Analysis of Risk Factors Causing New Symptomatic Vertebral Compression Fractures After Percutaneous Vertebroplasty for Painful Osteoporotic Vertebral Compression Fractures: A 4-year Follow-up.

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: New vertebral compression fracture (NVCF) is a highly potential risk after percutaneous vertebroplasty (PVP). The study aimed at analyzing the incidence and risk factors of NVCF and preventing its development. SUMMARY OF BACKGROUND DATA: PVP is widely used and highly effective technique for reducing pain caused by an osteoporotic vertebral compression fracture. However, there is a great deal of debate about whether PVP is associated with NVCF, and many risk factors of NVCF have been hypothesized. METHODS: From January to December 2008, a total of 198 patients (176 women, 22 men; mean age, 76.6±0.5 y) who underwent PVP at 270 levels for painful osteoporotic VCF were retrospectively analyzed during a 4-year follow-up. The following parameters were evaluated: NVCF incidence and average time, body mass index (BMI), smoking history, the existence of trauma, and bone mineral density (BMD) before and after PVP. Cement location, intradiscal leakage, distribution pattern, kyphotic angle, sagittal index, compression ratio, injected cement volume, and numbers of fractures and thoracolumbar junction fractures were analyzed. RESULTS: During follow-up, 34 patients (17.2%) sustained symptomatic NVCF for 4-year follow-up. All 34 patients with NVCF had lower BMD than that before initial PVP. For adjacent VCF, multivariable analysis showed that a higher risk of NVCF after vertebroplasty was associated with a larger number of VCF (P=0.025) and lower BMI (P=0.045), whereas for remote VCF, the risk of NVCF was higher in patients who had not experienced trauma and lower BMD (P=0.045). None of the radiographic evaluation values were related to the occurrence of NVCF. CONCLUSIONS: The most important elements related to reducing NVCF were treating osteoporosis and improving BMD and BMI. More aggressive BMD and BMI correction is more important than the vertebroplasty technique.

Tapia's Syndrome after Posterior Cervical Spine Surgery under General Anesthesia.

We present a case report to remind surgeons of this unusual complication that can occur in any surgery, even posterior cervical spine surgery under general anesthesia and discuss its causes, treatment methods, and the follow-up results in the literature. The peripheral Tapia's syndrome is a rare complication of anesthetic airway management. Main symptoms are hoarseness of voice and difficulty of tongue movement. Tapia's syndrome after endotracheal general anesthesia is believed to be due to pressure neuropathy of the vagus nerve and the hypoglossal nerve caused by the endotracheal tube. To our knowledge, no report has been published or given an explanation for Tapia's syndrome after posterior cervical spine surgery. Two patients who underwent posterior cervical surgery complained hoarseness and tongue palsy postoperatively. There is no direct anatomical relation between the operation, the vagus nerves and the hypoglossal nerves, and there is no record of displacement or malposition of the endotracheal tube. After several months, all symptoms are resolved. To avoid this problem in posterior cervical spine surgery, we suggest paying special attention to the position of the endotracheal tube to avoid excessive neck flexion before and during the positioning of the patient.

Solitary osteochondroma of the twelfth rib with intraspinal extension and cord compression in a middle-aged patient.

BACKGROUND: Osteochondroma is a disease of growing bone and thus typically presents in younger patients. It has rarely been described in middle-aged and elderly patients. Data on the occurrence of osteochondroma show that the reported incidence of costal osteochondroma is very low. Moreover, costal osteochondroma arising at the costovertebral junction with neural foraminal extension and spinal cord compression is extremely rare. CASE PRESENTATION: This study reports the case of a 58-year-old patient with a solitary osteochondroma of the 12th rib with intraspinal extension and spinal cord compression. The clinical history, plain radiographs, computed tomography (CT), magnetic resonance imaging, and pathologic findings of the reported patient have been reviewed. The relevant medical literature has also been reviewed. The patient was treated with surgery for complete tumour excision to avoid tumour recurrence. After surgery, the patient's symptoms improved. An additional CT scan obtained at 1 year after surgery did not show any evidence of recurrence. CONCLUSIONS: This patient is the oldest patient reported to have this rare form of costal osteochondroma. The age of the patient and the erosion of the adjacent bones raised clinical suspicion of malignancy; therefore, surgical management involved complete tumour excision with thoracolumbar fixation and fusion.

