Clinical and Radiological Review of a Semi-Constrained Cervical Disc Replacement with a Ceramic-Ceramic Articulation with a Minimum Seven Years Follow-Up.

PURPOSE OF THE STUDY Artificial cervical disc replacement (CDR) has emerged as a viable treatment alternative to fusion for the management of symptomatic compressive radiculopathy and potentially for cervical myelopathy. The aim of our study was to evaluate the clinical and radiological outcomes of patients treated with a second generation semi-constrained CDR with a ceramicceramic articulation. MATERIAL AND METHODS A prospective cohort study of all patients undergoing a cervical disc replacement for cervical disc pathology, during the period from April 2007 to April 2011 using a ceramic-ceramic disc replacement comprised the study group. 52 patients were available for final clinical and radiological follow-up. Both, clinical and radiological evaluation were performed at each clinical visit at 6 weeks, 6 months, 12 months, 2 years, 5 years and 7 years. RESULTS There were a total of 52 patients, with 44 single level cases and 8 two level cases. The NDI improved significantly (p < 0.05) from a mean preoperative score of 56 % to a score of 20% at final follow-up. The mean preoperative mobility at the index level unit was 12.2 ± 4.5°, this decreased to 7.9 ± 3.2° at six weeks, but slightly increased to 12.9 ± 2.9° at final follow-up (gain not significant). Heterotrophic ossification (HO) was noted in 13 (25%) patients. CONCLUSIONS Cervical disc replacement with a ceramic-ceramic bearing surface is a viable option in the treatment of variety of cervical pathologies. This ceramic-ceramic interface may eliminate the potential problems of metallosis and poly-wear but further longer-term results should be studied. Key words: Cervical spine; disc replacement; ceramic articulation; neck disability; heterotrophic ossification.

Kyphoplasty Augmentation in Thoracolumbar Spine - Clinical Outcomes after 2 Years.

PURPOSE OF THE STUDY With the ageing of population the vertebral insufficiency fractures are increasing in number and occur ever more frequently. Symptomatic relief is often difficult to achieve by non-operative treatment. The aim of this study was to determine the level of pain relief and functional outcomes in patients who failed initial non-operative treatment and, because of persisting or growing symptoms, underwent kyphoplasty. MATERIAL AND METHODS Total number of 303 patients who underwent balloon kyphoplasty between January 2011 and December 2016 were included in our study. These 303 patients had 357 surgeries. This is a retrospective review of a prospectively updated database maintained by our spinal surgery department. In total, 575 levels were augmented. The patients were mostly females (246). The age of the patients ranged from 30 years to 98 years, with the mean age being 72.6 years. The average follow-up for our series was 17.2 months (2-63 months). Pain relief was assessed using the Visual Analogue Scale (VAS) and functional outcome using the Oswestry Disability Index (ODI). RESULTS The average pre-operative VAS was 6.34 (p = 0.00003). At 6 weeks postoperatively the average VAS decreased to 3.80 (p = 0.00000). In our series, the VAS scores showed a progressive decline progressing from the mean value of 3.18 (p = 0.15890) at 1 year to the mean value of 2.85 (p = 0.00205) at 2 years. The average pre-operative ODI was 25.65 (p = 0.03604). At 6 weeks, the value improved to 17.69 (p = 0,00120) and further improvements were seen at 1 year (ODI 14.13) and at 2 years (ODI 12.08). In our series no clinically significant complications were reported. The social drift was observed in 17 patients in our study. DISCUSSION The pain relief and the improvement of functional outcomes were maintained even at a two-year follow-up. No clinically significant complications were reported that would require further surgical intervention and that would affect the good clinical results of our study. CONCLUSIONS Balloon kyphoplasty proved to be a safe surgical technique and should be considered in patients with an ongoing pain following vertebral insufficiency fractures that do not improve with the initial non-operative treatment. Cement augmentation significantly improves pain levels and as well functional status in elderly patients. Key words:cement augmentation, osteoporotic fracture, kyphoplasty, vertebroplasty, osteoporotic spine fracture.

