Predictors of conversion surgery after conservative treatment for pyogenic spondylitis.

BACKGROUND: Patient demographic and clinical characteristics may be factors associated with the success of conservative treatment for pyogenic spondylitis. The ability of imaging findings at initial diagnosis to predict patient outcomes remains unclear. The aim of this study was to investigate the risk factors associated with conversion surgery after conservative treatment for pyogenic spondylitis, with a special focus on the initial computed tomography (CT) findings. METHODS: This study enrolled 35 patients with pyogenic spondylitis who underwent CT and magnetic resonance imaging (MRI) at diagnosis and were followed-up for more than 6 months. Patients were diagnosed by MRI, and the degree of bone destruction was assessed on CT cross-sectional images. Vertebral body destruction was classified as grades 0 (almost normal), 1 (endplate irregularity), 2 (vertebral body destruction not involving the posterior wall), and 3 (destruction involving the posterior wall). Patients were divided into four groups based on grade of bone destruction and their clinical characteristics were compared. RESULTS: 1, 11, 11, and 12 patients were classified as grades 0, 1, 2, and 3, respectively. Univariate analysis showed no significant differences in the demographic and clinical characteristics of the four groups. Eighteen (51.4 %) patients had been treated surgically, with the rate of surgical treatment being significantly higher in patients with grade 3 (83.3 %) than in those with grades 0 + 1 (25 %) and grade 2 (45.5 %) (P < 0.05). Multivariate analysis showed that epidural abscess on MRI (odds ratio [OR] 10.8, 95 % confidence interval [CI] 1.68-69.7), grade 3 bone destruction on CT (OR 3.97, 95 % CI 1.21-13.0), and C-reactive protein (CRP) improvement rate after 1 week of treatment (OR 0.95, 95 % CI 0.91-0.99) were risk factors for surgery. CONCLUSIONS: Early surgical treatment should be considered for patients with pyogenic spondylitis who present with an epidural abscess on MRI and bone destruction extending to the posterior wall on CT at the time of diagnosis.

The Effect of Local Administration of Vancomycin Suspended in Fibrin Glue for Prevention of Surgical Site Infection After Spinal Instrumentation: Comparison by Probability of Treatment Weighting Model.

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: To compare the surgical site infection (SSI) rate in patients undergoing spinal instrumentation surgery who received vancomycin suspended in fibrin glue at the surgical site and those who did not. SUMMARY OF BACKGROUND DATA: The intrawound application of vancomycin powder for preventing SSI after spinal surgery remains controversial. Vancomycin suspended in fibrin glue is another option for local administration that may be effective. The present study assessed whether vancomycin suspended in fibrin glue could prevent SSI after spinal instrumentation surgery. MATERIALS AND METHODS: We enrolled patients who underwent posterior spinal instrumentation surgery with or without fusion for degenerative conditions, spinal trauma, or tumor. A multiple logistic regression model with inverse probability of treatment weighting based on propensity score was used to assess the efficacy of vancomycin suspended in fibrin glue and to account for confounding. A secondary multivariate logistic regression analysis was performed to identify the risk factors associated with SSI. RESULTS: Of the 264 patients enrolled in this study, 134 underwent application of vancomycin suspended in fibrin glue at the surgical site and 130 did not. The incidence of SSI was lower in patients who were treated with vancomycin suspended in fibrin glue (2.2% vs. 8.5%) even after inverse probability of treatment weighting adjustment (adjusted odds ratio: 0.25; 95% CI, 0.0768-0.91; P =0.03). Multivariate logistic regression analysis showed that the treatment with vancomycin suspended in fibrin glue was significantly associated with a lower odds of SSI (odds ratio: 0.2; 95% CI, 0.05-0.85; P =0.03). CONCLUSIONS: The administration of vancomycin suspended in fibrin glue was significantly associated with a lower likelihood of SSI in patients undergoing spinal instrumentation surgery.

Clinical utility of minimally invasive posterior internal fixation within the pelvic ring using S2 alar iliac screws for unstable pelvic ring fracture.

