervical disc herniation manifested by radiculopathy. In addition to eliminating some of the disadvantages of open surgical approaches, it may also have swifter symptoms resolution compared with laminoforaminotomy without discectomy.
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http://dx.doi.org/10.1097/BSD.0b013e31820679e3DOI Listing
December 2011

Minimally invasive approach to far lateral lumbar disc herniation: technique and clinical results.

Acta Neurochir (Wien) 2010 Apr 16;152(4):663-8. Epub 2009 Oct 16.

Spine Care Unit, Department of Neurosurgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv University, Tel-Aviv, Israel.

Background: To describe our minimally invasive technique for the surgical treatment of far lateral lumbar disc herniation (FLLDH) using MetRx tissue dilators system and a surgical microscope; and to report our experience with this method.

Methods: Retrospective analysis of data of all patients with FLLDH treated by minimally invasive discectomy. Outcome assessment was performed using neurological status, the visual analog scale (VAS) for back pain and leg pain, and the Short Form-36 Health Survey Questionaire (SF-36).

Results: Thirty-one patients were included in this study. The mean follow-up time was 25.16 months. Muscle weakness improved in all patients. Sensory deficits disappeared in 22 patients and improved in the other five patients. The mean VAS for radicular pain showed significant improvement from 8.6 preoperatively, to 3.8 in the immediate postoperative period (P-value <.01), and 0.6 at the last follow-up. The mean VAS for back pain also showed significant improvement from 5.8 preoperatively, to 4.8 in the immediate postoperative period and 0.7 at the last follow-up visit. The SF 36 data showed significant improvement in all the eight domains: the physical functioning improved from 9.68 preoperatively to 76.33 at 6-month follow-up and SF 36 bodily pain index improved from 6.71 before surgery to 79.53 at 6-month follow up. Complications included two cases of incidental dural tear, without postoperative CSF leakage and one case of residual sequestered disc that was successfully removed by a second minimally invasive procedure.

Conclusion: Our results suggest that this minimally invasive technique is safe and efficacious for the management of FLLDH and might be an alternative to open microsurgical approaches.
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http://dx.doi.org/10.1007/s00701-009-0519-7DOI Listing
April 2010

Facial nerve reconstruction using a split hypoglossal nerve with preservation of tongue function.

J Reconstr Microsurg 2008 Oct 16;24(7):469-74. Epub 2008 Sep 16.

Division of Peripheral Nerve Reconstruction, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel.

A prospective study conducted on 13 patients suffering from complete facial nerve injury (for 4 months up to 2 years) aimed to show that using the split hypoglossal nerve allows for reconstruction of the facial nerve with preservation of tongue function. The hypoglossal nerve was split longitudinally. For each half, a split of the hypoglossal nerve's response was measured intraoperatively by recording the compound muscle action potential of the tongue muscle. The half that showed the least response was selected for anastomosis. The facial nerve was transected at the stylomastoid foramen, and its distal part underwent a direct anastomosis with the selected half of the hypoglossal nerve. The six grades of the House-Brackman grading system were used to analyze the results. The average postoperative follow-up period was 3 years. Before surgery, 12 patients in this study were graded VI, with total paralysis, and 1 was graded V. After surgery, 2 of the 13 patients showed mild dysfunction (grade II), 7 patients showed moderate dysfunction (grade III), 3 patients showed moderately severe dysfunction (grade IV), and 1 patient showed a severe dysfunction (grade V). Microsurgical facial nerve reconstruction using a split hypoglossal nerve results in functional facial nerve improvement with preservation of tongue function.
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http://dx.doi.org/10.1055/s-0028-1088225DOI Listing
October 2008

Facet asymmetry in normal vertebral growth: characterization and etiologic theory of scoliosis.

Spine (Phila Pa 1976) 2008 Apr;33(8):898-902

Spinal Research Laboratory, Department of Physical Therapy, The Stanley Steyer School of Health Professions, Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Israel.

Study Design: The shape and orientation of the thoracic and lumbar zygapophyseal facets at the T1-L5 level in children were measured and analyzed.

Objective: To detect the pattern of zygapophyseal facet asymmetry in the thoracic and lumbar spines in children.