Coccydynia - could age, trauma and body mass index be independent prognostic factors for outcomes of intervention?

Introduction The aetiology of coccydynia can be multifactorial, with several associated factors such as obesity, female gender and low mood. The long-term results of operative interventions, such as manipulation under anaesthesia and coccygectomy are variable, ranging from 63-90%. Materials and methods Our aim was to identify whether age, trauma and body mass index (BMI) were independent prognostic factors in coccydynia treatment. All patients who presented to the Royal Derby Hospital with a primary diagnosis of coccydynia between January 2011 and January 2015 who had injections, manipulation under anaesthesia or coccygectomy were included. We used patient-reported satisfaction score as the primary outcome measure. We hypothesised that patients with preceding history of trauma and with high BMI (> 25) would be less satisfied. We divided patient BMI into four groups, following World Health Organization guidelines: group A (18.5-24.9), group B (25-29.9), group C (30-39.9) and group D (> 40). Results A total of 748 patients were diagnosed with coccydynia. Of these, 201 patients had 381 injections, 40 had 98 manipulations under anaesthesia and 9 had coccygectomy. Mean age was 46.4 years; 26% of patients had trauma to the coccyx. The mean time to follow-up was 7.3 months. We found a statistically significant difference (P = 0.03) between satisfaction scores in groups B and D. Patients who had trauma improved significantly (P = 0.04). The odds ratio calculation of coccygectomy and BMI revealed a higher risk of coccygectomy in Group A. Discussion This is the first study to establish BMI and trauma as independent prognostic factors for coccydynia treatment. Our hypothesis that patients with higher BMI would have lower satisfaction levels has been proven true.

Impact of the quantity of intradiscal cement leak on the progression of intervertebral disc degeneration.

Introduction We aim to assess the impact of the quantity of intradiscal cement leak during kyphoplasty on the rate of progression of degenerative changes in the affected disc. Methods Of 316 kyphoplasty procedures, we identified 32 episodes of intradiscal cement leak in 26 patients. The quantity of cement leaked was graded from I to IV. Disc degenerative changes were assessed at presentation and follow-up using radiographical scoring and magnetic resonance imaging (MRI) grading systems. Data for low-grade leaks (grade I) were compared with the medium- and high-grade leaks (grades II-IV) using a chi-squared test. Results Median follow-up radiographic and MRI assessments were made at 18 and 21 months, respectively. Medium- and high-grade leaks were associated with a significantly higher radiographic disc degeneration scores compared with low-grade leaks (P = 0.04295) but no difference was found in MRI disc degeneration grades and in adjacent vertebral fracture rates. Conclusions Our findings indicate that the quantity of cement leaking into the disc space significantly influences the rate of progression of disc degeneration.

Study investigating the role of skeletal muscle mass estimation in metastatic spinal cord compression.

BACKGROUND: Age-related loss of functional muscle mass is associated with reduced functional ability and life expectancy. In disseminated cancer, age-related muscle loss may be exacerbated by cachexia and poor nutritional intake, increasing functional decline, morbidity and accelerate death. Patients with spinal metastases frequently present for decompressive surgery with decision to operate based upon functional assessment. A subjective assessment of physical performance has, however, been shown to be a poor indicator of life expectancy in these patients. We aimed to develop an objective measure based upon lean muscle mass to aid decision making, in these individuals, by investigating the association between muscle mass and 1-year survival. METHODS: Muscle mass was calculated as total psoas area (TPA)/ vertebral body area (VBA), by two independent blinded doctors from CT images, acquired within 7 days of spinal metastases surgery, at the mid L3 vertebral level. Outcome at 1 year following surgery was recorded from a prospectively updated metastatic spinal cord compression database. RESULTS: 86 patients were followed for 1 year, with an overall mortality of 39.5%. Mortality rates at 1 year were significantly high among patients in the lowest quartile of muscle mass, compared with those in the highest quartile (57.1 vs 23.8%, p=0.02). CONCLUSION: Death within 1 year in individuals with spinal metastases is related to lean muscle mass at presentation. Assessment of lean muscle mass may inform decision to operate in patients with spinal metastases.

