Intra-cranial hypertension and vision-threatening papilloedema caused by intradural spinal tumours: a case series of three.

Spinal tumours infrequently cause hydrocephalus, on rare occasions, they can also cause papilloedema, in the absence of ventriculomegaly. When the latter occurs, they can be a diagnostic challenge for physicians. In the absence of limb neurology, much of the initial diagnostic effort is focused solely on intra-cranial causes. This can result in diagnostic delay, misdiagnosis and mistreatment.We describe three cases of intradural spinal tumours that presented with isolated vision-threatening papilloedema. We compare and contrast these patients who had similar presentations, but different management strategies. The different operative management of their spinal tumours, as well as the acuity of visual deterioration determined their respective clinical course and patient journeys. We emphasise the need to preserve vision as a priority, through emergency cerebrospinal fluid (CSF) diversion if necessary. We remind our readers to 'think outside the box' in cases of unexplained papilloedema, and recognise spinal pathology as a possibility amongst the differentials.

Factors Influencing Surgical Outcomes for Intradural Spinal Tumours: A Single-Centre Retrospective Cohort Study.

Introduction Intradural spinal tumours are relatively uncommon tumours of the central nervous system. In this study, we sought to assess our current practice and determine the factors which affect the surgical outcomes of intradural spinal tumour resection. Methods All consecutive patients who underwent surgical resection of intradural spinal tumours from December 2011 to November 2018 were retrospectively reviewed. The Modified McCormick Scale (MMS) was used to grade patients' neurological status both pre-operatively and at the latest follow-up. The associations between changes in MMS and variables such as patient demographics, tumour location, number and experience of consultants involved in the procedure, use of intraoperative neuro-monitoring, bony spinal exposure and dural closure methods were assessed. A multivariable binary logistic regression model was performed to identify independent predictors of improvements in MMS. All analyses were performed using IBM SPSS 22 (IBM Corp. Armonk, NY), with p<0.05 deemed to be indicative of statistical significance throughout. Results A total of 145 patients met the inclusion criteria, with a median age of 56.5 years; of whom 119 had extramedullary tumours and 26 had intramedullary tumours. Methods of dural closure were variable, and there was an increasing trend over time towards using the laminoplasty approach for bony exposure. Neither the experience of consultants (p=0.991) nor the number of consultants involved (p=0.084) was found to be significantly associated with the change in MMS, with the strongest predictor being the baseline MMS (p<0.001). Patients who had adjuvant therapy were also significantly more likely to have a poorer neurological outcome (p=0.001). Conclusion A good neurological baseline is a significant positive predictor of an improved functional outcome. The number and seniority of consultant surgeons involved in intradural spinal tumour resections did not significantly alter the postoperative outcomes of patients in our single-unit retrospective study.

Patient journey following lumbar discectomy surgery: protocol for a single-centre qualitative analysis of the patient rehabilitation experience (DiscJourn).

INTRODUCTION: Lumbar discectomy is a widely used surgical procedure internationally with the majority of patients experiencing significant benefit. However, approximately 20% of patients report suboptimal functional recovery and quality of life. The impact and meaning of the surgical experience from the patients' perspective are not fully understood. Furthermore, there is limited evidence guiding postoperative management with significant clinical practice variation and it is unclear if current postoperative support is valued, beneficial or meets patients' needs and expectations. This study aims to address the evidence gap by moving beyond current knowledge to gain insight into the lived experiences relating to patients' lumbar discectomy surgery journey. Results will inform more meaningful and specific care, thus, enhance rehabilitation and outcomes. METHODS AND ANALYSIS: A qualitative investigation using interpretative phenomenology analysis (IPA) will provide a flexible inductive research approach. A purposive sample (n=20) of patients undergoing primary discectomy will be recruited from one UK NHS secondary care centre. Semi-structured interviews will be conducted postsurgery discharge. A topic guide, developed from the literature and our previous work with input from two patient co-investigators, will guide interviews with the flexibility to explore interesting or patient-specific points raised. Providing longitudinal data, patients will keep weekly diaries capturing experiences and change over time throughout 12 months following surgery. A second interview will be completed 1 year postsurgery with its topic guide informed by initial findings. This combination of patient interviews and diaries will capture patients' attitudes and beliefs regarding surgery and recovery, facilitators and barriers to progress, experiences regarding return to activities/function and interactions with healthcare professionals. The rich density of data will be thematically analysed in accordance with IPA, supported by NVivo software. ETHICS AND DISSEMINATION: Ethical approval has been granted by the London-Bloomsbury Research Ethics Committee (18/LO/0459; IRAS 241345). Conclusions will be disseminated through conferences and peer-reviewed journals.

Subdural empyema following lumbar facet joint injection: An exceeding rare complication.