Summary Of Background Data: Whereas many studies have defined the pattern of zygapophyseal facet asymmetry in adults, there is insufficient data in children.

Methods: A 3-dimensional digitizer was used to measure zygapophyseal facet size, topography (length, width, concavity, convexity, and lateral interfacet height), and orientation (transverse and sagittal facet angles) at the T1-L5 level. Thirty-two complete, nonpathologic skeletons of children (age range from 4 to 17 years), housed at the Hamman-Todd Human Osteological Collection (Cleveland Museum of Natural History, Cleveland, OH) were assessed. Statistical analysis included paired t tests and analysis of variance.

Results: In general, zygapophyseal facet asymmetry in children exists only in the superior facets of the thoracic spine and is independent of age: The right superior facet is significantly shorter than the left in all thoracic vertebrae T1-T12 (up to -2.91 mm at T1), and significantly wider than the left in thoracic vertebrae T1-T9 (T8 excluded) (P < 0.003). The right superior transverse and sagittal facet angles are significantly greater than the left in thoracic vertebrae T1-T11, indicating a lesser inclination (in the sagittal plane) and more frontally positioned facet (in the transverse plane) (P < 0.003). Facet asymmetry was not evident in the superior or inferior facets of the lumbar vertebrae.

Conclusion: Facet asymmetry in thoracic vertebrae appears in early childhood. The pattern of this asymmetry differs from that reported for adults and may be considered as a possible contributing etiological factor in the development of different types of idiopathic scoliosis.
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http://dx.doi.org/10.1097/BRS.0b013e31816b1f83DOI Listing
April 2008

Vertebral body shape variation in the thoracic and lumbar spine: characterization of its asymmetry and wedging.

Clin Anat 2008 Jan;21(1):46-54

Spinal Research Laboratory, Department of Physical Therapy, School of Health Professions, Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Tel-Aviv, Israel.

This study was designed to characterize the vertebral body (VB) shape, focusing on vertebral wedging, along the thoracic and lumbar spine, and to look for shape variations with relation to gender, age, and ethnicity. All thoracic and lumbar (T1-L5) dissected vertebrae of 240 individuals were measured and analyzed by age, gender, and ethnicity. A 3D digitizer was used to measure all VB lengths, heights, and widths, and their ratios were calculated. This study showed that the VB size was independent of age or ethnicity. VB left lateral wedging was found in most vertebrae of most individuals, yet systematically was absent in six vertebrae (T4, T8-T9, T11, L3-L4) with a greater tendency in females than males ( approximately 92% vs. 86%). The VB was anteriorly wedged from T1 through L2 (peak at T7), nonwedged at L3, and posteriorly wedged at L4-L5 (peak at L5). VB width decreased from T1 to T4 and then increased toward L4-L5, so that the spinal configuration in the coronal plane resembled two pyramids of opposite directions, sharing an apex at T4. The inferior VB width was significantly greater than the superior width of both the same vertebra and the adjacent lower vertebra, indicating a trapezoidal shape of the VB and an inverted trapezoidal shape of the intervertebral space. In conclusion, these findings indicate that the human vertebra, in its normal condition, maintains its external dimensions with age, independent of gender or ethnic origin. Clinical and surgical implications of the unique thoracolumbar architecture are discussed.
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http://dx.doi.org/10.1002/ca.20532DOI Listing
January 2008

Traumatic Facial Diplegia and Horner Syndrome: Case Report.

Eur J Trauma Emerg Surg 2007 Aug 9;33(4):425-9. Epub 2007 Apr 9.

Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.

Traumatic facial diplegia is an uncommon pathology, and is usually associated with bitemporal bone fractures. Traumatic Horner syndrome is mostly associated with carotid artery dissection. We present a case with traumatic facial diplegia and a unilateral Horner syndrome where the mechanisms of injury were unusual. The patient had developed his neurological deficits 9 days following trauma. We discuss the mechanisms of the facial palsy and Horner syndrome and the importance of their diagnosis.
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http://dx.doi.org/10.1007/s00068-007-6913-zDOI Listing
August 2007

Lumbar facet anatomy changes in spondylolysis: a comparative skeletal study.

