Skull fracture and epidural hematoma caused by use of a Mayfield skull clamp in an adult patient with chronic hemodialysis: a case report.

BACKGROUND: Mayfield skull clamps are widely used and indispensable in current neurosurgery. Complications such as skull fractures or intracranial hematoma from using a Mayfield skull clamp have largely been reported in the pediatric population, are likely related to the relative thinness of the skull, such as in patients with hydrocephalus, and are extremely rare in adults. Here, we report a case of skull fracture and epidural hematoma caused by a Mayfield skull clamp used for posterior decompression surgery in an adult patient with chronic hemodialysis. CASE PRESENTATION: A 67-year-old Asian male patient with a history of dialysis-dependent chronic renal failure over 36 years suffered from severe cervical myelopathy. Neurological examination and radiographic images revealed cervical spondylotic myelopathy due to dialysis-related spondyloarthropathy. Laminoplasty was planned on patient consent. A Mayfield skull clamp was applied with the patient supine. Torque was applied to the screws with gentle care, but there was no resistance and it was not easy to reach the standard 60 lb (267 N) to 80 lb (356 N). Because a skull fracture was suspected, we canceled the surgery. Emergency head computed tomography showed depressed skull fractures underlying the single-pin sites with an associated epidural hematoma. The fractures and epidural hematoma were treated conservatively, and spontaneous resolution of the hematoma was confirmed. Cervical laminoplasty was performed successfully using a mask-type head holder on the subsequent day. CONCLUSIONS: As a precaution for fractures and epidural hematoma in neurosurgical patients with bone fragility or a thin skull, use of a mask-type fixing device or halo ring is recommended.

The nature of osteoporotic low back pain without acute vertebral fracture: A prospective multicenter study on the analgesic effect of monthly minodronic acid hydrate.

BACKGROUND: Patients with osteoporosis but no evidence of fracture can sometimes report low back pain. However, few studies have evaluated the nature of osteoporotic low back pain in a clinical situation. Therefore, the aim of this study was to examine the nature of osteoporotic low back pain without fracture, and the analgesic effect of minodronic acid hydrate on such pain. METHODS: The current study examined 136 patients with osteoporotic low back pain and no lower extremity symptoms. The following factors were evaluated before and after minodronic acid hydrate administration: the nature of osteoporotic low back pain was evaluated using the painDETECT questionnaire, numeric rating scale (NRS) score for low back pain at rest and in motion, bone mineral density (BMD) of the lumbar spine, and the serum concentration of tartrate-resistant acid phosphatase 5b (TRACP-5b) as a bone metabolism marker. RESULTS: A total of 113 patients were enrolled. The painDETECT questionnaire revealed the percentage of patients with nociceptive pain and neuropathic or mixed pain was approximately 85% and 15%, respectively. the average NRS scores for low back pain at rest decreased significantly 2 months after treatment (p = 0.01), while those in motion decreased significantly 1 month after treatment (p = 0.04). The average lumbar spine BMD tended to increase after treatment, but not significantly. On the other hand, the changes in the average serum concentration of TRACP-5b did significantly decrease 1 month after treatment. There was a significant positive correlation between the rate of NRS score improvement for low back pain at rest, and the rate of improvement in serum concentration of TRACP-5b (p < 0.05). CONCLUSIONS: Osteoporotic low back pain consisted of 85% nociceptive pain and 15% neuropathic or mixed pain. The pain is strongly related to pain at rest rather than that in motion.

Effects of Incentive Spirometry on Respiratory Motion in Healthy Subjects Using Cine Breathing Magnetic Resonance Imaging.

OBJECTIVE: To investigate the effectiveness of incentive spirometry on respiratory motion in healthy subjects using cine breathing magnetic resonance imaging (MRI). METHODS: Ten non-smoking healthy subjects without any history of respiratory disease were studied. Subjects were asked to perform pulmonary training using incentive spirometry every day for two weeks. To assess the effectiveness of this training, pulmonary function tests and cine breathing MRI were performed before starting pulmonary training and two weeks after its completion. RESULTS: After training, there were significant improvements in vital capacity (VC) from 3.58±0.8 L to 3.74±0.8 L and in %VC from 107.4±10.8 to 112.1±8.2. Significant changes were observed in the right diaphragm motion, right chest wall motion, and left chest wall motion, which were increased from 55.7±9.6 mm to 63.4±10.2 mm, from 15.6±6.1 mm to 23.4±10.4 mm, and from 16.3±7.6 mm to 22.0±9.8 mm, respectively. CONCLUSION: Two weeks of training using incentive spirometry provided improvements in pulmonary function and respiratory motion, which suggested that incentive spirometry may be a useful preoperative modality for improving pulmonary function during the perioperative period.

