Predictive Factors for Sustained Pain after (sub)acute Osteoporotic Vertebral Fractures. Combined Results from the VERTOS II and VERTOS IV Trial.

PURPOSE: Osteoporotic vertebral compression fractures are treated conservatively or in selected cases with percutaneous vertebroplasty (PV). The purpose of this retrospective analysis is to determine predictive factors for a high visual analogue scale (VAS) pain score after conservative, sham or PV and is based on previously published randomized trials. METHODS: The VERTOS II compared conservative versus PV, and VERTOS IV compared sham versus PV treatment. The conservative group received pain medication. The sham and PV group received subcutaneous lidocaine/bupivacaine. In addition, the PV group received cementation, which was simulated in the sham group. Nineteen different predictors of high (≥ 5) versus low (< 5) VAS pain score at 12 months were investigated. RESULTS: 20.7% of patients in the PV group demonstrated a VAS ≥ 5 at the 12-month, compared to 40.1% in the conservative or sham group, with a significant difference (χ2(1) = 15.26, p < 0.0001, OR = 2.57, 95% CI = 1.59 to 4.15). In the subgroup analysis, we detected five predictors for the risk of high pain scores (VAS ≥ 5 after 12 months follow-up), namely: female, baseline VAS > 8, long-term baseline pain, mild/severe Genant and new fractures. CONCLUSIONS: Statistically significant more patients had a high pain score at 12 months in the sham and conservative group when compared with the PV group. Five predictors were identified for sustained high local back pain, regardless of the received treatment. Patients with moderate fracture deformity were less likely to have high pain scores at 12 months if they received PV than if they had sham or conservative therapy.

Feasibility of Combined Doppler-ECG Assessment of Internal Jugular Veins.

A standardized combined Doppler-electrocardiography technique was developed for measurement of the triphasic waveform characteristics in the internal jugular vein. Flow velocities at the A, X, V and Y peaks, the RR interval and the PA and RX times were measured. From these the venous impedance index ([X-A]/X) and the ratios PA/RR and RX/RR were calculated. Six measurements were performed at three different locations by two ultrasonographers in 21 randomly selected pregnant and non-pregnant women. Statistical models proved the feasibility and reproducibility of this technique, with the highest concordance correlation coefficients in the right distal internal vein. Bootstrapping revealed that repeating the measurements more than four times would not significantly enhance the precision of the estimated mean. Concordance correlation coefficients for the venous impedance index, PA time and PA/RR ratio were >0.63 for all three locations, proving their possible use in ongoing and future studies, analogous to previous studies in kidney and liver.

Criteria for the appropriate treatment of osteoporotic vertebral compression fractures.

BACKGROUND: The heterogeneity of patients with osteoporotic vertebral compression fractures (VCF) necessitates a tailored approach of balancing the benefits and limitations of available treatments. Current guidelines are divergent, sometimes contradictory, and often insufficiently detailed to guide practice decisions. OBJECTIVES: This study aimed at establishing treatment recommendations at the patient-specific level. STUDY DESIGN: Using the RAND/UCLA Appropriateness Method (RAM), the appropriateness of different treatment options for osteoporotic VCFs was assessed. SETTING: The assessment was conducted by a European multidisciplinary panel of 12 experts. METHODS: The appropriateness of non-surgical management (NSM), vertebroplasty (VP), and balloon kyphoplasty (BKP) was determined for 128 hypothetical patient profiles. These were unique combinations of clinical factors considered relevant to treatment choice (time since fracture, MRI findings, impact and evolution of symptoms, spinal deformity, ongoing fracture process, and pulmonary dysfunction). After 2 individual rating rounds and plenary meetings, appropriateness statements (appropriate, inappropriate, and uncertain) were calculated for all clinical scenarios. RESULTS: Disagreement dropped from 31% in the first round to 7% in the second round. Appropriateness outcomes showed specific patterns for the 3 treatments. For three-quarters of the profiles, only one treatment was considered appropriate: NSM 25%, VP 6%, and BKP 45%. NSM was usually appropriate in patients with a negative MRI or a positive MRI without other unfavorable conditions (poor outcomes for the other variables). VP was usually appropriate in patients with a positive MRI, time since fracture ≥ 6 weeks, and no spinal deformity. BKP was recommended for all patients with an ongoing fracture process, and also in most patients with a positive MRI and ≥ 1 other unfavorable factor. LIMITATIONS: The prevalence of the patient profiles in daily practice is yet unknown. CONCLUSION: The panel results may help to support treatment choice in the heterogeneous population of patients with osteoporotic VCF.