Otolaryngological complications of occipitocervical injury.

Occipitocervical injuries are rare, accounting for 15% of all fatal spinal trauma. In patients who survive the initial incident, early detection and appropriate management is vital to avoid significant neurological disability and mortality. We present the case of a patient with neck trauma who was initially cleared of spinal injuries in the emergency department but who later developed acute hearing loss. We describe how the investigation of the hearing loss led to the detection of this devastating injury and report its successful management. Patients with persistent neck pain following trauma, particularly in the presence of degenerative spinal disease, should have cervical spine computed tomography to exclude occipitocervical injuries and other occult injuries.

Cervical spondylotic myelopathy: the outcome and potential complications of surgical treatment.

PURPOSE OF THE STUDY: Cervical spondylotic myelopathy is the most common cause of spinal cord dysfunction in patients over 60 years old. Symptoms often develop gradually and insidiously and are characterized by neck stiffness, arm pain, numbness and clumsiness of hands, as well as weakness of the hands and legs frequently leading to a change in mobility. Surgery is performed primarily to prevent the progression of symptoms but also with the aim of improving existing symptoms. Aim of our study was to assess the outcomes and potential complications of surgical decompression of cervical spondylotic myelopathy (CSM). MATERIAL AND METHODS: Prospective data was collected from 71 patients who were treated surgically for CSM over a four-year period (June 2006 to June 2010). Only patients with confirmed spondylotic cervical myelopathy were included in the study; those with an inflammatory, infectious or neoplastic etiology were excluded. The Nurick scale was used as a primary outcome measure, and the improvement in upper limb function as a secondary outcome measure. Statistical significance was assessed using the paired t-test. RESULTS: 34/71 (47.9%) patients had an anterior decompression, 36/71 (50.7%) patients underwent posterior surgery and one patient (1.4%) received a combined approach: The Nurick score: The mean score improved by 0.9 from 2.4 preoperatively to 1.5 postoperatively for the whole series. Three patients were able to return to work. The preoperative Nurick score showed a positive correlation with the postoperative Nurick score at one year (Pearson Coefficient = 0.85). Upper limb symptoms: Postoperatively, 24 patients were free of any upper limb involvement compared with 6 patients preoperatively. The main improvement was in patients who prior to surgery had subjective symptoms with no objective signs of weakness or muscle wasting. 35/48 (72.9%) of this group showed improvement compared to 7/17 (41.2%) of patients who demonstrated objective weakness and/or wasting preoperatively. COMPLICATIONS: The overall rate of complications was 18.2%. There were two mortalities as a result of pneumonia (2.8%), one patient had to be transferred to the intensive care unit for cardiac failure (1.4%), fixation failure occurred in two patients (2.8%), worsening of myelopathy occurred in two patients (2.8%), C5 temporary radiculopathy presented in two patients (2.8%), superficial wound infection developed in one patient (1.4%) and three patients (4.2%) complained of severe axial pain in the postoperative period. DISCUSSION Our results demonstrate that the greater the preoperative disability the greater the final disability is expected to be. Cord signal change, as an indicator of the pathological severity of the disease, correlates with a worse functional outcome. The degree of improvement postoperatively (i.e. the functional change) does not show a significant correlation with the initial preoperative status. It appears however, that there is a better chance of improvement in patients with no objectively detectable weakness or muscle wasting. The rate of complications encountered in this series is comparable with those in the literature, which renders them valid for quoting when considering surgical treatment for CSM. CONCLUSION: Surgical decompression offers a real chance of improvement in the functional outcome of CSM, especially during the earlier stages of the disease. The surgical decision needs to be considered carefully due to the advanced age of the patient population and the greater burden of co-morbidities, which increase the surgical risks significantly.

Tertiary syphilis in the cervical spine: a case report and review of the literature.

As the prevalence of syphilis rises, an increase in tertiary syphilis with spinal involvement is predicted. We report what we believe to be the first case of compressive cervical spine syphilitic gummata, with central cord compression signs. We also review the relevant literature to date. The diagnosis of syphilis in the spine relies on the physician to be aware of it as part of the differential diagnosis. Treponemal laboratory tests are an important aid in establishing a diagnosis.