Comparison of instrumented posterolateral fusion versus percutaneous pedicle screw fixation combined with anterior lumbar interbody fusion in elderly patients with L5-S1 isthmic spondylolisthesis and foraminal stenosis.

OBJECT: The purpose of this study was to compare the clinical and radiological outcomes of treating L5-S1 isthmic spondylolisthesis and foraminal stenosis in elderly patients with instrumented posterolateral fusion (PLF) versus percutaneous pedicle screw fixation (PSF) combined with anterior lumbar interbody fusion (ALIF). METHODS: Forty-nine patients older than 65 years of age with L5-S1 isthmic spondylolisthesis and symptomatic foraminal stenosis who underwent ALIF were retrospectively analyzed. An ALIF with instrumented PLF (Group A) was performed in 23 patients, and ALIF with percutaneous PSF (Group B) was performed in 26 patients. Data were collected preoperatively and at 3 months, 6 months, 1 year, and every subsequent year. A comparative analysis was made between the 2 groups using clinical (visual analog pain scale [VAS] and modified MacNab criteria) and radiological (dynamic plain radiographs and CT scans) measures. RESULTS: The mean follow-up duration was 30.3 months (range 24-47 months). The mean preoperative scores on the VAS for low-back pain in Groups A and B were 5.9 and 5.7, respectively, decreasing to 1.4 and 3.6, respectively, at 6 months after surgery (p = 0.001), whereas VAS scores for low-back pain in Groups A and B at 2 years postoperatively were 1.3 and 2.3, respectively (p = 0.005). The mean preoperative scores on the VAS for leg pain in Groups A and B were 7.5 and 7.8, respectively, decreasing at 6 months after surgery to 1.2 and 1.6, respectively (p = 0.201), whereas VAS scores for leg pain in Groups A and B at 2 years postoperatively were 1.3 and 1.4, respectively (p = 0.803). The rates of patients with excellent or good outcomes in terms of the modified MacNab criteria in Groups A and B were 91.3% and 69.2%, respectively, at 6 months after surgery (p = 0.010). Those rates in Groups A and B at 2 years after the operation were 91.3% and 84.6%, respectively (p = 0.203). The fusion rates in Groups A and B were 91.3% and 57.7%, respectively, at 6 months after surgery (p = 0.008), whereas the fusion rates in Groups A and B were 91.3% and 76.9%, respectively, at 2 years after surgery (p = 0.103). There was no significant difference in terms of the complication rate between Group A (4.3%) and B (3.8%) (p = 0.691). CONCLUSIONS: A relatively longer time until, and lower rate for, fusion in the patients treated with ALIF and percutaneous PSF were noted, which may be correlated with a relatively lower rate of patients with excellent or good outcomes. These results seem to favor ALIF with instrumented PLF rather than ALIF with percutaneous PSF in the treatment of elderly patients with L5-S1 isthmic spondylolisthesis and foraminal stenosis. However, additional long-term follow-up, a larger number of patients, and well-designed studies are necessary for a more rigorous evaluation of the outcome of patients treated using these surgical techniques.

Comparison study of the instrumented circumferential fusion with instrumented anterior lumbar interbody fusion as a surgical procedure for adult low-grade isthmic spondylolisthesis.