Vertebroplasty versus conservative treatment in acute osteoporotic vertebral compression fractures (Vertos II): an open-label randomised trial.

BACKGROUND: Percutaneous vertebroplasty is increasingly used for treatment of pain in patients with osteoporotic vertebral compression fractures, but the efficacy, cost-effectiveness, and safety of the procedure remain uncertain. We aimed to clarify whether vertebroplasty has additional value compared with optimum pain treatment in patients with acute vertebral fractures. METHODS: Patients were recruited to this open-label prospective randomised trial from the radiology departments of six hospitals in the Netherlands and Belgium. Patients were aged 50 years or older, had vertebral compression fractures on spine radiograph (minimum 15% height loss; level of fracture at Th5 or lower; bone oedema on MRI), with back pain for 6 weeks or less, and a visual analogue scale (VAS) score of 5 or more. Patients were randomly allocated to percutaneous vertebroplasty or conservative treatment by computer-generated randomisation codes with a block size of six. Masking was not possible for participants, physicians, and outcome assessors. The primary outcome was pain relief at 1 month and 1 year as measured by VAS score. Analysis was by intention to treat. This study is registered at ClinicalTrials.gov, number NCT00232466. FINDINGS: Between Oct 1, 2005, and June 30, 2008, we identified 431 patients who were eligible for randomisation. 229 (53%) patients had spontaneous pain relief during assessment, and 202 patients with persistent pain were randomly allocated to treatment (101 vertebroplasty, 101 conservative treatment). Vertebroplasty resulted in greater pain relief than did conservative treatment; difference in mean VAS score between baseline and 1 month was -5·2 (95% CI -5·88 to -4·72) after vertebroplasty and -2·7 (-3·22 to -1·98) after conservative treatment, and between baseline and 1 year was -5·7 (-6·22 to -4·98) after vertebroplasty and -3·7 (-4·35 to -3·05) after conservative treatment. The difference between groups in reduction of mean VAS score from baseline was 2·6 (95% CI 1·74-3·37, p<0·0001) at 1 month and 2·0 (1·13-2·80, p<0·0001) at 1 year. No serious complications or adverse events were reported. INTERPRETATION: In a subgroup of patients with acute osteoporotic vertebral compression fractures and persistent pain, percutaneous vertebroplasty is effective and safe. Pain relief after vertebroplasty is immediate, is sustained for at least a year, and is significantly greater than that achieved with conservative treatment, at an acceptable cost. FUNDING: ZonMw; COOK Medical.

Persistent hypoglossal artery detected incidentally in a hypertensive patient with intracerebral hemorrhage: a case report and review of the literature.

A 73-year-old woman with a history of chronic hypertension admitted to our clinic with complaint of acute paresis in her left arm. Computed tomography and magnetic resonance imaging were performed to the patient which displayed intracerebral hemorrhage in the right parieto-occipital lobe. Further review of the computed tomography and magnetic resonance imaging scan showed an enlarged left hypoglossal canal with a large vessel passing through it. The patient was thereafter examined with cerebral digital subtraction angiography to determine the cause of hemorrhage, but no vascular etiology was demonstrated, except from a persistent hypoglossal artery. We present a rare case of persistent hypoglossal artery, which we detected incidentally during angiographic evaluation, with a review of the literature.

Amygdalohippocampal involvement in tinnitus and auditory memory.