INTRODUCTION: Posterior internal fixation for unstable pelvic ring fractures is often associated with complications, including pelvic hemorrhage and gluteal necrosis. Pelvic ring fixation using the S2 alar iliac screw (SAIS) without fixation of the lumbosacral vertebrae may have potential as a novel, minimally invasive technique for treating unstable pelvic ring fractures. The present study compared clinical outcomes in patients who underwent SAIS fixation within the pelvic ring with a historical control group of patients who underwent conventional trans-iliac plate fixation for the treatment of unstable pelvic ring fractures. MATERIALS AND METHODS: Thirty-two patients diagnosed with unstable pelvic fractures with sacral fracture or sacroiliac joint fracture dislocation were retrospectively evaluated. Eight consecutive patients underwent trans-iliac plate fixation from April 2012 to March 2015, and 24 consecutive patients underwent SAIS fixation from April 2015 to February 2020. Rates of soft tissue complications, intraoperative blood loss, and intraoperative blood transfusion volume were compared in these two groups. RESULTS: Mean intraoperative blood loss was significantly lower in patients who underwent SAIS fixation than in those who underwent trans-iliac plate fixation (141.0 ml vs 315.0 ml; P = 0.027), although there were no between-group differences in intraoperative blood transfusion volume (0.0 ml vs 140 ml; P = 0.105), incidence rate of soft tissue complications (4.2% vs 0%; P = 1.000), and operation time (88.5 min vs 93.0 min; P = 0.862). Bone healing was confirmed in all patients who underwent SAIS fixation without dislocation of the fracture site, whereas one patient who underwent trans-iliac plate fixation experienced a dislocation of the fracture site during follow-up (0% vs 12.5%; P = 0.250). CONCLUSIONS: SAIS fixation reduces intraoperative blood loss and ensures bone healing without major complications, including dislocation of the fracture site. SAIS fixation may therefore be an alternative, minimally invasive method of treating unstable pelvic fractures.

[A Case of Postoperative Pulmonary Metastasis of Breast Cancer with Complete Response by Abemaciclib plus Fulvestrant Therapy].

A 66-year-old woman underwent total mastectomy with level Ⅰ and Ⅱ axillary lymph node dissection for right breast cancer in July 2007. The pathology results indicated the presence of T2N0M0 invasive ductal carcinoma(tubule forming type), that was estrogen receptor-positive and human epidermal growth factor 2-negative. She received postoperative adjuvant therapy with oral anastrozole(ANA)for 5 years. Eleven years after surgery, at the age of 77 years, a chest X-ray examination during a routine health checkup identified a mass shadow in the right lung. Further investigation revealed bilateral multiple lung metastases due to breast cancer recurrence. Histological examination of a tissue obtained by computed tomography(CT)-guided lung biopsy confirmed that the histological type and subtype were identical to those found in the initial surgery. Hence, endocrine therapy with ANA plus CDK4/6 inhibitor was started in November 2018. However, the first CDK4/6 inhibitor, palbociclib, caused severe myelosuppression even when the dose was reduced by 2 levels. Therefore in January 2019, the patient was switched to abemaciclib, with the dose reduced by 1 level initially and then reduced by 2 levels from August 2019. In June 2019, new multiple lung metastases appeared, and the patient was switched from ANA to fulvestrant, after which complete response was achieved in 6 months. CT in June 2021 showed no recurrence, and the patient(now 80-year-old)continues to take abemaciclib plus fulvestrant therapy.

Risk Factors Associated with Aggravation of Cervical Spine Lesions in Patients with Rheumatoid Arthritis: A Retrospective Longitudinal Cohort Study.