BACKGROUND: Instrumented circumferential fusion has been used as a primary and salvage procedure in lumbar spine fusion, especially for adult low-grade isthmic spondylolisthesis. Recently, instrumented anterior lumbar interbody fusion (ALIF) has been shown to provide good clinical and radiologic results that are comparable with those attained with traditional lumbar fusion. However, there have been no reports available that compare instrumented circumferential fusion with instrumented ALIF. METHODS: Between January 2003 and November 2004, a total of 43 consecutive patients underwent instrumented ALIF (group I) at one hospital of the authors. Between February 2003 and October 2006, a total of 32 consecutive patients underwent instrumented circumferential fusion (group II) at the other hospital of the authors. The authors retrospectively reviewed clinical and radiologic data from patients. The time spent on the operation, blood loss, blood transfusions, the length of hospital stay, complications, clinical results, and radiologic results, including disc height (DH), degree of listhesis, segmental lordosis (SL), and whole lumbar lordosis (WL), were analyzed and compared. Clinical outcomes were graded using visual analog scale (VAS) scores. Functional outcomes were measured using Oswestry Disability Index (ODI) scores and return-to-work status. RESULTS: The mean follow-up period was 41.1 and 32.9 months in group I and group II, respectively. Radiologic evidence of fusion was noted in 42 of 43 patients in group I and in 32 of 32 patients in group II. In both groups, all of the radiologic data, including the DH, degree of listhesis, SL, and WL significantly changed from the preoperative to postoperative period except for WL in group II. In both groups, VAS scores for back and leg pain and ODI scores significantly changed from the preoperative to postoperative period. There was no significant difference for VAS scores for back ODI scores in the two treatment groups after surgery. The mean time until return to work was 3.7 months in group I and 3.6 months in group II (p < .05). The mean hospital stay for group I (7.4 days) was shorter than that for group II (15.2 days) (p < .05). The mean operation time in group I (190 minutes) was shorter than that in group II (260.8 minutes) (p < .05). The mean blood loss in group I (300 mL) was less than that in group II (379 mL) (p < .05). CONCLUSIONS: According to the present clinical outcome, instrumented ALIF is at least as effective as instrumented circumferential fusion for the treatment of back pain in adult patients with low-grade isthmic spondylolisthesis. Moreover, in terms of operative data including the duration of operation and hospital stay, as well as blood loss, instrumented ALIF demonstrates better results.

A comparison of angled sagittal MRI and conventional MRI in the diagnosis of herniated disc and stenosis in the cervical foramen.

The object of this study is to demonstrate that angled sagittal magnetic resonance imaging (MRI) enables the precise diagnosis of herniated disc and stenosis in the cervical foramen, which is not available with conventional MRI. Due to both the anatomic features of the cervical foramen and the limitations of conventional MR techniques, it has been difficult to identify disease in the lateral aspects of the spinal canal and foramen using only conventional MRI. Angled sagittal MRI oriented perpendicular to the true course of the foramina facilitates the identification of the lateral disease. A review of 43 patients, who underwent anterior cervical discectomy and interbody fusion, is presented with a herniated disc and/or stenosis in the cervical foramen. They all had undergone conventional MRI and angled sagittal MRI. Fifty levels were surgically explored for evidence of foraminal herniated disc and stenosis. The results of each test were correlated with what was found at each explored surgical level. The sensitivity, specificity, and accuracy of both examinations for making the diagnosis of foraminal herniated disc and stenosis were compared. During the diagnosis of foraminal herniated disc, the sensitivity, specificity, and accuracy of angled sagittal MRI were 96.7, 95.0, and 96.0%, respectively, compared with 56.7, 85.0, and 68.0% for conventional MRI. In making the diagnosis of foraminal stenosis, the sensitivity, specificity, and accuracy of angled sagittal MRI were 96.3, 95.7, and 96.0%, respectively, compared with 40.7, 91.3, and 66.0% for conventional MRI. In the above groups, the difference between the tests for making the diagnosis of both foraminal herniated disc and stenosis was found to be statistically significant in sensitivity and accuracy. Angled sagittal MRI was a more accurate test compared to conventional MRI for making the diagnosis of herniated disc and stenosis in the cervical foramen. It can be utilized for the precise diagnosis of foraminal herniated disc and stenosis difficult or ambiguous in conventional MRI.

Treatment of Cerebral Rete Mirabile in Children by Encephalo-duro-arterio-synangiosis: Report of Two Operative Cases

Cerebral rete mirabile is a unusual form of chronic cerebrovascular occlusive disease characterized usually by bilateral stenosis of distal internal carotid arteries and their vicinity, by a hazy network of collateral circulation at the base of brain called moyamoya vessels and clinically by recurring hemispheric ischemic attack in children. We have reported here 2 cases of cerebral rete mirabile in children and performed newly developed operative procedure which we think is an ideal surgical method for treatment of this disease in children and is compared with other surgical treatment.