CONCLUSION: The preliminary results suggest that in chronic unilateral tinnitus the contralateral amygdalohippocampal complex does seem to be involved in tinnitus perception of pure tones. OBJECTIVES: Functional neuroimaging studies have revealed that the hippocampus and amygdala are involved in tinnitus perception. The amygdala and hippocampus are supplied by the anterior choroidal artery. Selective amobarbital injections in the anterior choroidal artery result in a non-functional amygdalohippocampal area for 10 min. The aim of this study was to assess the influence of this procedure on tinnitus perception. PATIENTS AND METHODS: Amobarbital (80 mg in total) was injected selectively in two sessions in the left and right anterior choroidal artery in six male patients with tinnitus: four with unilateral tinnitus, two with bilateral tinnitus. Of the patients with unilateral tinnitus, three had right-sided tinnitus and one had left-sided tinnitus. The average age was 57.3 years (range 43-69). Average tinnitus duration was 5.3 years (range 1-10). The differences in visual analogue scale (VAS) scores before and after the amytal tests were analysed. RESULTS: Amytal injection ipsilateral to the side where the tinnitus was perceived resulted in a maximum of 30% tinnitus suppression, whereas amytal injection contralateral to the tinnitus side yielded a 60-70% tinnitus suppression in three patients with unilateral chronic tinnitus (>4 years). Only pure tone tinnitus was suppressed, white noise was not. Two patients with bilateral tinnitus had no suppression, irrespective of the tinnitus type. A third patient without clinical tinnitus suppression had tinnitus of more recent origin (1.5 years).

Endovascular treatment of a ureteroiliac fistula associated with ureteral double J-stenting and an aortic-bifemoral stent graft for an inflammatory abdominal aortic aneurysm.

We report an unusual case of a ureteroiliac fistula due to prolonged ureteral stenting for hydronephrosis combined with an aortic-bifemoral stent graft in an inflammatory abdominal aortic aneurysm (AAA), treated with an endovascular stent graft. In a 77-year-old man ureteral J-stents were placed for bilateral hydronephrosis due to retroperitoneal fibrosis caused by an inflammatory AAA. The aneurysm was treated with an endovascular aortic-bifemoral stent graft. Three months later, the patient suffered from severe hypovolemic shock. Emergency angiography showed a fistula between the right ureter and the right common iliac artery just distal to the right leg of the stent graft. The ureteroiliac fistula was treated with a wall graft (10F). The patient recovered well and remained asymptomatic. Ureteroiliac fistula remains a rare complication of ureteral stenting. Several risk factors have been described before. This case emphazes the increased risk of an arterial-ureteral fistula due to an indwelling ureteral stent and an inflammatory AAA, especially in combination with an additional stent graft for this inflammatory AAA.

The risk of new osteoporotic vertebral compression fractures in the year after percutaneous vertebroplasty.

PURPOSE: To prospectively assess the incidence, location, and possible causative mechanisms of new vertebral compression fractures (VCFs) in 66 symptomatic patients with osteoporotic VCFs treated with percutaneous vertebroplasty (PV) and to study the relation between new VCFs and back pain symptoms. MATERIALS AND METHODS: Sixty-six patients with 102 painful symptomatic VCFs were treated with PV. All patients had baseline total spinal magnetic resonance (MR) imaging. Follow-up MR imaging was performed at 3, 6, and 12 months to locate new VCFs. Visual analog scales for pain and pain medication consumption were used to assess clinical outcomes. The following characteristics were compared in patients with new VCFs after PV versus patients without new VCFs: patient age, sex, presence of secondary osteoporosis, bone mineral density, number of preexisting VCFs, shape and grade of VCFs, type of bone cement used for PV, volume of injected cement, and cement leakage in intervertebral disc spaces. RESULTS: Sixteen of 66 patients had 26 new VCFs during 1 year of follow-up after PV. Most new VCFs occurred within 3 months of PV, half of new VCFs appeared in levels adjacent to treated levels, and half of the new VCFs were symptomatic. The presence of more than two preexisting VCFs was the only independent risk factor for the development of a new VCF. CONCLUSIONS: New VCFs occurred after PV in 24% of patients. Half of new VCFs occurred in levels adjacent to treated levels and half were symptomatic. The presence of more than two preexisting VCFs was the only independent risk factor for the development of a new VCF.

Hemilingual spasm: a new neurosurgical entity? Case report.

Hemilingual spasm is a little-known movement disorder, presenting as intermittent paroxysmal involuntary contractions of half of the tongue muscles. The authors report a case of hemilingual spasm caused by an arachnoid cyst. After marsupialization of the cyst, the patient's symptoms immediately resolved. There has been no recurrence of hemilingual spasm during the follow-up period of more than 40 months.