[Exploratory study on spinal musculoskeletal health of osteopathy students]. / Étude exploratoire de la santé musculo-squelettique du rachis d'étudiants en ostéopathie.

BACKGROUND: During their training, students in osteopathy regularly undergo spinal manipulation exercises. This exposes the students' spine to unskilled gestures performed by their colleagues learning spinal manipulation. Discomfort, muscle soreness or moderate pain following spinal manipulations lasting two or three days are commonly reported. In addition, some students may have ongoing spinal musculoskeletal disease (SMSD) during their studies. The purpose of this study was to evaluate the prevalence of SMSDs and their maximum intensity in a population of osteopathy students and to determine whether individual differences exist. METHOD: An exploratory cross-sectional study took place over three years. Data were collected by means of a self-administrated standardised questionnaire screening for MSD: the Nordic questionnaire. RESULTS: There were 733 exploitable questionnaires, giving an average response rate of 91.5%. Average prevalence of SMSD was 98.4% during the last 12 months. Average maximum intensity perceived was 6/10 and 45% of students experienced an intense SMSD (scored between 7 and 10/10). Variation of the maximum intensity of SMSD between "before osteopathy studies" and "the last 12 months" was 1.2/10. This variation was influenced by the number of days students were manipulated during a week (p<0.0001). On average, students underwent manipulation three days a week. CONCLUSION: This study confirms the important prevalence of SMSD among osteopathy students. This result led us to carry out a qualitative study for exploring students' conceptions in health and spinal manipulative practices.

Lumbar vertebral osteoradionecrosis: a rare case report with 10-year follow-up and brief literature review.

BACKGROUND: Osteoradionecrosis (ORN) is a complication that occurs after radiotherapy for head or neck malignancies. ORN of the spine is rare, with only few cases affecting the cervical spine reported to date. To our knowledge, no case of lumbar ORN has been reported. We report a rare case of ORN in the lumbar spine that occurred 2 years after radiotherapy and perform a literature review. CASE PRESENTATION: We present a case of lumbar ORN that occurred 2 years after radiotherapy for gallbladder carcinoma. The patient was successfully treated conservatively and followed up for > 10 years. CONCLUSIONS: ORN of the spine is a rare complication of radiotherapy. Spinal ORN is clinically described as a chronic disease with a slow onset. The most common presenting symptom of spinal ORN is pain. However, as ORN progresses, spinal kyphosis and instability can lead to neurological compression and thus to induced myelopathy or radiculopathy. Treatment of spinal ORN is comprehensive, including orthosis, medication, hyperbaric oxygen therapy, surgery, and new treatment combinations of pentoxifylline and tocopherol. The surgical rate for spinal ORN is relatively high.

A patient with extensive cerebral calcification due to pseudohypoparathyroidism: a case report.

BACKGROUND: Pseudohypoparathyroidism(PHP) is a heterogeneous group of disorders due to impaired activation of c AMP dependant pathways following binding of parathyroid hormone (PTH) to its receptor. In PHP end organ resistance to PTH results in hypocalcaemia, hyperphosphataemia and high PTH levels. CASE PRESENTATION: A 59 year old male presented with a history of progressive impairment of speech and unsteadiness of gait for 1 week and acute onset altered behavior for 1 day and one episode of generalized seizure. His muscle power was grade four according to MRC (medical research council) scale in all limbs and Chovstek's and Trousseau's signs were positive. Urgent non contrast computed tomography scan of the brain revealed extensive bilateral cerebral and cerebellar calcifications. A markedly low ionized calcium level of 0.5 mmol/l, an elevated phosphate level of 9.5 mg/dl (reference range: 2.7-4.5 mg/dl) and an elevated intact PTH of 76.3 pg/l were noted. His renal functions were normal. His hypocalcemia was accentuated by the presence of hypomagnesaemia. His 25 hydroxy vitamin D level was only marginally low which could not account for severe hypocalcaemia. A diagnosis of pseudohypoparathyroidism without phenotypic defects, was made due to hypocalcaemia and increased parathyroid hormone levels with cerebral calcifications. The patient was treated initially with parenteral calcium which was later converted to oral calcium supplements. His coexisting Vitamin D deficiency was corrected with 1αcholecalciferol escalating doses. His hypomagnesaemia was corrected with magnesium sulphate parenteral infusions initially and later with oral preparations. With treatment there was a significant clinical and biochemical response. CONCLUSION: Pseudohypoparathyroidism can present for the first time in elderly resulting in extensive cerebral calcifications. Identification and early correction of the deficit will result in both symptomatic and biochemical response.

