Clinical predictors of vertebral osteoporotic fractures in post-menopausal women: a cross-sectional analysis.

BACKGROUND: Osteoporosis is a very common bone disorder and accounts for 1.4 million vertebral compression fractures (VCFs) per year, mostly in post-menopausal women. AIM: The aim of this study was to develop a risk scoring system to identify and gauge the risk of osteoporotic VCFs in post-menopausal women. MATERIALS AND METHODS: We conducted a retrospective cross-sectional study on 477 post-menopausal women consecutively visited at our institution. We studied 15 different clinical variables, i.e. age, body mass index (BMI), weight, L1-L4 lumbar T-Score, L1-L4 lumbar Z-Score, L1-L4 lumbar bone mineral density (BMD), femoral neck T-Score, femoral neck Z-Score, femoral neck BMD, smoking habit, alcohol consumption, 25-OH-vitamin D, total alkaline phosphatase, bone alkaline phosphatase, and L4 vertebral volume. Study population was split in a derivation and a validation cohort. A logistic regression model was used to develop a predictive score of osteoporotic VCFs in the derivation cohort, finally the performance of the score was tested in the validation cohort. RESULTS: Age, L1-L4 lumbar T-Score, femoral neck T-Score, L4 vertebral volume, and smoking habit were found to be predictors of VCFs. To each variable a score from 0 to +12 was assigned to the magnitude of regression coefficient. A score ≥ 22 identified VCFs with a sensitivity of 87%/89% and a specificity of 87%/90% in the derivation and validation cohorts, respectively. CONCLUSIONS: Our findings indicate that a simple score derived from clinical history and routine diagnostic workout can be usefully employed to gauge the risk of fragility VCFs in post-menopausal women.

Medical and surgical treatment of pyogenic spondylodiscitis.

BACKGROUND: Pyogenic vertebral osteomyelitis (PVO) represents approximately 2-7% of all cases of osteomyelitis. The approach to the treatment of PVO may be conservative, which includes antibiotic therapy and orthopaedic treatment, or surgical. AIM: To overview conservative and surigical approaches to PVO. METHODS: A literature review was performed using the Pubmed database to identify studies published in the last 20 years, addressing the treatment of PVO. RESULTS: Empirical antibiotic treatment of PVO, while waiting for the results of cultures or in culture-negative cases, should include broad spectrum agents in association with agents active on Staphylococcus (S.) aureus. Based on local epidemiological data, antibiotics active on methicillin resistant S. aureus (MRSA) should be included. Once an organism has been identified, antibiotics should be initially administered intravenously but the optimal duration of antimicrobial therapy is unclear. Studies have reported that the incidence of treatment failure was higher when i.v. therapy was administered for less than 4 weeks. Rifampin is widely used in the combination therapy of PVO, but no controlled trials are available to define weather this approach is beneficial. Many PVO need a surgical treatment and can represent a real challenge for the orthopaedic surgeon. Anterior and posterior cervical, thoracic, lumbar approaches and the relatives surgical strategies are reported in this review. Moreover, recently the mininvasive posterior stabilization have been proposed as a efficient alternative to open surgery in elderly with severe comorbidities. Possible advantages and limitations of this technique are also reported. CONCLUSIONS: Further research is needed in order to define the optimal duration of antibiotic therapy, and the benefits and limitations of open or mini-invasive surgical techniques.

Surgical treatment of tuberculous spondylodiscitis.

BACKGROUND: Most patients affected by spinal tuberculosis can be successfully treated conservatively with chemotherapy, external bracing and prolonged rest. Nevertheless, kyphotic deformity, spinal instability and neurological deficit remain a common complication associated with conservative approach. AIM: To illustrate different indications and treatment modalities for tuberculous spondylodiscitis, focusing on the role of surgery as an adjuvant of effective chemotherapy in the management of selected patients. MATERIALS AND METHODS: Various early and late surgical procedures are recommended to treat spinal tuberculosis. The Authors analyzed surgical indications, approaches, complications and outcomes comparing their experience with available Literature. RESULTS: Conservative management is preferable in patients without vertebral instability and deformity; in presence of abscesses, invasive radiological techniques in combination with abscess drainage and chemotherapy are recommended. In patients with vertebral collapse, kyphotic deformity or abscess formation, vertebral instability or neurological deficits, anterior radical debridement, anterior strut grafting and anterior instrumentation is an optimal standardized procedure. In patients with involvement of more than two vertebral levels or lumbosacral junction and in those whose sagittal alignment is markedly deformed with segmental kyphosis, and in patients who have difficulty in undergoing anterior instrumentation, posterior instrumentation is recommended in combination with anterior radical debridement and anterior strut grafting in one or two staged procedures. CONCLUSIONS: Since surgery for spinal tuberculosis is demanding, it should be performed only after taking into account the risks and benefits in operable patients. Various surgical procedures are recommended to treat spinal tuberculosis but the common goals are to eradicate the infection and to prevent or to treat neurologic deficits or spinal deformity.