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: To examine factors related to severe aggravation of preexisting cervical lesions in patients with rheumatoid arthritis (RA) under current pharmacologic treatments with biologics. SUMMARY OF BACKGROUND DATA: Advanced RA cervical lesions carry a risk of irreversible damage to the spinal cord; however, risk factors for aggravation are unclear after the use of biologics became more popular. METHODS: Of 166 patients with preexisting cervical lesions at baseline, 87 who had cervical X-ray images taken at baseline and at the final visit (with an interval of more than 1 yr) were evaluated retrospectively. Aggravated instabilities determined at the final visit, were defined as follows: atlantoaxial subluxation (AAS) = atlantodental interval ≧ 10 mm; vertebral subluxation (VS) = a Ranawat value < 10 mm; and subaxial subluxation (SAS) = an anterior vertebral slip ≧ 4 mm or a multilevel slip ≧ 2 mm. Patients were divided into two groups based on the radiographic results: severe aggravation and non-severe aggravation. Explanatory variables were gender, age of RA onset, duration of disease, average observation period, Disease Activity Score 28 based on C-reactive protein (DAS28-CRP) at baseline, drug treatment history, presence of mutilating deformities in the hands, presence of RA-related joint surgery, and the prevalence of each cervical lesion at baseline. RESULTS: The severe group comprised 14 patients (16.1%). There was no significant difference between the two groups with respect to demographic data. Multivariate logistic regression analysis revealed that preexisting SAS lesions (odds ratio: 7.59, 95% confidence interval: 1.16-49.6) and no history of biologic treatment (odds ratio, 0.10; 95% confidence interval, 0.17-0.58) were associated with aggravation. CONCLUSION: Preexisting SAS lesions were associated with aggravation. Meanwhile, biologics may be effective at preventing aggravation.Level of Evidence: 3.

[Primary Peritoneal Carcinoma with Long Term Survival-A Case Report].

A 62-year-old woman underwent upper endoscopy in January 2009 to reveal the presence of an extrinsic compression measuring approximately 3 cm in the anterior wall of the gastric antrum. Further examinations suggested that it was caused by peritoneal cancer of an unknown origin; thus, staging laparoscopy was performed in May 2009. Multiple white nodules of varying sizes were found scattered throughout the right upper quadrant of the abdomen and the right abdomen. Based on a biopsy of the greater omentum, the patient was diagnosed with papillary serous adenocarcinoma. As no abnormalities were observed in the uterus and ovary, it was suspected that the patient had primary peritoneal cancer. Hence, in July 2009, the patient underwent resection of the greater omentum, gastric pylorus, gall bladder, and right hemicolon where the tumors were localized, as well as bilateral adnexectomy. Based on intraoperative findings and postoperative histology, the patient was diagnosed with high-grade primary peritoneal serous adenocarcinoma and received paclitaxel and carboplatin therapy. Subsequent follow-up examinations, including positron emission tomography-computed tomography(PET-CT), indicated repeated recurrences in the mesentery, the pelvic floor, and around the remnant stomach. After identifying these recurrences, the patient was treated with platinum-based drugs, experiencing repeated response and cessation cycles. Since September 2019, the patient has received olaparib therapy. PET-CT examination performed in September 2020 indicated that the patient remained in complete remission.

Analysis of the risk factors for tracheostomy and decannulation after traumatic cervical spinal cord injury in an aging population.

STUDY DESIGN: Retrospective study. OBJECTIVES: To investigate the risk factors associated with tracheostomy after traumatic cervical spinal cord injury (CSCI) and to identify factors associated with decannulation in an aging population. SETTING: Advanced critical care and emergency center in Yokohama, Japan. METHODS: Sixty-five patients over 60 years with traumatic CSCI treated between January 2010 and June 2017 were enrolled. The parameters analyzed were age, sex, American Spinal Injury Association impairment scale score (AIS) at admission and one year after injury, neurological level of injury (NLI), injury mechanism, Charlson's comorbidity index (CCI), smoking history, radiological findings, intubation at arrival, treatment choice, length of intensive care unit (ICU) stay, tracheostomy rate, improvement of AIS, decannulation rate, and mortality after one year. RESULTS: The study included 48 men (74%; mean age 72.8 ± 8.3 years). Twenty-two (34%), 10 (15%), 24 (37%), and 9 (14%) patients were classified as AIS A, B, C, and D, respectively. The tracheostomy group showed significantly more severe degree of paralysis, more patients with major fractures or dislocations, more operative treatment, longer ICU stay, poorer improvement in AIS score after one year and higher rate of intubation at arrival. AIS A at injury was the most significant risk factor for tracheostomy. The non-decannulation group had a significantly higher mortality. The risk factor for failure of decannulation was CCI. CONCLUSIONS: Risk factors for tracheostomy after traumatic CSCI were AIS A, operative treatment, major fracture/dislocation, and intubation at arrival. The only factor for failure of decannulation was CCI.

Combined teriparatide and denosumab therapy accelerates spinal fusion following posterior lumbar interbody fusion.