Turning the backbone into an ankylosed concrete-like structure: Case report.

RATIONALE: Progressive restriction of the spinal bio-mechanics is not-uncommon deformity encountered in spine clinics. Congenital spinal fusion as seen in Klippel-Feil-anomaly, progressive non-infectious anterior vertebral fusion, and progressive spinal hyperostosis secondary to ossification of the anterior longitudinal spinal ligament are well delineated and recognized. PATIENT CONCERNS: A 24-year-old girl has history of osteoporosis since her early childhood, associated with multiple axial and appendicular fractures and scoliosis. Recently she presented with episodes of severe back pain, spinal rigidity/stiffness with total loss of spine biomechanics. DIAGNOSES: She was provisionally diagnosed as having osteogenesis imperfecta and was investigated for COL1A1/A2 mutations which have been proven to be negative. Autosomal recessive type of osteogenesis imperfecta was proposed as well, no mutations have been encountered. A homozygous for CTSA gene mutation, the gene associated with Galactosialidosis was identified via whole exome sequencing (Next-Generation Sequencing projects) has been identified. INTERVENTIONS: Early in her life she had a history of frequent fractures of the long bones since she was 4 years which was followed by vertebral fractures at the age of 12 years. She manifested lower serum 25OH-D levels and were associated with lower LS-aBMD Z-scores with higher urinary bone turnover indexes (urinary NTX/Cr). OUTCOMES: Lysosomal storage diseases (LSD) have a strong correlation with the development of osteoporosis. LSD causes skeletal abnormalities results from a lack of skeletal remodeling and ossification abnormalities owing to abnormal deposition of GAGs (impaired degradation of glycosaminoglycans ) in bone and cartilage. 3D reconstruction CT scan of the spine showed diffuse hyperostosis of almost the entire spine (begins at the level of T4- extending downwards to involve the whole thoraco-lumbar and upper part of the sacrum) with total diffuse fusion of the pedicles, the transverse and articular processes, the laminae and the spinous processes. LESSONS: This is the first clinical report of adult patient with a history of osteoporosis and fractures with the late diagnosis of Galactosialidosis. Osteogenesis imperfecta (autosomal dominant and recessive) were the first given diagnoses which proven negative. The pathophysiology of the spine ankylosis in our current patient and its correlation with LSD, antiresorptive medications, vitamin D3 and supplemental calcium is not fully understood. Therefore, further studies are needed to elucidate this sort of correlation.

Graft subsidence as a predictor of revision surgery following stand-alone lateral lumbar interbody fusion.