Eur Spine J 2007 Jul 15;16(7):993-9. Epub 2007 Feb 15.

Spinal Research Laboratory, Physical Therapy, The Stanley Steyer School of Health Professions, Sackler Faculty of Medicine, Tel-Aviv University, P.O. Box 39040, 69978 Tel-Aviv, Israel.

Unlabelled: Opinions differ as to the exact mechanism responsible for spondylolysis (SP) and whether individuals with specific morphological characteristics of the lumbar vertebral neural arch are predisposed to SP. The aim of our study was to reveal the association between SP and the architecture of lumbar articular facets and the inter-facet region.

Methods: Using a Microscribe three-dimensional apparatus (Immersion Co., San Jose, CA, USA), length, width and depth of all articular facets and all inter-facet distances in the lumbar spine (L1-L5) were measured. From the Hamann-Todd Human Osteological Collection (Cleveland Museum of Natural History, OH, USA) 120 normal male skeletons with lumbar spines in the control group and 115 with bilateral SP at L5 were selected. Analysis of variance was employed to examine the differences between spondylolytic and normal spines.

Results: Three profound differences between SP and the norm appeared: (1) in individuals with SP, the size and shape of L4's neural arch had significantly greater inter-facet widths, significantly shorter inter-facet heights and significantly shorter and narrower articular facets; (2) only in the L4 vertebra in individuals with SP was the inferior inter-facet width greater in size than the superior inter-facet width of the vertebra below (L5) (38.7 mm versus 40 mm); (3) in all lumbar vertebrae, the right inferior articular facets in individuals with SP were flatter compared to the control group.

Conclusions: Individuals with L4 "SP" characteristics are at a greater risk of developing fatigue fractures in the form of spondylolysis at L5.
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http://dx.doi.org/10.1007/s00586-007-0328-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2219650PMC
July 2007

Lumbar facet orientation in spondylolysis: a skeletal study.

Spine (Phila Pa 1976) 2007 Mar;32(6):E176-80

Spinal Research Laboratory, Department of Physical Therapy, The Stanley Steyer School of Health Professions, Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Israel.

Study Design: Orientation of the lumbar articular facets at the L1-L5 level was measured and analyzed.

Objective: To characterize the relationship between lumbar facet orientation and isthmic spondylolysis.

Summary Of Background Data: Whereas many studies have explored the relationship between facet orientation in the transverse plane and various spinal pathologies, there is insufficient data regarding this relationship and isthmic spondylolysis.

Methods: A 3-dimensional digitizer was used to measure the transverse orientation of the lumbar facet joints at the L1-L5 level in 115 male individuals with bilateral isthmic spondylolysis (at L5) and 120 age and sex-matched normal control subjects from the Hamann-Todd Human Osteological Collection (Cleveland Museum of Natural History, Cleveland, OH). Statistical analysis included paired t tests and analysis of variance.

Results: In both isthmic spondylolysis and control groups, considerable shifts were noticed from sagittally oriented articular facets at L1 to frontally oriented facets at L5. The change in orientation was significantly greater (up to 13 degrees at L4) in the isthmic spondylolysis group (right inferior facets). Three of the 4 articular facets of L5 (right and left inferior and right superior) were significantly more frontally oriented in isthmic spondylolysis compared to the control group. A greater tendency of asymmetry in facet orientation was noticed in the isthmic spondylolysis group.

Conclusion: Individuals with more frontally oriented facets in the lower lumbar vertebrae incorporated with facet tropism are at a greater risk for developing isthmic spondylolysis at L5.
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http://dx.doi.org/10.1097/01.brs.0000257565.41856.0fDOI Listing
March 2007

The use of carbon fiber cages in anterior cervical interbody fusion: report of 100 cases.

Neurosurg Focus 2002 Jan 15;12(1):E1. Epub 2002 Jan 15.

Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Object: Cage devices were introduced in spinal fusion to overcome the shortcomings of autograft, allograft, and biocompatible implants. The aim of this study was to assess the short-term results of anterior cervical discectomy and fusion (ACDF) in which an interbody carbon fiber cage (CFC) and local osteophyte-derived bone graft were implanted.