Accuracy of prognostic scores in decision making and predicting outcomes in metastatic spine disease.

INTRODUCTION: Management of metastatic spinal disease has changed significantly over the last few years. Different prognostic scores are used in clinical practice for predicting survival. The aim of this study was to assess the accuracy of prognostic scores and the role of delayed presentation in predicting the outcome in patients with metastatic spine disease. METHODS: Retrospectively, four years of data were collected (2007-2010). Medical records review included type of tumour, duration of symptoms, expected survival and functional status. The Karnofsky performance score was used for functional assessment. Modified Tokuhashi and Tomita scores were used for survival prediction. RESULTS: A total of 55 patients who underwent surgical stabilisation were reviewed. The mean age was 63 years (range: 32-87 years). The main primary sources of tumours included myeloma, breast cancer, lymphoma, lung cancer, renal cell cancer and prostate cancer. Of the cases studied, 29 patients had posterior instrumented stabilisation alone, 10 patients had an anterior procedure alone and 16 patients (with an expected survival of more than one year) had both anterior and posterior procedures performed. Twenty-three patients presented with spinal cord compression. The mean follow-up duration was 9 months (range: 1-39 months). Patients who were treated within one week of referral survived longer than anticipated. Patients were divided into three groups based on their expected survival. Actual survival was better in all three groups after surgery. Discrepancies in scores were prominent in patients with myeloma, breast and prostate cancers. Functional outcome was better in patients under 65 years of age. CONCLUSIONS: The prognostic scoring systems are not uniformly effective in all types of primary tumours. However, they are useful in decision making for surgical intervention, taking other factors into account, in particular the age of the patient, the type and stage of the primary tumour and general health.

Spondylodiscitis in children: a retrospective series.

We retrospectively reviewed the records of 16 children treated for spondylodiscitis at our hospital between 2000 and 2007. The mean follow-up was 24 months (12 to 38). There was a mean delay in diagnosis in hospital of 25 days in the ten children aged less than 24 months. At presentation only five of the 16 children presented with localising signs and symptoms. Common presenting symptoms were a refusal to walk or sit in nine children, unexplained fever in six, irritability in five, and limping in four. Plain radiography showed changes in only seven children. The ESR was the most useful investigation when following the clinical course of the disease. Positive blood cultures were obtained in seven children with Staphylococcus aureus being isolated in five. Antibiotics were used in 14 children and spinal bracing in six. Children with spondylodiscitis often present with a confusing clinical picture leading to late diagnosis. The early use of MRI in the investigation of children with an atypical picture may avoid unnecessary delay in starting treatment and possibly prevent long-term problems. All except one of our children had made a complete clinical recovery at final follow-up. However, all six children in the > 24-month age group showed radiological evidence of degenerative changes which might cause problems in the future.

Impact of kyphoplasty treatment for vertebral compression fractures on pain and function in 105 patients.