OBJECTIVE Lateral lumbar interbody fusion (LLIF) is a less invasive surgical option commonly used for a variety of spinal conditions, including in high-risk patient populations. LLIF is often performed as a stand-alone procedure, and may be complicated by graft subsidence, the clinical ramifications of which remain unclear. The aim of this study was to characterize further the sequelae of graft subsidence following stand-alone LLIF. METHODS A retrospective review of prospectively collected data was conducted on consecutive patients who underwent stand-alone LLIF between July 2008 and June 2015; 297 patients (623 levels) met inclusion criteria. Imaging studies were examined to grade graft subsidence according to Marchi criteria, and compared between those who required revision surgery and those who did not. Additional variables recorded included levels fused, DEXA (dual-energy x-ray absorptiometry) T-score, body mass index, and routine demographic information. The data were analyzed using the Student t-test, chi-square analysis, and logistic regression analysis to identify potential confounding factors. RESULTS Of 297 patients, 34 (11.4%) had radiographic evidence of subsidence and 18 (6.1%) required revision surgery. The median subsidence grade for patients requiring revision surgery was 2.5, compared with 1 for those who did not. Chi-square analysis revealed a significantly higher incidence of revision surgery in patients with high-grade subsidence compared with those with low-grade subsidence. Seven of 18 patients (38.9%) requiring revision surgery suffered a vertebral body fracture. High-grade subsidence was a significant predictor of the need for revision surgery (p < 0.05; OR 12, 95% CI 1.29-13.6), whereas age, body mass index, T-score, and number of levels fused were not. This relationship remained significant despite adjustment for the other variables (OR 14.4; 95% CI 1.30-15.9). CONCLUSIONS In this series, more than half of the patients who developed graft subsidence following stand-alone LLIF required revision surgery. When evaluating patients for LLIF, supplemental instrumentation should be considered during the index surgery in patients with a significant risk of graft subsidence.

Treating the Aging Spine.

Demographic trends make it incumbent on orthopaedic spine surgeons to recognize the special challenges involved in caring for older patients with spine pathology. Unique pathologies, such as osteoporosis and degenerative deformities, must be recognized and treated. Recent treatment options and recommendations for the medical optimization of bone health include vitamin D and calcium supplementation, diphosphonates, and teriparatide. Optimizing spinal fixation in elderly patients who have osteoporosis is critical; cement augmentation of pedicle screws is promising. In the management of geriatric odontoid fractures, nonsurgical support with a collar may be considered for low-demand patients, whereas surgical fixation is favored for high-demand patients. Management of degenerative deformity must address sagittal plane balance, which includes consideration of pelvic incidence. Various osteotomies may prove helpful in this setting.

Efficiency of Hyperbaric Oxygen Therapy in Iatrogenic Spinal Infections.

STUDY DESIGN: Retrospective clinical study. OBJECTIVE: The aim of this study is to reveal the effectiveness of HBO therapy in iatrogenic spinal infections intractable to antibiotic therapy alone. SUMMARY OF BACKGROUND DATA: The efficiency of hyperbaric oxygen (HBO) therapy, which is currently being used in many areas, has been proven in infections in deep and superficial locations and in osteomyelitis. The aim of this study is to reveal effectives of HBO therapy in iatrogenic spinal infections intractable to antibiotic alone therapy. METHODS: HBO therapy was given to 19 cases of iatrogenic spinal infection between 2008 and 2013. Adjuvant HBO therapy was applied to cases that had exhibited no improvement in clinical and laboratory findings despite medical treatment for at least 3 weeks. Several parameters including demographic characteristics, surgical area, etiology and the surgical treatment modality, microbiology (culture material and causative organism), clinical and laboratory results, duration of HBO therapy, and outcome were reviewed. RESULTS: The mean age was 54.6 years (range: 32-75 years). Iatrogenic spinal infections were most frequent in the lumbar region. It occurred after spine instrumentation in 12 cases and after micro-discectomy in 7 cases. The average number of HBO therapy sessions applied was 20.1 (range: 10-40). Wound discharge and clinical and laboratory findings recovered in all cases at the end of the therapy course. No revision or removal of the instrumentation was necessary in the instrumented cases. CONCLUSION: HBO therapy is a treatment modality, which is safe and efficient as an adjuvant therapy in the treatment of infections. It was also seen to be effective in the prevention of revision procedures and instrumentation failures in iatrogenic osteomyelitis cases, which had occurred following spinal instrumentation. LEVEL OF EVIDENCE: 4.

Tissue-engineered bone formation in vivo for artificial laminae of the vertebral arch using ß-tricalcium phosphate bioceramics seeded with mesenchymal stem cells.