Chronic low back pain is extremely common with a life time prevalence estimated at greater than 70%. Facet joint arthrosis is thought to be the causative aetiological substrate in approximately 25% of chronic low back pain cases. Facet joint injection is a routine intervention in the armamentarium for both the diagnostic and therapeutic management of chronic low back pain. In fact, a study by Carrino et al. reported in excess of 94,000 facet joint injection procedures were carried out in the US in 1999. Although generally considered safe, the procedure is not entirely without risk. Complications including bleeding, infection, exacerbation of pain, dural puncture headache, and pneumothorax have been described. We report a rare case of a 47-year-old female patient who developed a left L4/5 facet septic arthrosis with an associated subdural empyema and meningitis following facet joint injection. This case is unique, as to the best of our knowledge no other case of subdural empyema following facet joint injection has been reported in the literature. Furthermore this case serves to highlight the potential serious adverse sequelae of a routine and apparently innocuous intervention. The need for medical practitioners to be alert to and respond rapidly to the infective complications of facet joint injection cannot be understated.

Preliminary biomechanical evaluation of prophylactic vertebral reinforcement adjacent to vertebroplasty under cyclic loading.

BACKGROUND CONTEXT: Percutaneous vertebroplasty has become a favored treatment option for reducing pain in osteoporotic patients with vertebral compression fractures (VCFs). Short-term results are promising, although longer-term complications may arise from accelerated failure of the adjacent vertebral body. PURPOSE: To provide a preliminary biomechanical assessment of prophylactic vertebral reinforcement adjacent to vertebroplasty using a three-vertebra cadaveric segment under dynamic loads that represent increasing activity demands. In addition, the effects of reducing the elastic modulus of the cement used in the intact vertebrae were also assessed. STUDY DESIGN/SETTING: Three-vertebra cadaveric segments were used to evaluate vertebroplasty with adjacent vertebral reinforcement as an intervention for VCFs. METHODS: Nine human three-vertebra segments (T12-L2) were prepared and a compression fracture was generated in the superior vertebrae. Vertebroplasty was performed on the fractured T12 vertebra. Subsequently, the adjacent intact L1 vertebra was prophylactically augmented with cement of differing elastic moduli (100-12.5% modulus of the base cement value). After subfailure quasi-static compression tests before and after augmentation, these specimens were subjected to an incrementally increasing dynamic load profile in proportion to patient body weight (BW) to assess the fatigue properties of the construct. Quantitative computed tomography assessments were conducted at several stages in the experimental process to evaluate the vertebral condition and quantify the gross dimensions of the segment. RESULTS: No significant difference in construct stiffness was found pre- or postaugmentation (t=1.4, p=.19). Displacement plots recorded during dynamic loading showed little evidence of fracture under normal physiological loads or moderate activity (1-2.5x BW). A third of the specimens continued to endure increasing load demands and were confirmed to have no fracture after testing. In six specimens, however, greater loads induced 11 fractures: 7 in the augmented vertebra (2xT12, 5xL5) and 4 in the adjacent L2 vertebra. A strong correlation was observed between the subsidence in the segmental unit and the incidence of fracture after testing (r(Spearman's)=-0.88, p=.002). Altering the modulus of cement in the intact vertebra had no effect on level of segmental compromise. CONCLUSIONS: These preliminary findings suggest that under normal physiological loads associated with moderate physical activity, prophylactic augmentation adjacent to vertebroplasty showed little evidence of inducing fractures, although loads representing more strenuous activities may generate adjacent and peri-augmentation compromise. Reducing the elastic modulus of the cement in the adjacent intact vertebrae appeared to have no significant effect on the incidence or location of the induced fracture or the overall height loss of the vertebral segment.

The biomechanics of vertebroplasty in multiple myeloma and metastatic bladder cancer: a preliminary cadaveric investigation.