Cervical myelopathy due to ossification of the transverse atlantal ligament: a Caucasian case report operated on and literature analysis.

One case of cervical myelopathy associated to ossification of transverse atlantal ligament (OTAL) and C1 posterior arch hypoplasia in a Caucasian adult female is reported. A 53-year-old female affected by cervical myelopathy was treated with C1 laminectomy and posterior arthrodesis. CT scan demonstrated that the distance between ossification of the ligament and anterior cortex of the posterior arch of atlas was 6,2mm leading to consistent space reduction for spinal cord at this level. Patient underwent spinal cord decompression and fixation with C1 poliaxial screws in lateral masses and two bilateral crossing C2 laminar screws with an improvement of neurological functions at 4-years follow-up. The association between OTAL and C1 hypoplasia was reported in very few cases. The treatment with C1 laminectomy without fusion is reported in medical literature with good clinical outcome. Our patient obtained a neurological improvement at midterm follow-up with spinal cord decompression and fusion.

Transdiscal L5-S1 screws for the treatment of adult spondylolisthesis.

PURPOSE: The aim of the study was to evaluate clinical and radiographic outcome of patients treated with a modified Grob technique analysing the advantages related to increased mechanical stability. METHODS: 30 patients that underwent "in situ" fusion for L5-S1 spondylolisthesis were evaluated. All patients presented a low-dysplastic developmental L5-S1 spondylolisthesis. Patients were divided into two groups: A, in which L5-S1 pedicle instrumentation associated with transsacral screw fixation was performed, and B, in which L5-S1 pedicle instrumentation associated with a posterolateral interbody fusion (PLIF) was performed. RESULTS: Patients treated with transdiscal L5-S1 fixation observed a faster resolution of the symptoms and a more rapid return to daily activities, especially at 3-6 months' follow-up. The technique is reliable in giving an optimal mechanical stability to obtain a solid fusion. CONCLUSIONS: The advantages of this technique are lower incidence of neurologic complications, speed of execution and faster return to normal life.

Bisphosphonate therapy in multiple myeloma in preventing vertebral collapses: preliminary report.

PURPOSE: The aim of the study was to report and discuss the preliminary data obtained in a homogeneous series of 50 patients affected by multiple myeloma treated with bisphosphonates. METHODS: Patients were followed for a minimum of 1 year. Main orthopaedic data were recorded. Visual Analogue Score and QLQ-C30 and MY 20 were used to assess the quality of life. RESULTS: Statistical analysis showed less lytic lesions in the group with zoledronate therapy and stable primary disease compared with a greater number of lesions in the non-treated group. Results regarding VAS score and QLQ-C30 and MY were statistically better in the first group than in the second. CONCLUSIONS: Our results confirm the efficacy of zoledronate in ensuring an acceptable quality of life restraining the aggressiveness of the myeloma on bone tissue, especially in spine although further prospective studies have to be conducted to determine its correct use in myeloma patients.

A minimally invasive posterior lumbar interbody fusion for degenerative lumbar spine instabilities.

Percutaneous techniques may be helpful to reduce approach-related morbidity of conventional open surgery. The aim of the study was to evaluate the feasibility and safety of mini-open posterior lumbar interbody fusion for instabilities and degenerative disc diseases. From May 2005 until October 2008, 20 patients affected by monosegmental instability and disc herniation underwent mini-open lumbar interbody fusion combined with percutaneous pedicle screw fixation of the lumbar spine. Clinical outcome was assessed using the Visual Analog Scale, Oswestry Disability Index, and Short Form Health Survey-36. The mean follow-up was 24 months. The mean estimated blood loss was 126 ml; the mean length of stay was 5.3 days; the mean operative time was 171 min. At 24-month follow-up, the mean VAS score was 2.1, mean ODI was 27.1%, and mean SF-36 was 85.2%. 80 screws were implanted in 20 patients. 74 screws showed very good position, 5 screws acceptable, and 1 screw unacceptable. A solid fusion was achieved in 17 patients (85%). In our opinion, mini-open TLIF is a valid and safe treatment of lumbar instability and degenerative disc diseases in order to obtain faster return to daily activities.