STUDY DESIGN: A rabbit laminectomy model was used to evaluate the efficacy of artificial laminae of vertebral arch using bone marrow-derived mesenchymal stem cells (MSCs) transplanted in porous beta-calcium phosphates (ß-TCP) bioceramics. OBJECTIVE: The aim of this study was to establish artificial lamina of the vertebral arch for bone tissue engineering using ß-TCP bioceramics seeded with MSCs in a rabbit model of decompressive laminectomy. SUMMARY OF BACKGROUND DATA: Decompressive laminectomy may induce various degrees of scar tissue and adhesion formation in the epidural space, and thus is the most common cause of failed back surgery syndrome. However, there is no effective method of bone defect treatment to control and reduce the scar tissue formation. METHODS: MSCs were harvested from New Zealand rabbits (2-week old) by femoral bone marrow extraction. These cells were seeded into porous ß-TCP bioceramics and cultivated for up to 3 weeks in the presence of osteogenic supplements. Segmental defects (20 × 8 mm) were created in 48 adult New Zealand rabbits that underwent laminectomy at the L5 to L6 levels. The animals were transplanted with cell media (control), ß-TCP bioceramics (group I), or MSC-loaded ß-TCP bioceramics (group II). Bone formation was evaluated after operation using scanning electron microscopy, computed tomography, magnetic resonance imaging, histomorphometry, and immunohistochemistry. RESULTS: Scanning electron microscopy showed that MSCs filled the pores and surfaces of bioceramics in MSC-loaded ß-TCP. In addition, significant increases in bone formation were observed in group II compared with other groups. Computed tomography and magnetic resonance imaging at 16 weeks showed that the artificial lamina of the vertebral arch was successfully formed. Hematoxylin-eosin and Masson trichrome staining were used to show the artificial laminae of the vertebral arch and the degraded bioceramics. In addition, immunohistochemistry results showed that the expression of bone morphogenetic protein-2 increased significantly in group II compared with group I at 2,4, and 8 weeks after implantation (P < 0.05). CONCLUSION: ß-TCP bioceramics seeded with MSCs are a promising source of tissue-engineered bone for the artificial lamina of the vertebral arch.

Factors influencing the evaluation and management outcomes of coccygodynia: a literature review.

BACKGROUND: This paper reviews various methods for the assessment and management of the coccygodynia. It included review of both conservative as well as operative methods. Goal of conservative methods in coccygodynia is to restore the functional status of the patients and to eliminate or at least minimize the discomfort associated with this disabling condition. Though various conservative methods have been used traditionally, yet not all patients respond positively to them. In such cases operative interventions are used, yet previous literature does suggest that even this method is not absolutely promising as not all patients do respond positively to it. METHODOLOGY: The purpose of this article is to review various literatures available for the assessment and the management of coccygodynia. It tends to identify the factors which could guide the selection of best intervention strategy for its management. English literature databases were searched to find the studies matching the predetermined inclusion criteria. CONCLUSION: Multiple factors (pathology, duration of pain, Body mass index, neurotic personality, associated disc pathologies, amount of inter-coccygeal movement) influence the outcomes of the remedial interventions. This study highlights multiple treatment approaches for the rehabilitation of the coccygodynia management.

Myeloneuropathy due to copper deficiency: clinical and MRI findings after copper supplementation.

Acquired copper deficiency constitutes an under-recognised cause of myelopathy. Aim of the study was to describe the clinical and imaging features at admission and after copper supplementation of a patient with acquired copper deficiency myeloneuropathy. A 73-year-old woman presented with anaemia and signs of posterior column dysfunction. Somatosensory evoked potentials showed impaired central pathway conduction. Serum copper and caeruloplasmin levels were low. Nerve conduction assessment revealed axonal polyneuropathy. Spinal magnetic resonance imaging (MRI) showed posterior column hyperintensity. Diffusion tensor imaging disclosed decreased fractional anisotropy (FA) corresponding to the hyperintensity. Copper supplementation normalised the haematological picture, whereas vibratory sensitivity was only slightly improved. Control MRI revealed a slight hyperintensity at C1-C2 level; FA values normalised. In conclusion, in acquired copper-deficiency-associated myelopathy, correction of blood and MRI alterations precedes that of neurological manifestations, which may remain suboptimal.

