Mega-granuloma After Using the Universal Clamp for Adolescent Idiopathic Scoliosis: What Is It and Can It Be Prevented?

STUDY DESIGN: Clinical case series. OBJECTIVE: To characterize the postoperative course and histopathology of peri-implant tissue of adolescent idiopathic scoliosis patients who experienced postoperative development of an aseptic soft tissue reaction, with granulomas adjacent to the sublaminar polyethylene terephthalate strap-titanium clamp used in Zimmer's Universal Clamp (UC) spinal fixation system after spinal surgery. BACKGROUND SUMMARY: The UC was designed for use with spinal deformity procedures in place of pedicle screws, hooks, or sublaminar wiring in fusion constructs. Recent studies of the UC lack emphasis on implant-related postoperative complications. METHODS: A total of 26 consecutive patients who underwent spinal deformity correction for scoliosis were reviewed for implant-related postoperative complications. Histology, scanning electron microscopy with energy-dispersive X-ray spectroscopy, fractional culture/biopsy, and Gram stain examination of the peri-implant tissue of patients with complications was performed. RESULTS: The authors reviewed 26 cases for correction of scoliosis. Two patients with adolescent idiopathic scoliosis who used the UC experienced implant-related complications with development of an aseptic soft tissue reaction with granulomas adjacent to the sublaminar polyethylene terephthalate straps-titanium clamp mechanism of the UC 8 months after AIS correction surgery. There were no signs or symptoms of wound infection. Gram stain revealed no organisms. There were many neutrophils and the surface of the wound revealed rare Staphylococcus aureus but the deep portions of the wounds were negative for organisms. Histopathology revealed extensive granulation tissue and histiocytes with engulfed birefringent particles or debris, and scanning electron microscopy with energy-dispersive X-ray spectroscopy analysis revealed macrophages containing many particles identified as titanium. CONCLUSIONS: adolescent idiopathic scoliosis patients who use the novel UC construct may develop postoperative foreign-body reaction.

Balloon Kyphoplasty for Refractory Vertebral Compression Fractures in a Growing Child With Duchenne Muscular Dystrophy With Five-Year Follow-Up: Case Report and Review of Literature.

OBJECTIVE: Presentation of previously unreported results and 5-year follow-up of balloon kyphoplasty used to treat an 8-year-old patient with refractory vertebral compression fractures resulting from 3 years of corticosteroid treatment for Duchenne muscular dystrophy. SUMMARY OF BACKGROUND DATA: Long-term corticosteroid treatment in patients with DMD has been used to try and improve muscle strength, prolong ambulation, and lower the prevalence of scoliosis. However, these patients have an increased risk of osteoporosis and vertebral fractures. METHODS: The patient was an 8-year-old boy with Duchenne muscular dystrophy who had received corticosteroid treatment for 3 years, with refractory vertebral compression fractures at T11, L1, and L3. Balloon kyphoplasty was performed at the 3 vertebral bodies using careful technique. RESULTS: The patient achieved immediate pain relief after the procedure. The height of the treated vertebrae remained stable without further collapse over a 5-year follow-up period. At 5-year follow-up, the patient developed 2 new vertebral compression fractures at T12 and L2 adjacent to the treated vertebrae. The treatment also did not affect the growth of the treated vertebrae or the patient's overall growth. CONCLUSIONS: Because the procedure resulted in rapid stabilization of the treated vertebrae, effective analgesia, and no effect on the growth of the treated vertebrae over a 5-year follow-up period, balloon kyphoplasty was a good therapeutic option for this pediatric patient.

An analysis of fusion cage migration in unilateral and bilateral fixation with transforaminal lumbar interbody fusion.