Relevance of the cranioaxial angle in the occipitocervical stabilization using an original construct: a retrospective study on 50 patients.

We present a retrospective study on a series composed of 50 patients, treated between 1992 and 2006, affected by pathologies of the craniocervical junction. All the patients were treated using an innovative procedure based on a cranial claw made up of low profile hooks, conceived by one of the authors. Advantages of this technique are, to our point of view, a higher resistance to cranial hooks dislodgment, when compared with screw fixation instrumentation, especially in pathological conditions, such as rheumatoid arthritis that leads to a qualitative deterioration of the bone stock and to the reduction of the occipital wall thickness. Occipitoaxial alignment was assessed radiographically using the McGregor line. We observed an improvement in the subjective evaluation of pain in all treated patients with a 46% improvement from the initial values. Moreover, patient stabilized with an occipitoaxial angle included in the physiological range showed better results either for the survival of the instrumentation or the onset of junctional pathology. Patients have been followed up afterwards and evaluated by the visual analogue scale for the assessment of pain and by the Nurick scale for the cases associated with myelopathy. We believe that cranial anchorage with a hook claw allows for an instrumentation provided with high stability, particularly useful in revision surgery and major instabilities. The study of the occipitoaxial angles showed that the better results and the long-lasting stability of the implant are correlated to a fusion angle included in the physiological range.

Cervical spondylotic myelopathy: proposal of a surveillance algorithm.

The review of the publications concerning cervical spondylotic myelopathy (CSM) suggests that it has not been achieved a clear consensus about the treatment of this pathology. In this paper an algorithm of surveillance, conceived as an assistant tool to decide the best indications of treatment is presented. The algorithm permits a clear separation of the symptomatic patients on the base of the presence or the absence of neurologic damage resulting at the evoked potentials examination. The negativity of the evoked potentials, that means neurologic integrity, excludes any type of surgical treatment. In case of proved neurologic damage, the algorithm permits a further differentiation in subgroups according to the degree of clinical disability. If evoked potentials are positive, a surgical decompression should be always performed in patients affected by a severe clinical disability. The group of patients affected by a mild degree of clinical disability but with positive evoked potentials represents the most challenging for the spinal surgeons. Actually, several studies support either surgical and non surgical treatment for these patients. Although the Authors think that a surgical decompression has to be always performed in case of proved neurologic damage, only further randomized studies based on accurate algorithms could elucidate the outcome of the CSM and could permit to choose the best treatment according to the degree of the disease.

A particular solution in the treatment of primitive neoplasms of the distal third of the tibia. Presentation of a clinical case and review of the literature.

Primitive malignant neoplasms affecting the distal third of the tibia are altogether rare, and their treatment is considerably controversial. The authors describe the diagnostic procedure and a particular surgical strategy of limb salvage in a case of malignant fibrous histiocytoma located at the distal third of the tibia, in particular pointing out the difficulties in restoring the continuity of the skeletal tissues and of the muscle, and with a review of the relevant literature.

Interleukin-6 gene polymorphism and risk of osteoarthritis of the hip: a case-control study.

OBJECTIVES: Osteoarthritis (OA) is considered a polygenic disease controlled by the expression of genetic factors. Genes encoding for cytokines have been associated with susceptibility for joint OA and interleukin (IL)-6 gene is also supposed to be involved in the cartilage degradation process. In this case-control study, we evaluated for the first time whether the risk of hip OA might be influenced by the -174 IL-6 gene polymorphism. METHODS: The distribution of IL-6 genotypes was evaluated in 75 patients affected by hip OA and in 107 age- and sex-matched controls. RESULTS: The distribution of IL-6 genotypes in (1) patients with hip OA: 33 GG, 30 GC, 12 CC and (2) control subjects: 34 GG, 40 GC, 33 CC. The frequency of the CC genotype was significantly higher in control patients (P=0.02). Logistic regression analysis indicated that the presence of the CC genotype is independently associated with a decreased risk of OA (odds ratio 0.4 [95% confidence interval 0.1-0.9], P=0.04). CONCLUSIONS: Primary OA of the hip has an important genetic component and variations of genes encoding for inflammatory cytokines, such as IL-6, may play an important role in the series of events responsible for the pathophysiology of OA.

