Preliminary Clinical Experience with a High-Definition Three Dimensional Exoscope for Spinal Surgery.

We retrospectively evaluated spinal surgeries performed using the high-definition three-dimensional exoscopic system, which became available at our institution in August 2020. Eleven patients (4 with cervical disease and 7 with lumbar disease) underwent surgery with the system. There were no surgical complications related to the system, and the results were satisfactory. The small, flexible camera of the exoscope allows the surgeon to view the surgical field from various angles, facilitating both the approach and technique. In addition, it allows the surgeon to operate in an upright position without strain on the head and neck. Although further surgical experience is needed, this system has the potential to improve the visualization of the surgical field in spinal surgery.

Reverse Obliquity Intertrochanteric Fracture Treated with a Dynamic Distal Locked Intramedullary Hip Nail.

INTRODUCTION: The aim of this study was to describe the clinical and radiological results of reverse obliquity intertrochanteric fractures treated with dynamic distal locked intramedullary hip nails. MATERIALS AND METHODS: Patients with a reverse obliquity intertrochanteric fracture (AO/OTA type 31 A3.1 or A3.3) underwent surgical treatment with a dynamic distal locked intramedullary hip nail between August 2017 and September 2020. Fracture type, reduction quality, change in the position of the distal bone fragment, bone union, complications, and walking ability were evaluated. RESULTS: Ten patients with reverse obliquity intertrochanteric fractures (seven females and three males) underwent dynamic distal locked intramedullary hip nailing. The mean age was 72.0 ± 18.9 years. Two patients were classi fied as having A3.1 fractures; eight patients were classified as having A3.3 fractures. Anatomical reduction was achieved in six patients, medial displacement remained in three patients, and lateral displacement remained in one patient postoperatively. In 9 out of 10 patients, the center of the proximal end of the distal bone fragment had moved laterally between the time immediately after surgery and the time of the final evaluation. Bone union was obtained uneventfully without any additional treatments in all patients. There were no complications such as infection or implant failure. Walking ability decreased in four patients. CONCLUSION: In all patients, bone union was achieved due to good contact of the medial cortices or the migration of the distal bone fragment into the proximal bone fragment. This procedure can be an option for treating reverse obliquity intertrochanteric fractures.

Improved intervertebral bone union in ALIF rat model with porous hydroxyapatite/collagen combined with platelet-rich plasma.

BACKGROUND CONTEXT: Platelet-rich plasma (PRP) can accelerate bone union in spinal fusion surgery with an autogenous bone graft. However, it is unclear whether bone union can be obtained by using artificial bone and PRP together in spinal interbody fusion surgery. PURPOSE: This study aimed to determine whether interbody fusion can be achieved by transplanting porous hydroxyapatite/collagen(HAp/Col) which is an artificial bone material frequently used in spinal fusion surgery, together with PRP in the intervertebral disc space in rats. STUDY DESIGN AND SETTING: A controlled laboratory study. METHODS: A total of fourty 10-week old Sprague-Dawley rats were used in this study and assigned to three groups as follow: disc curettage only (control group, n=10), disc curettage + HAp/Col transplant (H group, n=10), and disc curettage + HAp/Col + PRP transplant (H+P group, n=10). The other 10 rats were sacrificed as blood donors for acquisition of PRP. Microcomputed tomography (µCT) examinations were performed to evaluate bone union, bone volume (BV), and bone mineral density (BMD) at 4, 8, and 12 weeks following surgery. Twelve weeks postoperatively, each group of three of L4-L5 spines was harvested to perform histological examination (hematoxylin & eosin stain) and the others were subjected to biomechanical testing (compression properties). RESULTS: The platelet count in PRP was approximately 4.1 times greater than that in whole blood (260.6±26.2 × 104 mg/dL and 64.3±2.9 × 104 mg/dL in PRP and whole blood, respectively). All the L4-L5 lumbar discs were fused in the H+P group, whereas only one case was fused in the H group and none in the control group at 12 weeks after surgery. BV was significantly higher in the H+P group than in the H group or control groups (both p<.01), although BMD was not significantly different among the three groups. Upon histological analysis, mature bone formation was observed at the transplanted space in all cases in the H+P group, whereas fibrous tissue was observed at the location in the H and control groups. Regarding biomechanical properties, the ultimate load to failure was significantly higher in the H+P group than in the H group or control group (p=.021 and .013, respectively), although stiffness was not significantly different between the three groups. CONCLUSION: The combination of porous HAp/Col and PRP at an appropriate concentration can promote bone union in the intervertebral disc space without using an autologous bone graft in the rat model. Bone tissue formation was histologically confirmed, and it was mechanically strong. CLINICAL SIGNIFICANCE: This preclinical study showed that porous HAp/Col, when combined with PRP at an appropriate concentration, can induce bone union without autologous bone grafts. The results may eliminate the need for autologous bone collection for spinal fusion surgery in the future.

Suicidal jumper's fracture reduced with hyperextension and the joystick method: A case report.

Suicidal jumper's fractures are transversal fractures of the upper sacrum. The treatment for this type of fracture remains controversial. We present a case of a Roy-Camille type 2 suicidal jumper's fracture treated with reduction by hyperextension of the lumbosacral junction, the joystick method, and percutaneous fixation on the day of injury. After the operation, the sacral canal at the S2 level was enlarged and both lower extremities began to move gradually. At 19 days after the injury, direct decompression via sacral laminectomy was performed to promote further neurological improvement. At 10 months after the injury, cauda equina syndrome and radicular symptoms were completely resolved. Considering its minimal invasiveness, we recommend trying hyperextension and the joystick method to treat Roy-Camille type 2 suicidal jumper's fractures on the day of injury.