PURPOSE: To investigate if instrumentation (unilateral vs. bilateral fixation) has an effect on the rate of fusion cage migration. METHODS: This clinical study of transforaminal lumbar interbody fusion involved a prospective group of 116 patients who were randomly assigned to either unilateral (n = 57) or bilateral (n = 59) fixation. Fourteen were lost to follow-up (11 from the unilateral group and 3 from the bilateral group). RESULTS: The unilateral fixation group consisted of 20 male and 26 female patients. In the unilateral group, the mean age was 53.5 years (range, 18-77), and the preoperative diagnosis consisted of degenerative disc disease, with or without herniated disc (n = 44), and degenerative spondylolisthesis with spinal stenosis (n = 2). The bilateral fixation group consisted of 20 male and 36 female patients. In the bilateral group, the mean age was 55.7 years (range, 26-82), and the preoperative diagnosis consisted of degenerative disc disease, with or without herniated disc (n = 40), and degenerative spondylolisthesis with spinal stenosis (n = 16). A total of 17 cases of cage migration were found; of these, 11 were from the unilateral group and 6 from the bilateral group, resulting in rates of cage migration of 23 and 11 % (p = 0.03), respectively. In regard to migration cases, 5 were male and 12 were female. Ages ranged from 27 to 79 years (mean age, 55 years). CONCLUSION: We conclude that unilateral fixation is not stable enough to prevent fusion cage migration in some patients who undergo TLIF.

Intraoperative decrease in amplitude of somatosensory-evoked potentials of the lower extremities with interbody fusion cage placement during lumbar fusion surgery.

STUDY DESIGN: A retrospective analysis was performed. OBJECTIVE: To characterize neurophysiological data of patients who had a decrease in amplitude of somatosensory-evoked potentials (SSEP) of the lower extremities secondary to interbody fusion cage placement during lumbar fusion surgery with no alert of the electromyography (EMG). SUMMARY OF BACKGROUND DATA: The most consistently used and studied modalities of neurophysiological monitoring during spine surgery are SSEPs, motor-evoked potentials (MEPs), and EMG. In general, it is accepted that MEPs along with SSEPs are used to detect spinal cord injury and EMGs are used to detect nerve root injury. METHODS: The medical records of a consecutive series of 115 patients who had undergone a transforaminal lumbar interbody fusion (TLIF) procedure in which SSEPs, MEPs, and EMGs were utilized for neurophysiological monitoring were retrospectively reviewed. RESULTS: One hundred fifteen cases of TLIF procedures were reviewed. The follow-up was 2 years after the last procedure. A total of 5 cases that demonstrated intraoperative SSEP changes were found. The age range for these cases was from 39 to 81 years (mean age, 61 yr). All 5 patients developed SSEP changes that were secondary to interbody fusion cage placement. All 5 cases demonstrated reversal of the SSEP changes to baseline after removal of the interbody cage. Three of these cases had no new postoperative neurological findings. However, given that these 3 cases of SSEP change were associated with a surgical event that improved secondary to an intervention (in this case removal of the interbody cage), those cases were classified as presumed positive. Two of the 5 cases were in fact associated with a new postoperative neurological deficit. CONCLUSION: To our knowledge this study demonstrates the first reported SSEP alerts that were associated with a posterior lumbar interbody cage placement without a corresponding EMG alert.

Cauda equina syndrome following decompression for spinal stenosis.

Cauda equina syndrome following decompression for spinal stenosis appears to occur more commonly than the literature suggests. A large series of spinal stenosis decompressions was reviewed. Based on these findings, a theory is put forth as to the cause of this complication. One hundred seventy-five cases of decompression for spinal stenosis done over a 2.5-year period were reviewed. Follow-up was 1year to 2 years and 4 months. There were 14 cases of postoperative urinary retention, for an incidence of 8%. Of those, five were ultimately diagnosed with cauda equina syndrome, for an incidence of 2.8%. Of the nine cases that were not diagnosed as cauda equina syndrome, five resolved spontaneously over 2 to 6 weeks. The remaining four were diagnosed as having mechanical urinary problems (e.g., prostate or prolapsed bladder) that required surgical treatment. Anal sphincter monitoring at the time of surgery was not predictive in those patients who developed cauda equina syndrome. All patients who developed cauda equina syndrome improved over 3 to 9 months, but none completely resolved. Three cases underwent further decompression with no apparent improvement. Cauda equina syndrome occurs in 2.8% of decompressions for spinal stenosis.