INTRODUCTION: Previous studies reported that teriparatide (recombinant human parathyroid hormone) accelerated spinal fusion following posterior lumbar inter-body fusion surgery, and combination therapy using teriparatide and denosumab increased bone marrow density more than teriparatide alone. The purpose of this study is to evaluate the influence of combination therapy with teriparaide and denosumab on spinal fusion after posterior lumbar interbody fusion. MATERIALS AND METHODS: Sixteen osteoporotic patients with lumbar canal stenosis were randomly divided into two treatment groups, a teriparatide group (n=8; 20µg of teriparatide daily alone, administered from a month before surgery to 12 months after surgery) and a combination group (n=8; 20µg of teriparatide administered daily from a month before surgery to 12 months after surgery with 60mg denosumab every 6 months, administered at 2 and 8 months following surgery). All patients underwent posterior lumbar interbody fusion with local bone grafts. At 3, 6, 9, and 12 months following surgery, bone mineral density at the femoral neck was measured, and biochemical markers were obtained for bone turnover for all cases. Clinical findings were quantified using the Japanese Orthopedic Association scores before surgery, and at 6 and 12 months following surgery. Fusion rates were measured using computed tomography images before surgery, and 6 and 12 months following surgery. RESULTS: Alkaline phosphatase in the teriparatide group increased more than in the combination group at 3 months following surgery (p<0.05). Femoral neck BMD increased more in the combination group than in the teriparatide group at 12 months following surgery. The combination group achieved higher fusion rates than the teriparatide group at 6 months following surgery. CONCLUSIONS: Combination therapy with teriparatide and denosumab increased bone mineral density more than teriparatide alone, and accelerated spinal fusion following posterior lumbar interbody fusion.

[A Case of Recurrent Breast Cancer with Complete Response to Eribulin Monotherapy after Bevacizumab plus Paclitaxel Combination Therapy].

A 65-year-old woman underwent mastectomy and dissection of a level I axillary lymph node in January 2002 for left breast cancer. The diagnosis was T1N0M0 scirrhous carcinoma that was estrogen receptor-positive, progesterone receptorpositive, and human epidermal growth factor receptor 2-negative. After 3 years 10 months, during which the patient underwent adjuvant therapy with oral aromatase inhibitors, she developed bilateral multiple lung metastases. These were treated with the anticancer agents anthracycline and taxane. Progressive disease(more and larger lung metastases)was diagnosed in April 2013, and bevacizumab plus paclitaxel combination therapy was started. After completion of 4 courses, a lung abscess appeared, which was conjectured to represent rapid tumor necrosis that had become infected. As several tumors remained solid even after the lung abscess improved, the patient received 18 courses of eribulin monotherapy. Computed tomography in April 2016 revealed only patches of linear or cord-like scarring in both lungs, with no metastatic or recurrent foci. In this case, a patient with recurrent breast cancer responded to the sequential administration of bevacizumab plus paclitaxel combination therapy followed by eribulin monotherapy.

The surgical outcome of decompression alone versus decompression with limited fusion for degenerative lumbar scoliosis.

OBJECTIVE The aim of this study was to assess the usefulness of radiological parameters for surgical decision-making in patients with degenerative lumbar scoliosis (DLS) by comparing the clinical and radiological results after decompression or decompression and fusion surgery. METHODS The authors prospectively planned surgical treatment for 298 patients with degenerative lumbar disease between September 2005 and March 2013. The surgical method used at their institution to address intervertebral instability is precisely defined based on radiological parameters. Among 64 patients with a Cobb angle ranging from 10° to 25°, 57 patients who underwent follow-up for more than 2 years postoperatively were evaluated. These patients were divided into 2 groups: those in the decompression group underwent decompression alone (n = 25), and those in the fusion group underwent decompression and short segmental fusion (n = 32). Surgical outcomes were reviewed, including preoperative and postoperative Cobb angles, lumbar lordosis based on radiological parameters, and Japanese Orthopaedic Association (JOA) scores. RESULTS The JOA scores of the decompression group and fusion group improved from 5.9 ± 1.6 to 10.0 ± 2.8 and from 7.2 ± 2.0 to 11.3 ± 2.8, respectively, which was not significantly different between the groups. At the final follow-up, the postoperative Cobb angle in the decompression group changed from 14° ± 2.9° to 14.3° ± 6.4° and remained stable, while the Cobb angle in the fusion group decreased from 14.8° ± 4.0° to 10.0° ± 8.5° after surgery. CONCLUSIONS The patients in both groups demonstrated improved JOA scores and preserved Cobb angles after surgery. The improvement in JOA scores and preservation of Cobb angles in both groups show that the evaluation of spinal instability using radiological parameters is appropriate for surgical decision-making.