Methods: A retrospective review was conducted of 100 consecutive patients treated by ACDF in which a CFC was packed with bone fragments obtained from osteophytes at the surgical site. Plain radiographs with dynamic lateral views obtained 1 year postoperatively were used to assess bone fusion, alignment of the cervical spine, and stability. Dynamic radiographs were also obtained at last follow up to determine whether loss of cervical alignment or collapse at the fused disc had occurred. The mean follow-up period was 25 months. In all cases the cervical lordosis was maintained or corrected to different extents and disc height was restored. Solid fusion was achieved in 98% of the cases. There were no cage-related complications and no cases of cage failure.

Conclusions: The authors conclude that application of the CFC for ACDF is safe, effective, and technically feasible. Osteophytes resected during surgery may be a good alternative material for bone grafting in cage-assisted cervical interbody fusion.
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http://dx.doi.org/10.3171/foc.2002.12.1.2DOI Listing
January 2002

Surgical anatomy of the cervical segment of the hypoglossal nerve.

Clin Anat 2006 Jan;19(1):37-43

Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Israel.

The surgical anatomy of the extracranial segment of the hypoglossal nerve (HN) has been sparsely investigated in the literature. This article studies the course and anatomical and topographic relationships of the HN in 23 formalin fixed cadavers bilaterally dissected under a surgical microscope. The descriptive anatomy is presented with relevant clinical and surgical implications.
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http://dx.doi.org/10.1002/ca.20141DOI Listing
January 2006

Facet tropism and interfacet shape in the thoracolumbar vertebrae: characterization and biomechanical interpretation.

Spine (Phila Pa 1976) 2005 Jun;30(11):E281-92

Tel-Aviv University, Sackler Faculty of Medicine, Department of Physical Therapy, Ramat-Aviv, Tel-Aviv, Israel.

Study Design: Thoracolumbar facet and interfacet linear dimensions were measured and analyzed.

Objective: To characterize and analyze the thoracolumbar facet and interfacet size and shape in relation to gender, ethnic group, and age and to detect the extent of normal facet tropism along the thoracolumbar spine.

Summary Of Background Data: Knowledge on facet tropism and interfacet shape is limited in the literature as most data are based on 2-dimensional measurements, small samples, or isolated vertebrae.

Methods: Facet shape as represented by width, length, width/length ratio and interfacet distances was obtained directly from dry vertebrae of 240 adult human spines. The specimen's osteologic material is part of the Hamann-Todd Osteological Collection housed at the Cleveland Museum of Natural History, Cleveland, OH. A total of 4080 vertebrae (T1-L5) from the vertebral columns of individuals 20 to 80 years of age were measured, using a Microscribe 3-dimensional apparatus (Immersion Co., San Jose, CA). Data were recorded directly on computer software. Statistical analysis included paired t tests and ANOVA.

Results: A significant correlation was found between all thoracolumbar facet dimensions and an individual's height and weight. Facet tropism is a major characteristic of the thoracolumbar spine, the left being longer in the thorax while the right is longer in the lumbar. In general, facet size is age-independent and greater in males compared with females with a significant ethnic component. Facet length is similar for all thoracic vertebrae, whereas it sharply and continuously increases in the lumbar vertebrae. Facet dimension manifests a bipolar distribution along the thoracolumbar vertebrae. Width/length ratio indicates that facets are longer than wider for most verte-brae. The interarticular area manifests a marked inverted trapezoidal shape at T1-T2, a rectangular shape at T3-L3, and an ordinary trapezoidal shape at L4-L5.

Conclusions: Facet tropism is a normal characteristic in humans, yet it varies along the thoracolumbar spine.
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http://dx.doi.org/10.1097/01.brs.0000164098.00201.8dDOI Listing
June 2005

A new approach to monitor spinal cord vitality in real time.

Adv Exp Med Biol 2003 ;540:125-32

Faculty of Life Sciences, Bar-Ilan University, Ramat Gan 52900, Israel.

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http://dx.doi.org/10.1007/978-1-4757-6125-2_18DOI Listing
July 2004
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