Accuracy of Pedicle Screw Placement in Scoliosis Surgery: A Comparison between Conventional Computed Tomography-Based and O-Arm-Based Navigation Techniques.

STUDY DESIGN: Retrospective study. PURPOSE: We compared the accuracy of O-arm-based navigation with computed tomography (CT)-based navigation in scoliotic surgery. OVERVIEW OF LITERATURE: No previous reports comparing the results of O-arm-based navigation with conventional CT-based navigation in scoliotic surgery have been published. METHODS: A total of 222 pedicle screws were implanted in 29 patients using CT-based navigation (group C) and 416 screws were implanted in 32 patients using O-arm-based navigation (group O). Postoperative CT was performed to assess the screw accuracy, using the established Neo classification (grade 0: no perforation, grade 1: perforation <2 mm, grade 2: perforation ≥2 and <4, and grade 3: perforation ≥4 mm). RESULTS: In group C, 188 (84.7%) of the 222 pedicle screw placements were categorized as grade 0, 23 (10.4%) were grade 1, 11 (5.0%) were grade 2, and 0 were grade 3. In group O, 351 (84.4%) of the 416 pedicle screw placements were categorized as grade 0, 52 (12.5%) were grade 1, 13 (3.1%) were grade 2, and 0 were grade 3. Statistical analysis showed no significant difference in the prevalence of grade 2.3 perforations between groups C and O. The time to position one screw, including registration, was 10.9±3.2 minutes in group C, but was significantly decreased to 5.4±1.1 minutes in group O. CONCLUSIONS: O-arm-based navigation facilitates pedicle screw insertion as accurately as conventional CT-based navigation. The use of O-arm-based navigation successfully reduced the time, demonstrating advantages in the safety and accuracy of pedicle screw placement for scoliotic surgery.

Rod fracture after long construct fusion for spinal deformity: clinical and radiographic risk factors.

BACKGROUND: No reports have been published on detailed risk factors for rod fracture after spinal deformity correction and fusion. The purpose of this study was to analyze clinical and radiographic risk factors of rod fracture after long construct fusion for spinal deformity. METHODS: The survey subjects were 155 cases who were diagnosed with spinal deformity and underwent correction and fusion surgery with long construct instrumentation (>3 levels, average 10.3 levels) between July 2004 and June 2010. The subjects comprised 32 males and 123 females with a mean age of 19.0 (range 8-78) years. The mean Cobb angle was 61.0 ± 16.1° preoperatively and 25.7 ± 16.9° postoperatively. Univariate analysis and logistic regression analysis were performed. RESULTS: Rod fracture occurred in 8 of 155 cases (5.2 %). The mean period from surgery to rod fracture was 18.1 months (range 2-37). The level of fracture ranged from the thoracolumbar junction to the lumbosacral vertebrae. Six patients had fracture near the fused lower end and two patients had fracture at the thoracolumbar junction. Univariate analysis revealed that non-ambulatory status, preoperative kyphosis, small-diameter rods, multiple surgery, and use of iliac screws were significant risk factors for rod fracture. Sex, obesity, severity of preoperative scoliosis, and rod material were not significant risk factors. Logistic regression analysis revealed that use of iliac screws (odds ratio: 81.9, 95 % confidence interval: 7.2-935.0, p < 0.001) and small-diameter (<6 mm) rods (odds ratio: 16.3, 95 % confidence interval: 1.7-152.6, p = 0.015) were risk factors for rod fracture. CONCLUSIONS: The incidence of rod fracture after long construct fusion for spinal deformity was 5.2 %. Iliac screw fixation and small-diameter rods were risk factors for rod fracture.

Virtual endoscopic imaging of the spine.

STUDY DESIGN: Prospective trial of virtual endoscopy in spinal surgery. OBJECTIVE: To investigate the utility of virtual endoscopy of the spine in conjunction with spinal surgery. SUMMARY OF BACKGROUND DATA: Several studies have described clinical applications of virtual endoscopy to visualize the inside of the bronchi, paranasal sinus, stomach, small intestine, pancreatic duct, and bile duct, but, to date, no study has described the use of virtual endoscopy in the spine. METHODS: Virtual endoscopy is a realistic 3-dimensional intraluminal simulation of tubular structures that is generated by postprocessing of computed tomographic data sets. Five patients with spinal disease were selected: 2 patients with degenerative disease, 2 patients with spinal deformity, and 1 patient with spinal injury. RESULTS: Virtual endoscopy software allows an observer to explore the spinal canal with a mouse, using multislice computed tomographic data. Our study found that virtual endoscopy of the spine has advantages compared with standard imaging methods because surgeons can noninvasively explore the spinal canal in all directions. CONCLUSION: Virtual endoscopy of the spine may be useful to surgeons for diagnosis, preoperative planning, and postoperative assessment by obviating the need to mentally construct a 3-dimensional picture of the spinal canal from 2-dimensional computed tomographic scans.