Primary treatment of atlantoaxial rotatory fixation in children: a multicenter, retrospective series of 125 cases.

OBJECTIVE: The primary treatment for atlantoaxial rotatory fixation (AARF) remains controversial. The aim of this study was to investigate the primary treatment for AARF and create an algorithm for primary treatment. METHODS: The authors analyzed the data of 125 pediatric patients at four medical institutions from April 1989 to December 2018. The patients were reported to have neck pain, torticollis, and restricted neck range of motion and were diagnosed according to the Fielding classification as type I or II. As a primary treatment, 88 patients received neck collar fixation, and 28 of these patients did not show symptom relief and required Glisson traction. Thirty-seven patients were primarily treated with Glisson traction. In total, 65 patients, including neck collar treatment failure patients, underwent Glisson traction in hospitals. RESULTS: The success rate of treatment was significantly higher in the Glisson traction group (97.3%) than in the neck collar fixation group (68.2%) (p = 0.0001, Wilcoxon test). In the neck collar effective group, Fielding type I was more predominant (p = 0.0002, Wilcoxon test) and the duration from onset to the first visit was shorter (p = 0.02, Wilcoxon test) than that in the neck collar ineffective group. Using multivariate logistic regression analysis with the above items, the authors generalized from the estimated formula: logit [p(success group by neck collar fixation group)|duration from onset to the first visit (x1), Fielding type (x2)] = 0.4(intercept) - 0.15x1 + 1.06x2, where x1 is the number of days and x2 = 1 (for Fielding type I) or -1 (for Fielding type II). In cases for which the score is a positive value, the neck collar should be chosen. Conversely, in cases for which the score is a negative value, Glisson traction should be the first choice. CONCLUSIONS: According to this formula, in patients with Fielding type I AARF, neck collar fixation should be allowed only if the duration from onset is ≤ 10 days. In patients with Fielding type II, because the score would be a negative value, Glisson traction should be performed as the primary treatment.

Pyogenic Spondylitis: Clinical Features, Diagnosis and Treatment.

Although pyogenic spondylitis is an infrequent infection, its incidence is increasing because of the growing number of elderly people and immunocompromised patients. Diagnosis is often difficult and appropriate imaging, blood cultures and/or biopsy are essential in making an early diagnosis. Most of the cases can be treated non-operatively. Surgical treatment is indicated in patients with spinal cord or cauda equine compression with progressive neurological deficits and/or patients who have failed conservative treatment. Early and accurate diagnosis of pyogenic spondylitis is important for timely and effective management, in order to reduce the occurrence of spinal deformity and dysfunction.

Clinical outcomes of percutaneous suction aspiration and drainage for the treatment of infective spondylodiscitis with paravertebral or epidural abscess.

BACKGROUND CONTEXT: Patients with infective spondylodiscitis who failed conservative treatment are generally indicated for open surgery. However, some patients are poor candidates for standard surgery, hence the need to evaluate less invasive approaches. Good outcomes were previously reported for percutaneous suction aspiration and drainage (PSAD) in the treatment of infective spondylodiscitis resistant to conservative therapy. We recently extended the surgical approach of PSAD to allow drainage of paravertebral or epidural abscesses in patients with progressive infective spondylodiscitis. PURPOSE: To evaluate the clinical outcomes of PSAD for infective spondylodiscitis with paravertebral or epidural abscess. DESIGN: Retrospective case series. PATIENT SAMPLE: Patients with infective spondylodiscitis and associated epidural or paravertebral abscess treated using PSAD at our institution, between 1998 and 2014. OUTCOME MEASURES: Serum levels of C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and imaging data obtained via plain radiography, computed tomography, and magnetic resonance imaging were analyzed. Serum measurements were taken preoperatively and at several time points postoperatively. Clinical outcomes were evaluated using the modified MacNab criteria for overall functional mobility. METHODS: Data were obtained from the patients' case notes, radiological images, and medical records. Student t test was used to assess the relevance of changes in serum levels of CRP and ESR at each evaluated time point, as well as the change in sagittal Cobb angle between the preoperative state and the state at final follow-up. RESULTS: Fifty-two patients (31 men and 21 women; average age, 70.6 years) were included in our analysis. The median (range) CRP levels and ESR values at the time of diagnosis were 6.86 (0.04-20.15) mg/dL and 78.8 (26-120) mm/h, respectively. At 1 year postoperatively, these values had decreased to 0.18 (0.0-1.2) mg/dL and 13.8 (4-28) mm/h for CRP and ESR, respectively. At final follow-up, bone union was observed in 80.8% (42 of 52) of patients, with instability identified in five patients. Regarding functional mobility, excellent outcomes were obtained in 26.9% (14 of 52) of patients, whereas good, fair, and poor outcomes were noted in 42.3% (22 of 52), 3.9% (2 of 52), and 26.9% (14 of 52) of patients, respectively. Overall, treatment was considered effective in 69.2% (36 of 52) of patients. CONCLUSIONS: Percutaneous suction aspiration and drainage can serve as an effective alternative to open surgery for the treatment of patients with progressive infective spondylodiscitis and associated paravertebral or epidural abscess.