Delayed surgery in neurologically intact patients affected by thoraco-lumbar junction burst fractures: to reduce pain and improve quality of life.

BACKGROUND: This is a retrospective study on 18 patients affected by thoraco-lumbar junction burst fractures (TLJBF) A3 or A4 at computed tomography (CT) scan who referred to our hospital. To assess the surgical results in terms of pain and quality of life in a series of neurologically intact patients affected by TLJBF who underwent surgery after 3-4 months from the injury. In literature there is controversy if pain could be an indication for surgery in TLJBF and series of patients conservatively managed with success have been reported. METHODS: A retrospective study on 18 patients is reported. Patients included in this series were neurologically intact and affected by a TLJBF A3 or A4 at CT scan, the height of the burst vertebral body was >50%, spinal canal invasion was <30% and kyphosis deformity <30 degrees. Pain and quality of life were evaluated using graphic rating scale (GRS) and EuroQol (EQ-5D) scores on admission, at the clinical follow-up and in post-surgical period. RESULTS: Comparing pre- and post-operative EQ-5D, the scores had a statistically significant decrease after the operation (P<0.001) [pre-surgery EQ-5D was 2.60 (SD =0.67), post-surgery EQ-5D was 1.37 (SD =0.41)]. Also analyzing the EQ5D-VAS scores, the t-test revealed that surgery (P<0.01) improved the quality of life with statistically significance (EQ5D-VAS pre =43.89, SD =12.43 and EQ5D-VAS post =73.33, SD =10.84). Analyzing pre- and post-surgical GRS scores, the pain decreased significantly with the maximum mean difference among the 2nd and 3rd month before surgery and at 12 months after surgery (respectively D =5.444, P<0.001 and D =5.167, P<0.001). CONCLUSIONS: Conservatively managed patients affected by TLJBF require a strict clinical follow-up since pain sometimes is present in the following months and it affects the quality of life. Surgery should be considered for these cases.

Surgery for vertebral involvement in multiple myeloma.

BACKGROUND: To evaluate the results of surgery for vertebral involvement in multiple myeloma (MM) following the introduction of the new chemotherapy in 2006. METHODS: Retrospective cohort study evaluating the patients with MM vertebral lesions from January 2006 to January 2014. Outcomes were based upon participation in ODI and EQ-5D. Statistical interpretation of the data was performed with SPSS version 19 software (SPSS Inc, Chicago, IL, USA). RESULTS: One hundred twenty patients affected by MM were potentially eligible for recruitment. About 1/3 patients needed an operation for vertebral involvement. The disability was mainly related to the number of vertebrae affected by MM. No difference in disability and quality of life was observed between operated and non-operated patients, according to age, levels, and follow-up. The operated patients with a Thoracic location reported lower disability and higher quality of life than non-operated patients. Non-operated patients with one or two vertebrae affected reported lower levels of quality of life. CONCLUSIONS: When a spinal column involvement occurs, the probability of undergoing surgery is about 40%. Operated patients show a moderate disability and the increased tendency is related to the number of vertebrae involved. The quality of life is middle in average and middle-high in patients operated for thoracic lesions. Nowadays the spinal surgeon must have a perspective view about MM vertebral lesions, evaluating the stability of the spine, the presence of deformity, the risk of vertebral fractures and the presence of drug resistant pain, that deteriorate the disability and the quality of life related to the underlying disease.

Static and dynamic cervical MRI: two useful exams in cervical myelopathy.

BACKGROUND: Cervical magnetic resonance imaging (MRI) is the gold standard exam in the assessment of patients affected by cervical myelopathy and is very useful in planning the operation. Herein we present a series of patients affected by long tract symptoms who underwent dynamic MRI in addition to the static exam. METHODS: In the period between March 2010 and March 2012, three-hundred-ten patients referred to our department since affected by neck/arm pain or symptoms related to cervical myelopathy. Thirty-eight patients complained "long-tract symptoms" related to cervical myelopathy. This series of patients was enrolled in the study. All patients underwent clinical and neurological exam. In all the cases, a static and dynamic cervical MRI was executed using a 3.0-T superconducting MR unit (Intera, Philips, Eindhoven, Netherlands). The dynamic exam was performed with as much neck flexion and extension the patient could achieve alone. On T2-weigthed MRI each level was assessed independently by two neuroradiologists and Muhle scale was applied. RESULTS: According to Muhle's classification of spinal cord compressions, static MRI demonstrated 156 findings: 96 (61.54%) anterior and 60 (38.46%) posterior. Dynamic MRI showed 186 spinal cord compressions: 81 (43.5%) anterior and 105 (56.5%) posterior. The anterior compressions were: grade 1 in 23 cases (28.4%), grade 2 in 52 cases (64.2%), grade 3 in 6 cases (7.4%). The posterior compressions were: 32 (30.48%) of grade 1, 60 (57.14%) of grade 2, 13 (12.38%) of grade 3. CONCLUSIONS: The dynamic MRI demonstrated a major number of findings and spinal cord compressions compared to the static exam. Finally, we consider the dynamic exam able to provide useful information in these patients, but we suggest a careful evaluation of the findings in the extension exam since they are probably over-expressed.