PURPOSE OF THE STUDY: Vertebral compression fractures are very common. Symptomatic relief with conservative therapy is often difficult to achieve. Balloon kyphoplasty is a relatively new technique which stabilises the vertebral body and restores spinal alignment in recent fractures, it achieves significant pain relief and improved functional outcome is reported. The aim of this prospective study was to determine the level of pain relief and functional outcome in patients who were initially treated conservatively for 4-6 weeks and if symptoms did not have tendency to resolve, then had kyphoplasty surgery. MATERIAL AND METHODS: 105 patients underwent balloon kyphoplasty between April 2006 and August 2010 and had 1 year follow up. Total 170 levels were augmented, 65% (n=68) of patients were female and the average age was 74 years. Pain relief was assessed using visual analogue score (VAS) and functional outcome using Oswestry Disability Index (ODI). RESULTS: Results showed decrease of the average pre-operative VAS from 8.2 to 4.4 in the immediate postoperative period (p=0.000). This dramatic improvement remained and was 4.1 at 6 weeks, 3.3 at 6 months and 3.6 at 1 year. The average pre-operative ODI was 58. This improved to 47 in the immediate post-operative period (p=0.002). At 6 weeks this had improved further to 40 and further improvements were seen at 6 months (ODI 37) and 1 year (ODI 38). The average screening time was 2 minutes and 20 seconds. The average volume of cement used per level was 5.5 cm3. Radiographic measurements were performed by independent radiologist. The average pre-operative vertebral angle was 11.6° and 10.9° postoperatively. This was maintained throughout the follow up. This represented a negligible 6% improvement in vertebral body angle. We did not experience any clinically significant complications, we have encountered 11 minor complications which did not require any additional measures (cement leaks, penetration of the vertebral body margins by balloons or K wires and rib fractures). DISCUSSION: Pain relief and improvement of functional outcome was sustained after one year. Limited number of patients who had 2 year follow up showed trend of minimal deterioration of both parameters (VAS and ODI). This can be explained by incidence of few adjacent segment fractures and progressive overall osteoarthritic changes in this aging population. Radiological evaluation showed maintenance of achieved alignment which did not deteriorate over time. Complication rate was low and did not require any further surgical interventions and did not have any effect on final good clinical outcome. CONCLUSION: Balloon kyphoplasty proved to be safe surgical technique and should be considered in patients with ongoing pain following an acute vertebral compression fracture that does not improve with initial conservative treatment. It significantly improves pain and functional status in elderly patients.

Calcineurin deficiency decreases inflammatory lesions in transforming growth factor beta1-deficient mice.

Transforming growth factor (TGF) beta1) is an immunoregulatory cytokine involved in self-tolerance and lymphocyte homeostasis. Tgfb1 knock-out (KO) mice develop severe multi-focal autoimmune inflammatory lesions due to [Ca(2+)]i deregulation in T cells, and die within 3 weeks after birth. Because the calcineurin inhibitor FK506 inhibits the hyperresponsiveness of Tgfb1(-/-) thymocytes, and because calcineurin Abeta (CNAbeta)-deficient mice do not reject allogenic tumours, we have generated Tgfb1(-/-) Cnab(-/-) mice to address whether CNAbeta deficiency prevents T cell activation and inflammation in Tgfb1(-/-) mice. Here we show that in Tgfb1(-/-) Cnab(-/-) mice inflammation is reduced significantly relative to that in Tgfb1(-/-) mice. However, both CD4(+) and CD8(+) T cells in double knock-out (DKO) mice are activated, as revealed by up-regulation of CD11a lymphocyte function-associated antigen-1 (LFA-1), CD44 and CD69 and down-regulation of CD62L. These data suggest that deficiency of CNAbeta decreases inflammatory lesions but does not prevent activation of autoreactive T cells. Also Tgfb1(-/-) T cells can undergo activation in the absence of CNAbeta, probably by using the other isoform of calcineurin (CNAalpha) in a compensatory manner. CNAbeta-deficient T cells undergo spontaneous activation in vivo and are activated upon anti-T cell receptor stimulation in vitro. Understanding the role of calcineurin in T cell regulation should open up new therapeutic opportunities for inflammation and cancer.

[Surgical treatment of spinal infections]. / Operacní lécení infekcního postizení pátere.