Health-related quality of life and low back pain of patients surgically treated for scoliosis after 21 years or more of follow-up: comparison among nonidiopathic scoliosis, idiopathic scoliosis, and healthy subjects.

STUDY DESIGN: A case-control study. OBJECTIVE: To compare health-related quality of life and low back pain of healthy subjects with those of patients with nonidiopathic scoliosis (non-IS) and idiopathic scoliosis (IS) 21 years or more after surgery. SUMMARY OF BACKGROUND DATA: There have been a very small number of reports on long-term results of surgery for non-IS. There have not been any reports that compare non-IS, IS, and healthy subjects. METHODS: The subjects with scoliosis were 602 patients who had undergone surgery between 1968 and 1988. The Scoliosis Research Society Patient Questionnaire (SRS-22), Roland-Morris Disability Questionnaire (RDQ), and our institution's original questionnaire were used for evaluating long-term clinical outcomes. The 136 respondents consisted of 56 patients with non-IS (non-IS group) and 80 patients with IS (IS group). The control group (CTR group) consisted of 80 healthy volunteers who were age- and body mass index-matched to the scoliosis groups. RESULTS: In the SRS-22, the 3 groups had no significant differences in pain and mental health. For function and self-image, the non-IS group and the IS group had a significantly lower score than the CTR group. In the RDQ, the non-IS group had significantly more severe low back pain than the CTR group. There was no significant difference in low back pain between the non-IS group and IS group or between the IS group and CTR group. The non-IS group had a significantly lower marriage rate than the IS and CTR groups. CONCLUSION: The patients with non-IS and IS had similar health-related quality of life and low back pain. The patients with non-IS were found to have lower function and self-image in the SRS-22 questionnaire and more severe low back pain in the RDQ than healthy subjects. The patients with non-IS had a significantly lower marriage rate than the other 2 groups.

Long-term clinical outcomes of surgery for adolescent idiopathic scoliosis 21 to 41 years later.

STUDY DESIGN: A case control study. OBJECTIVE: To determine the clinical outcome of middle-aged patients surgically treated for adolescent idiopathic scoliosis and to compare their outcomes with assessments of age- and sex-matched healthy controls. SUMMARY OF BACKGROUND DATA: Several long-term follow-up studies have been published on the clinical outcomes of surgical treatment for adolescent idiopathic scoliosis in patients who have reached their 20s or 30s. However, clinical outcomes in patients who have reached middle age remain unknown. METHODS: This study included 256 patients surgically treated for adolescent idiopathic scoliosis (AIS) between 1968 and 1988. The Scoliosis Research Society Patient Questionnaire (SRS-22) and Roland-Morris Disability Questionnaire (RDQ) were used for evaluating long-term clinical outcomes. Sixty-six (25.8%; 62 females, 4 males; mean age, 46.0 years [range 34-56]) of the 256 patients responded to the questionnaires. The mean follow-up period was 31.5 (range 21-41) years. Seventy-six healthy age- and sex-matched individuals with neither a history of spinal surgery nor scoliosis were selected as a control (CTR) group. RESULTS: On the basis of the SRS-22 responses, AIS patients had significantly decreased function (AIS: 4.3 ± 0.6, CTR: 4.7 ± 0.5, P < 0.01) and decreased self-image (AIS: 3.0 ± 0.8, CTR: 3.7 ± 0.5, P < 0.01) in comparison with the controls, but the 2 groups were similar with respect to pain (AIS: 4.3 ± 0.6, CTR: 4.2 ± 0.5, P = 0.14) and mental health (AIS: 3.9 ± 0.9, CTR: 3.7 ± 0.7, P = 0.14). The RDQ responses indicated that low back pain was not significantly increased in the AIS group compared with the CTR group (AIS: 1.8 ± 3.5, CTR: 1.4 ± 3.1, P = 0.36). CONCLUSION: Surgery had no demonstrable adverse effects on pain or mental health in these middle-aged AIS patients 21-41 years after surgery, although the AIS patients did have significantly lower function and lower self-image than the controls.

[A case of allopurinol-induced muscular damage in a chronic renal failure patient].

A 73-year-old woman with chronic renal failure developed generalized muscular weakness and pain 6 days after the start of allopurinol treatment(200 mg/day). Routine laboratory tests revealed elevated levels of serum creatine kinase, and the patient was clinically diagnosed as rhabdomyolysis, due probably to severe myositis. A high level of serum oxipurinol, the chief active metabolite of allopurinol, was also revealed. The muscular weakness was relieved in seven weeks with intermittent hemodiafiltration.