C5 palsy after insertion of a winged expandable cervical cage: a case report and literature review.

C5 nerve root palsy is a well-known complication after anterior or posterior cervical decompression. Many theories have been proposed but the etiology is still unclear. The use of a winged expandable cage after single or multiple corpectomy is among the used techniques in reconstructing the cervical spine. Herein we report a case of C5 palsy after a three-level corpectomy and reconstruction using this device for the treatment of cervical spondylosis. In our case the preexisting foraminal stenosis, wide anterior decompression and partial improvement of cervical alignment were factors supposed contributing to the palsy.

A case of cervical tuberculosis with severe kyphosis treated with a winged expandable cage after double corpectomy.

In this case report, we demonstrate that the use of a winged expandable cage was able to obtain good clinical and radiological results in a case of cervical tuberculosis with severe kyphosis. However, case series will be necessary to affirm its validity as a stand-alone device for similar cases with high risk of instability.

Cervical reconstruction techniques. After adequate selection of the patient report of a series of 34 patients treated with winged expandable cages.

After single or multilevel cervical corpectomy for the treatment of different diseases, many surgical options have been proposed over the years. As a single device, a winged expandable titanium cage (WETC) has been developed. We report the use of this device and our clinical results at 24 months of follow-up in a prospective series of 34 patients who underwent single or multilevel corpectomy for the treatment of cervical spondylosis. Thirty-four consecutive patients underwent single or multilevel cervical corpectomy followed by the insertion of a WETC for the treatment of cervical spondylosis at Department of Neurology and Psychiatry "Sapienza" University of Rome, Italy, from May 2011 to May 2013. Patients affected by cervical spondylosis with cervical lordosis >0° were included. Patients affected by cervical lordosis <0°, osteoporosis, or other cervical diseases were excluded. The mean postsurgical Nurick's grade was significantly lower than the mean presurgical Nurick's grade (mean = 0.98 for postsurgical Nurick's grade and mean = 2.42 for presurgical Nurick's grade). Four patients (11.7 %) presented subsidence respectively of 1, 2, 2, and 3 mm at 24 months of radiological follow-up. Postoperative complications occurred in five patients (14.7 %). Our case series at 24 months of follow-up demonstrates that the use of a WETC obtains good clinical results after single or multiple corpectomy in patients not affected by osteoporosis who do not require cervical lordosis correction. During the insertion of the device, an adequate preparation of the end plates is suggested and their over distraction should be avoided.

Revision surgery for degenerative spinal deformity: a case report and review of the literature.

INTRODUCTION: Management of spinal degenerative deformities always represents a challenge for the spinal surgeon. CASE PRESENTATION: We report a case of revision surgery for adult scoliosis, focusing of most common errors in pre-surgical management and criteria for reoperation. We analyzed the spino-pelvic parameters on the standing whole-spine X-ray and the role of sagittal balance. To restore 45° of lumbar lordosis, we performed a L3 Pedicle Subtraction Osteotomy (PSO), along with L2-L3 and L3-L4 eXtreme Lateral Interbody Fusion (XLIF). DISCUSSION: In cases of adult scoliosis, careful preoperative planning is necessary in an attempt to avoid difficult, expensive, and high-risk additional procedures.

Surgical management of C-type subaxial cervical fractures using cervical traction followed by anterior cervical discectomy and fusion within 12 h after the trauma.

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: To report our 10-year experience of closed reduction using Crutchfield traction followed by anterior cervical discectomy and fusion within 12 h from injury for C-type subaxial cervical fractures (according to the AOSpine classification system). METHODS: Clinical records and neuroimaging were retrospectively reviewed. Surgical details were provided. RESULTS: A total of 22 patients were included in the study. The cervical fracture was diagnosed after whole-body computed tomography scan on admission in all cases. Crutchfield traction was applied within 1-5 h from the diagnosis. Surgery consisting of anterior microdiscectomy and fusion with interbody cage and plating was performed 6-12 h after traction positioning. Most patients (19, 86%) had spinal cord injury: 7 were Frankel A (31%), 3 Frankel B (14%), 6 Frankel C (27%), 3 Frankel D (14%), and 3 Frankel E (14%). No neurologic deterioration was observed after the treatment. In 10 cases (45%), neurological symptoms improved 1 year after the trauma. Two patients (10%) died for complication related to spinal cord transition or other organ damage. CONCLUSIONS: Early reduction gives the best chance of recovery for patients affected by C-type subaxial cervical fracture. Rapid traction is more often successful and safer than manipulation under anesthesia. After close reduction achieving, anterior microdiscectomy, cage, and plating implant seem to be safe and effective with a low rate of complications.