OBJECT: The vertebral column is the most common site for secondary bone metastases and lesions arising from hematological malignancies such as multiple myeloma (MM). These infiltrations can be lytic in nature and cause severe weakening of the vertebral body, an increased risk of fracture, and spinal cord compression leading to neurological deficit. Qualitatively it is apparent that increasing infiltration of these lytic lesions will have a deleterious effect on the mechanical behavior of the vertebrae. However, there is little quantitative information about the relationship between tumor deposits and the impact on the mechanical behavior of the vertebrae. In addition, there have been limited biomechanical assessments of the use of vertebroplasty in the management of these malignancies. The purpose of this preliminary study was to evaluate the mechanical behavior of lesion-infiltrated vertebrae from 2 malignant cancers and to investigate the effectiveness of vertebroplasty with and without tumor debulking. METHODS: Individual vertebrae from 2 donor spines--one with MM and another with bone metastases secondary to bladder cancer-were fractured under an eccentric flexion load, from which failure strength and stiffness were derived. Alternate vertebrae defined by spinal level were assigned to 2 groups: Group 1 involved removal of lesion material with Coblation (ArthroCare Corp.) preceding vertebroplasty; Group 2 received no Coblation prior to augmentation. All vertebrae were fractured postaugmentation under the same loading protocol. Micro-CT assessments were undertaken to investigate vertebral morphology, fracture patterns, and cement distribution. RESULTS: Multiple myeloma involvement was characterized by several small lesions, severe bone degradation, and multiple areas of vertebral shell compromise. In contrast, large focal lesions were present in the vertebrae with metastatic bladder cancer, and the shell generally remained intact. The mean initial failure strength of the vertebrae with metastases secondary to MM was significantly lower than in vertebrae with bone metastases secondary to bladder cancer (Load = 950 +/- 300 N vs 2200 +/- 750 N, p < 0.0001). A significant improvement in relative fracture strength was found postaugmentation for both lesion types (1.4 +/- 0.5, p < 0.001). Coblation provided a marginally significant increase in the same parameter postaugmentation (p = 0.08) and qualitatively improved the ease of injection and guidance of cement. CONCLUSIONS: In the vertebral column, metastatic lesions secondary to bladder cancer and MM showed variations in the pattern of infiltration, both of which led to significant reductions in fracture strength. Account should be taken of these differences to optimize the vertebroplasty intervention in terms of the cement formulation, delivery, and any additional surgical procedure.

The biomechanical effectiveness of prophylactic vertebroplasty: a dynamic cadaveric study.

OBJECT: The purpose of the study was to investigate the segmental effects of prophylactic vertebroplasty under increasingly demanding loading conditions and to assess the effect of altered cement properties on the construct biomechanics. METHODS: Twelve human cadaveric 3-vertebral functional spinal units (T12-L2) were prepared such that the intact L-1 vertebra was prophylactically augmented with cements of differing elastic moduli (100, 50, 25, and 12.5% modulus of the base cement). These specimens were subjected to quasistatic subfailure compression pre- and postaugmentation to 50% of the predicted failure strength and then cyclic loading in a fatigue rig (115,000 cycles) to characterize the high-stress, short-cycle fatigue properties of the construct. Loading was increased incrementally in proportion to body weight to a maximum of 3.5 x body weight. Quantitative computed tomography assessment was conducted pre- and postaugmentation and following cyclic testing to assess vertebral condition, cement placement, and fracture classification. RESULTS: Adjacent and periaugmentation fractures were induced in the prophylactically augmented segments. However, it appeared that these fractures mainly occurred when the specimens were subjected to loads beyond those that may commonly occur during most normal physiological activities. CONCLUSIONS: Lowering the elastic modulus of the cement appeared to have no significant effect on the frequency or severity of the induced fracture within the vertebral segment.

A biomechanical investigation of vertebroplasty in osteoporotic compression fractures and in prophylactic vertebral reinforcement.

STUDY DESIGN: Cadaveric single vertebrae were used to evaluate vertebroplasty as a prophylactic treatment and as an intervention for vertebral compression fractures. OBJECTIVE: To investigate the biomechanical characteristics of prophylactic reinforcement and postfracture augmentation of cadaveric vertebrae. SUMMARY OF BACKGROUND DATA: Percutaneous vertebroplasty is a treatment option for osteoporotic vertebral compression fractures. Short-term results are promising, but longer-term studies have suggested a possible accelerated failure rate in the adjacent vertebral body. Limited research has been conducted into the effects of prophylactic vertebroplasty in osteoporotic vertebrae. This study aims to elucidate the biomechanical differences between the 2 treatment groups. METHODS: Human vertebrae were assigned to 2 scenarios: Scenario 1 simulated a wedge fracture followed by cement augmentation; Scenario 2 involved prophylactic augmentation using vertebroplasty. Micro-CT imaging was performed to assess the bone mineral density, vertebral dimensions, fracture pattern, and cement volume. All augmented specimens were then compressed under an eccentric flexion load to failure. RESULTS: Product of bone mineral density and endplate surface area gave a good prediction of failure strength when compared with actual failure strength of specimens in Scenario 1. Augmented vertebral bodies showed an average cement fill of 23.9% +/- 8.07%. There was a significant postvertebroplasty increase in failure strength by a factor of 1.72 and 1.38 in Scenarios 1 and 2, respectively. There was a significant reduction in stiffness following augmentation for Scenario 1 (t = 3.5, P = 0.005). Stiffness of the vertebral body in Scenario 2 was significantly greater than observed in Scenario 1 (t = 4.4, P = 0.0002). CONCLUSION: Results suggest that augmentation of the vertebrae postfracture significantly increases failure load, while stiffness is not restored. Prophylactic augmentation was seen to increase failure strength in comparison to the predicted failure load. Stiffness appears to be maintained suggesting that prophylactic vertebroplasty maintains stiffness better than vertebroplasty postfracture.