[The use of baclosan in the complex therapy of muscle-tonic and myofascial pain syndromes in patients with dorsopathy].

Baclosan (baclofen), a GABA analogue, has been used in the treatment of 20 patients, aged 20-56 years, with a pain syndrome in dorsopathy of lumbar spine. Baclosan has been administered in the increasing dosages (from 10 mg to 30 mg per day) for 4 weeks in conjunction with traditional therapy (symptomatic pharmacotherapy, physiotherapy, reflexotherapy etc).The control group consisted of 10 patients who received only basic therapy (without baclosan). Patient's status has been measured clinically and with several scales. The results obtained allow to conclude that baclosan exerts a positive effect in the pain syndrome caused by dorsopathy. Its inclusion to the complex therapy reduces both the pain intensity and the degree of muscle-tonic tension as well as improves the motor function and emotional state of patients.

A case of vertebral metastasis with pathologic c2 fracture.

OBJECTIVE: This report discusses a patient with a pathologic fracture of the C2 vertebra secondary to osteolytic metastasis from squamous cell carcinoma of the lung. CLINICAL FEATURES: The patient was a 68-year-old man with a chief complaint of neck pain who was referred by his physician to a chiropractic office. The initial onset of neck pain began after a forceful sneeze that resulted in a sensation of "a twig snapping" in the neck. Radiographs revealed osteolytic destruction and pathologic fracture of the C2 spinous process. INTERVENTION AND OUTCOME: The patient was referred back to his primary care physician, who then referred him to an oncologist, who immediately initiated a course of radiation therapy and pain medication. Palliative care by the chiropractor consisted of soft tissue massage of the cervical spine musculature to treat associated muscle spasms and pain. The patient responded well to gentle myofascial therapy. However, the osteolytic destruction of the C2 posterior elements progressed, resulting in an unstable subluxation of C2 and associated cord compression. The spine was stabilized with a rigid collar, but the metastatic destruction progressed, eventually resulting in quadriplegia and subsequent death from respiratory distress. CONCLUSION: Patients with a history of cancer complaining of new onset of back or neck pain should be assumed to have vertebral metastasis until proven otherwise. Trivial trauma should be taken seriously in these cases and investigated with appropriate clinical, laboratory, and imaging examinations. Vertebral malignancies may be a contraindication to spinal manipulation; however, the chiropractic physician plays a significant role in early detection and diagnosis.

Acupuncture needles causing lumbar cerebrospinal fluid fistula. Case report.

Acupuncture is a frequently used adjuvant treatment for chronic pain conditions. The authors report the case of a patient in whom the delayed migration of embedded acupuncture needles into the lumbar spinal canal caused the formation of a cerebrospinal fluid fistula and spine-related headache. The needles were safely removed surgically and the patient improved clinically.

Intracranial hypotension with spinal pathology.