Decompression versus decompression and fusion for degenerative lumbar stenosis: analysis of the factors influencing the outcome of back pain and disability.

BACKGROUND: The objective of this study is to evaluate the factors influencing the outcome of back pain and disability in patients operated for lumbar stenosis without instability and deformity using two classical surgical techniques: decompression alone and decompression plus fusion. METHODS: This is a retrospective cohort study of patients who underwent lumbar surgery with standard posterior decompression or standard posterior decompression plus pedicle screw fixation for degenerative lumbar stenosis without deformity, spondylolisthesis or instability at our department from June 2010 to January 2014. They were divided into two groups: decompression group (D) and decompression-fusion group (F). We analyzed the following factors: age, gender, levels of stenosis, pre-surgical "micro-instability", and post-surgical "micro-instability". RESULTS: A total of 174 patients were enrolled in the study. Both Graphic Rating Scale (GRS) and Oswestry Disability Index (ODI) scores were significantly decreased after surgery (P<0.001). Female patients appeared to have lesser improvements from surgery, for both D and F groups. An analysis of variance using the decrease of pain (GRS pre-post) as dependent variable and type of surgery, age, gender and their interaction as factors showed that the main effects of type of surgery and gender were significant. The analysis of variance for the decrease of pain (GRS) and disability (ODI) according to the levels of stenosis showed a significant interaction for GRS scores. Female patients that underwent fixation surgery reported the least improvement in disability. A significant interaction was found on the one-way analysis of variance for the D group without pre-surgical micro-instability using post-surgical micro-instability as factor. CONCLUSIONS: Our study supports posterior decompression alone as the gold standard option as treatment for lumbar stenosis without instability and deformity. Additional fusion should be considered only to prevent post-surgical instability. The "micro-instability" is a radiological finding that has its clinical surrogate but is not able to guide the choice of the type of surgery. Moreover the significance of "micro-instability" is still unclear. We suggest a prospective study following patients with asymptomatic micro-instability to definitively understand the clinical history.

Thoracic Spondylodiscitis Caused by Methicillin-resistant Staphylococcus aureus as a Superinfection of Pulmonary Tuberculous Granuloma in an Immunocompetent Patient: A Case Report.

Study Design Case report. Objective To describe a very rare case of an immunocompetent man who underwent surgery for thoracic spondylodiscitis caused by methicillin-resistant Staphylococcus aureus (MRSA) that developed as a superinfection of a pulmonary tuberculous granuloma. Methods Posterior decompression and pedicle screw vertebral fixation were followed by T5-T6 anterior somatotomy with implant of an expandable mesh and lateral plating as symptoms worsened. During the anterior approach, an atypical resection of the left lower lobe was also performed. Results A tuberculous granuloma was detected on histology. Ziehl-Neelsen stain confirmed the diagnosis. Culture also detected MRSA. Conclusions Early medical management is the first choice for spondylodiscitis to eradicate the infection and alleviate pain. Immobilization of the affected spine segments can protect the patient from vertebral collapse and from the appearance of neurologic deficits. Surgery is suggested if there are compressive effects on the spinal cord, spinal epidural abscess, vertebral collapse, and deformity. We decided to remove the abscess and to restore the anterior column using an anterior approach. Moreover, in this case, an anterior approach allowed us to identify the etiology of the lesion and to determine the best chemotherapy regimen.

Hidden spondylolisthesis: unrecognized cause of low back pain? Prospective study about the use of dynamic projections in standing and recumbent position for the individuation of lumbar instability.

INTRODUCTION: Dynamic X-rays (DXR) are widely recognized as an effective method to detect lumbar instability (LI). They are usually performed with the patient in standing position (SDXR). In our opinion, standing position inhibits micromovements of the lumbar segment interested by the listhesis, thanks to paravertebral muscles antalgic contraction and augmented tone. We aim to demonstrate that DXR in recumbent position (RDXR), reducing the action of paravertebral muscles, can discover hypermovements not evidenced in SDXR. METHODS: Between January 2011 and January 2013, we studied 200 consecutive patients with lumbar degenerative disease with MRI, SDXR, and RDXR. We aimed to find a correlation between low back or radicular pain and the presence of a spondylolisthesis not showed by the SDXR, but showed by the RDXR. RESULTS: We analysed 200 patients: of the 133 not pathologic in SDXR, 43 patients (32.3 %) showed an hypermovement in RDXR (p = 0.0001) without any significant correlation between hidden listhesis and age, sex, or level involved. CONCLUSIONS: The aim of our study is to determine whether in patients with lumbalgy without evidence of listhesis in SDXR, pain can be attributed to a faccettal syndrome or to a spondylolisthesis. Consequence of pain is augmented muscular tone of the paravertebral musculature, particularly in standing position. Augmented muscular tone tries to inhibit the pain generator, attempting to limit the slippage of the involved segment. In patients examined in RDXR, the tone of paravertebral musculature is reduced, showing the hidden spondylolisthesis.