Risk factors associated with mortality after traumatic cervical spinal cord injury.

OBJECTIVES: To investigate the mortality rate following cervical spinal cord injury (SCI) injury and analyze the associated risk factors. DESIGN: Retrospective cohort study. SETTING: One Level 1 trauma center. PATIENTS/PARTICIPANTS: A cohort of 76 patients with traumatic cervical SCI was reviewed between January 2010 and May 2015, of which 54 patients were selected for the present retrospective study. INTERVENTION: Operative or conservative treatment. MAIN OUTCOME MEASUREMENTS: The following patient parameters were analyzed; age, sex, American Spinal Injury Association (ASIA) impairment scale, neurological impairment level, injury mechanism, radiological findings, treatment, tracheostomy rate, and mortality. RESULTS: The mean age of the patient cohort was 65 ±â€Š17 years, with 11 females (20%) and 43 males (80%). A total of 16 (30%), 4 (7%), 22 (41%), and 12 patients (22%) were scored A, B, C, and D, respectively, on the ASIA impairment scale. Most of the injuries were at the C4 (30%) and C5 (33%) levels. Falls from standing (35%) and heights (39%) were the most common injury mechanisms. SCI in 40 patients (74%) occurred without major fracture or dislocation. Surgery was performed on 26 patients. The overall mortality was 19%. Patients in the deceased group were significantly older at the time of injury, compared with those who survived. Paralysis had been more severe in the deceased group. A significantly high number of patients in the deceased group received a tracheostomy. When analyzed using a multivariate logistic regression model, an ASIA impairment scale of A was a significant risk factor for mortality. CONCLUSIONS: The risk factors associated with mortality were age, tracheostomy, and an ASIA impairment scale of A, the latter had the highest risk. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

[Total Gastrectomy for Advanced Gastric Cancer after Coronary Artery Bypass Grafting Using the Right Gastroepiploic Artery: Report of a Case].

An 82-year-old man, who had undergone coronary artery bypass grafting(CABG) with the right gastroepiploic artery( RGEA) 13 years previously, suffered with abdominal pain after meal and tarry stools, and was diagnosed with advanced gastric cancer. Gastroscopy revealed an advanced Borrmann type 4 cancer at the lesser curvature of the gastric body to the pyloric ring. The gastrogram showed poor extension and stenosis at the same part. Abdominal computed tomography showed the tumor reached the subserosal layer and infrapyloric lymph nodes were swollen. Abdominal angiography showed the RGEA graft remained well patent. Total gastrectomy with D2 lymph nodes dissection and arterial reconstruction between the splenic artery and the RGEA graft was performed. He has been well without any sign of cancer recurrence since the operation. Recently, more patients with CABG using RGEA are found to have gastric cancer and require the resection of RGEA for lymph nodes dissection as this case. We consider this procedure one of the options for advanced gastric cancer after coronary bypass grafting using RGEA.

Primary left atrial tumor showing mitral valve stenosis and left upper lobe pulmonary edema: report of a case.

Myxoma and other neoplasms in the left atrium often show signs and symptoms similar to those of mitral valve stenosis. Malignant fibrous histiocytoma, one of the most common sarcomas, occurs in the deep soft tissue of the limbs and retroperitoneum in adults. With the exception of primary lung cancer, however, sarcomatous intravascular extension in the lung and infiltration into the left atrium are rare. We report a case of overt left upper lobe pulmonary edema observed on chest radiograms and a mass occupying much of the left atrium and exhibiting hemodynamics similar to those of mitral valve stenosis on transthoracic echocardiography. Intraoperative and pathologic examination showed the mass to be a primary malignant fibrous histiocytoma extending from the left upper pulmonary vein into the left atrium.