Gene therapy for in vivo bone formation: recent advances.

Gene therapy has developed during the last two decades as a promising strategy for orthopaedics applications, since several different gene transfer techniques proved to be effective, both in vitro and in vivo, for the induction of bone formation. Successful results have been achieved with gene-based bone healing strategies in several preclinical studies, using different animal models. New genes and new viral and non-viral vector constructs have been developed to reduce the risks and safety issues, widening the field of possible applications and improving the potential therapeutical effects. We review the latest gene transfer technologies employed for in vivo bone formation, focusing on the recently identified network of growth factors and genes involved in the modulation of the osteogenetic process and on the variety of vectors utilized for gene delivery.

Chordoma: long-term evaluation of 15 cases treated surgically.

A series of 15 patients affected with chordoma localized in the clivus and the vertebral column treated surgically by a single surgeon were studied. Localizations in the proximal segments of the spine (clivus and cervical spine) become clinically evident earlier. Diagnosis and consequent treatment are carried out during a stage of progression that is less advanced than occurs in chordomas with lumbar and sacral localization. Based on a study of the material examined it may be observed that factors influencing prognosis are related to the phase of progression of the disease (stage of the tumor), site, whether or not previous surgery has been performed. The type of surgical resection varies in relation to the site of the lesion, at times allowing for wide margin resections. The progressive course of the tumor is positively influenced by early diagnosis, currently favored by progress made in the field of neuroradiology, surgical resection performed according to oncological criteria, and conventional high-dosage radiation therapy, with fractioned doses.

Histological analysis of the coracoacromial arch: correlation between age-related changes and rotator cuff tears.

The purpose of this study was to analyze age-related changes in the coracoacromial arch and correlate these degenerative changes with rotator cuff tears. We obtained 80 shoulders from 40 cadavers. The mean age at death was 58.4 years. We performed a gross examination of the rotator cuff and the acromion and histological examination of the coracoacromial ligament. The statistical significance of any difference for each group considered was determined by Student's t-test. The rotator cuff was normal in 66 specimens; there was an articular-side partial tear in 4 cases, a bursal-side partial tear in 6 cases, and a full-thickness tear in 4 cases. Age was correlated with increasing incidence and severity of cuff tears. We noted age-related degenerative changes in the coracoacromial ligament, degeneration of the acromial bone-ligament junction, and acromial spur formation. Anterior acromial spur was not related to the morphology of the acromion. We observed an increased incidence of bursal-side and complete cuff tears when the acromion was curved or beaked. Degenerative changes in the undersurface of the acromion were also present when the rotator cuff was normal. Bursal-side and complete cuff tears were associated with severe degenerative changes in the acromion in 100% of cases. Articular-side cuff tears were not related either to acromial morphology or degenerative changes in the coracoacromial arch. The association between cuff tears and acromial spur was more evident in the presence of a type III acromion. Our results would suggest that the incidence and severity of rotator cuff tears are correlated with aging and with the morphology of the acromion. Rotator cuff tears that involve the bursal side are often associated with changes in the coracoacromial ligament and the undersurface of the acromion. However, degenerative changes in the coracoacromial arch are always related to aging, also in the presence of a normal rotator cuff. Articular-side partial tears do not cause damage to the undersurface of the acromion.

Natural history of untreated idiopathic scoliosis after skeletal maturity.

A total of 187 random cases of untreated idiopathic scoliosis, seen from a minimum of 15 to a maximum of 47 years after the end of growth, were reviewed. All curves increased after skeletal maturity (average progression: 0.4 degrees per year). Thoracic curves tend to progress more than lumbar, lumbar more than thoracolumbar, and thoracolumbar more than double major curves. Pain was present in 114 cases (61%) and appeared more frequently in women, after pregnancies, and with fatigue. Cardiopulmonary symptoms were present in 42 patients (22%), especially those with thoracic and thoracolumbar curves greater than 40 degrees. Psychologic disturbances were found in 35 cases (19%), mostly female patients with thoracic curves greater than 40 degrees. The cosmetic appearance of these patients at long-term follow-up was better compared with that at the end of growth, even though the curves progressed. Patients with decompensation of the trunk at the end of growth seemed to improve with time. In an unselected group of patients with severe curves a mortality rate of 17% was found, twice as much as in the Italian general population.