PURPOSE OF THE STUDY: Although great advances have been made in both radiological diagnosis and antibiotic therapy of microbial infections, the treatment of spinal infections remains a major clinical challenge. Many of the patients affected are referred to spinal units with long delays. The general population is ageing and the number of immunocompromised patients, as well as the number of operative procedures for spinal disorders are increasing. The aim of our study was to evaluate the clinical presentations of spinal infections, options for their diagnosis, indications for treatment and their risk factors and the results of surgery. MATERIAL AND METHODS: The group of 112 patients evaluated after the treatment of spinal infection comprised 63 men and 49 women at an average age of 59.4 years (range, 17 to 84). The average follow-up was 3.2 years (range, 6 months to 8 years). Of these, 82 patients had primary hematogenous infection, 29 had post-operative infection,and one had an infected gun shot wound. Thirty-six patients showed neurological deficit and six were paraplegic. The diagnostic methods included FBC, CRP and EST tests, examination of blood cultures, aspirates and biopsy samples from the infected site, bone scintigraphy, MRI and CT scanning. Indications for surgery included an infection not responding to conservative treatment,with existing or impending spinal instability, and with or without neurological deficit. The surgical management involved transpedicular drainage of the abscess, wound debridement from the posterior approach and instrumented spondylodesis. Surgery which included spinal decompression with radical excision of infected tissue was augmented with posterolateral instrumented fusion and/or anterior stabilization, as indicated. RESULTS: Of the 112 patients treated, seven died of uncontrollable sepsis after surgery; the remaining 105 were followed up. Another four patients died of causes unrelated to the spinal problem treated within 12 months. All patients recovered except for two in whom the infection persisted, but 13 required more than one surgical procedure. One patient with CSF leakage failed to heal after five interventions. The most frequently isolated infectious agents were Staphylococus aureus, Staphylococus epidermidis and E. coli. Of the 33 patients with neurological deficit, 24 improved by one or two Frankel grades. The neurological status of six paraplegic patients did not improve, but their functional findings did after stabilization of the spine. Clinical evaluation showed 47 (44.7 %) very good, 40 (38 %) good, eight (7.6 %) unchanged and 10 (9.5 %) poor outcomes. CONCLUSION: Early diagnosis is a prerequisite for good treatment outcomes. Clinical examination, results of laboratory tests, and scintigraphy and MRI findings play the key role. When progressing osteolysis is suspected, a CT scan is necessary. Debridement should be as radical as possible, but always in compliance with the patient's health state. At an advanced stage of disease, spinal stabilization is important because it allows us to remove infected tissue. Intravenous and then oral antibiotic therapy at 2 to 4 and 6 to 12 weeks of follow-up is mandatory. The management of spinal infections is a complex process requiring good multidisciplinary cooperation.

Magnetic resonance image findings in the early post-operative period after anterior cervical discectomy.

If early neurological deterioration occurs following anterior cervical discectomy, the patient should be evaluated by urgent MRI scanning. In order to interpret such a scan it is essential to know what the normal post-operative MRI appearance is following an uncomplicated procedure. In the lumbar spine it is well recognized that early post-operative imaging following discectomy is difficult to interpret with a high rate of false positive scans. The normal appearance of MRI in the early post-operative period was evaluated prospectively in 15 patients undergoing anterior cervical discectomy without fusion for either cervical radiculopathy or myelopathy. MRI was performed on the first post-operative day, at 6 weeks and 6 months. The successful outcome of the procedure was validated by uniform improvement of Visual Analogue Scale measurement for neck and arm pain, the Neck Disability Index and European Myelopathy Score as appropriate. In contrast to the established findings following lumbar discectomy, only two cases showed a persistent epidural mass in the first post-operative scan and this had completely resolved at 6 months. All patients had foraminal narrowing and root or cord compression pre-operatively. Sixty six percent of cases showed persistent foraminal narrowing on sequential imaging up to 6 months despite showing good symptomatic improvement. All cases demonstrated high signal in the operated disc space on T2 weighted imaging on the first post-operative day and this finding persisted in 13 of 15 scans performed at 6 weeks. Post contrast imaging demonstrated no enhancement of operated disc space and adjacent vertebral body on the first post-operative day, whereas all scans at 6 weeks showed enhancement and such enhancement persisted at 6 months in 50%. Persistent epidural filling defects are uncommon following successful anterior cervical discectomy but persistence of foraminal narrowing is common despite successful outcome. Enhancement of the disc space is also common and does not in itself imply infection.

Oculocerebral non-Hodgkins lymhoma : a case report.

A three year female child presented with right proptosis of two months duration with destruction of bony walls of the right orbit, the tumour extending to surrounding sinuses, nasopharynx and middle cranial fossa. Biopsy of the tumour revealed non-Hodgkin's lymphoma, diffuse mixed type.