BACKGROUND CONTEXT: Intracranial hypotension (IH) is a syndrome in which volume depletion of the cerebrospinal fluid (CSF) results in various neurological symptoms. Most commonly, a small tear or defect in the spinal dural sac is the underlying lesion that results in a CSF leakage and IH. Causes of IH can be classified as 1) spontaneous (primary), and 2) secondary. Knowledge of IH is essential to spine surgeons, because a small proportion of patients with spontaneous IH require spine surgery, and secondary causes of IH include spine trauma, various spine-related diagnostic/therapeutic procedures (iatrogenic), and degenerative spine disorders. PURPOSE: The purpose of this review is to update knowledge of IH pertinent to spine surgery. STUDY DESIGN/SETTING: Review of the literature. METHODS: A systematic review of the literature was conducted using PUBMED. The literature regarding IH with spinal pathology published from 1966 to 2005 was searched and reviewed comprehensively. RESULTS/CONCLUSIONS: The lower cervical and upper thoracic spine are the predilection sites for a CSF leak in patients with spontaneous IH. Mechanical stress may have a role in the pathogenesis of spontaneous IH, and meningeal diverticula and connective tissue disorders may be important risk factors. Iatrogenic causes of IH include lumbar puncture, spine surgery, and chiropractic manipulation. Rarely, degenerative spine disorders are the secondary cause of IH. Although orthostatic headache is the characteristic symptom of IH, a small proportion of patients present with neck pain or radicular symptoms of the upper extremity. Imaging studies of the spine have contributed significantly to elucidation of the pathophysiology of IH as well as identification of the site of a CSF leak. Typical spinal radiographic findings of IH include extra-arachnoid or extradural fluid collections, meningeal enhancement, engorgement of the epidural venous plexus, and tonsilar descent into the foramen magnum. Most patients with spontaneous IH respond favorably to conservative management, including autologous epidural blood patch. Surgical intervention is reserved for those who fail the conservative management. Although immediate clinical improvement is usually achieved by surgery, the long-term outcomes of surgical patients need to be investigated further. In patients who have a secondary cause of IH, treatment of the underlying lesion or condition may terminate a CSF leak and result in reversal of symptoms.

Cervical myelopathy induced by pseudogout in ligamentum flavum and retro-odontoid mass: a case report.

STUDY DESIGN: Retrospective case study. OBJECTIVES: Report a rare case of cervical myelopathy induced by calcium pyrophosphate dehydrate (CPPD) deposition in multiple cervical levels. SETTING: An area teaching hospital in Taiwan. METHOD: A patient with cervical myelopathy was evaluated by computerized tomography (CT) scan and magnetic resonance (MR) image. CPPD deposition known as pseudogout was diagnosed and approved by a polarized microscope. RESULT: A prominent hypertrophy of ligmentum flavum and a retro-odontoid bulging mass induced cord compression were found in CT scan and MR image. CPPD deposition was confirmed by the histological examinations in the ligamentum flavum at the spinal levels of C3-C6. After decompression surgery of spine and comprehensive rehabilitation, the patient's neurological symptoms subsided and her neurological functions improved leading to a good prognosis. CONCLUSION: CPPD deposition in cervical spine occurring at multiple levels is rare. Image studies with CT scan and MR are complementary in the diagnosis of CPPD-induced myelopathy. Surgical decompression is always required and expected to have a good outcome.

Symptomatic hematoma of cervical ligamentum flavum: case report.

STUDY DESIGN: A case of symptomatic hematoma of cervical ligamentum flavum. OBJECTIVE: To report the first ligamentum flavum hematoma in the cervical spine and review the reported cases. SUMMARY OF BACKGROUND DATA: A herniated nucleus pulposis, spondylosis, epidural hematoma or abscess, neoplasm, or some pathology of the ligamentum flavum, such as hypertrophy, ossification, or calcification, are the most common causes of spinal cord and nerve root compression. A ligamentum flavum hematoma has also been reported as a cause of compression of the cauda equina and lumbar nerve roots but has never been found in the cervical spine. METHODS: A 72-year-old man presented with left upper arm pain and left hemiparesis following traditional massage therapy. Admission magnetic resonance images showed a posterior oval-shaped mass that was continuous with the ligamentum flavum at C3-C4 level. RESULTS: A C3-C4 laminectomy for decompression and resection of the lesion was performed. One year after surgery, the patient remained neurologically intact and symptom-free. CONCLUSIONS: Hematoma of the ligamentum flavum occurring in the cervical spine has never been reported previously. Repeated trivial injury on a degenerative ligamentum flavum might be the leading predisposing factor. Spine surgeons should be aware of a hematoma in the ligamentum flavum as a possible cause of spinal cord or root compression, especially in the mobile cervical and lumbar spine.