Surgery in extensive vertebral hemangioma: case report, literature review and a new algorithm proposal.

Hemangiomas are benign dysplasias or vascular tumors consisting of vascular spaces lined with endothelium. Nowadays, radiotherapy for vertebral hemangiomas (VHs) is widely accepted as primary treatment for painful lesions. Nevertheless, the role of surgery is still unclear. The purpose of this study is to propose a novel algorithm of treatment about VHs. This is a case report of an extensive VH and a review of the literature. A case of vertebral fracture during radiotherapy at a total dose of 30 Gy given in 10 fractions (treatment time 2 weeks) using a linear accelerator at 15 MV high-energy photons for extensive VH is reported. Using PubMed database, a review of the literature is done. The authors have no study funding sources. The authors have no conflicting financial interests. In the literature, good results in terms of pain and neurological deficits are reported. No cases of vertebral fractures are described. However, there is no consensus regarding the treatment for VHs. Radiotherapy is widely utilized in VHs determining pain. Surgery for VHs determining neurological deficit is also widely accepted. Perhaps, regarding the width of the lesion, no indications are given. We consider it important to make an evaluation before initiating the treatment for the risk of pathologic vertebral fracture, since in radiotherapy, there is no convention regarding structural changes determined in VHs. We propose a new algorithm of treatment. We recommend radiotherapy only for small lesions in which vertebral stability is not concerned. Kyphoplasty can be proposed for asymptomatic patients in which VHs are small and in patients affected by VHs determining pain without spinal canal invasion in which the VH is small. In patients affected by pain without spinal canal invasion but in which the VH is wide or presented with spinal canal invasion and in patients affected by neurological deficits, we propose surgery.

Posterolateral arthrodesis in lumbar spine surgery using autologous platelet-rich plasma and cancellous bone substitute: an osteoinductive and osteoconductive effect.

Study Design Prospective cohort study. Objectives To analyze the effectiveness and practicality of using cancellous bone substitute with platelet-rich plasma (PRP) in posterolateral arthrodesis. Methods Twenty consecutive patients underwent posterolateral arthrodesis with implantation of cancellous bone substitute soaked with PRP obtained directly in the operating theater on the right hemifield and cancellous bone substitute soaked with saline solution on the right. Results Computed tomography scans at 6 and 12 months after surgery were performed in all patients. Bone density was investigated by comparative analysis of region of interest. The data were analyzed with repeated-measures variance analyses with value of density after 6 months and value of density after 12 months, using age, levels of arthrodesis, and platelet count as covariates. The data demonstrated increased bone density using PRP and heterologous cancellous block resulting in an enhanced fusion rate during the first 6 months after surgery. Conclusions PRP used with cancellous bone substitute increases the rate of fusion and bone density joining osteoinductive and osteoconductive effect.

Surgery of intradural extramedullary tumors: retrospective analysis of 107 cases.

BACKGROUND: Intradural extramedullary tumors (IDEMTs) are uncommon lesions that cause pain and neurological deficits. OBJECTIVE: To evaluate the effects of surgery for IDEMTs. METHODS: This cohort study recruited all patients operated on for IDEMTs at the Department of Neurology and Psychiatry of Sapienza University of Rome from January 2003 to January 2013. The analysis was conducted on clinical records evaluation over a 1-year follow-up. The Graphic Rating Scale was used to assess pain. Neurological deficits were detected through neurological examination. Quality of life was evaluated with the EuroQol (EQ-5D). Statistical interpretation of the data was performed with SPSS version 19 software. RESULTS: One hundred seven patients were recruited. Three were lost to follow-up. Patients reported lower level of pain 1 year after surgery (before surgery, 6.05; after surgery, 3.65). Mean comparison showed a significant decrease of -2.400 (P < .001). Ninety-two patients (88.5%) were neurologically asymptomatic 1 year after surgery. Only 12 patients (11.5%) presented with a deficit, with a global decrease of 39% (χ(2) = 27.6; P < .005). The quality of life in patients was middle to high (mean rating of EQ-5D visual analog score, 61.78%). The lowest levels of quality of life were found in patients with sphincter dysfunctions (mean, 33.4). CONCLUSION: Surgery for IDEMTs has a good outcome. Patients reported lower levels of pain and a drastic reduction in neurological symptoms 1 year after surgery. The quality of life is middle to high. It is influenced mainly by the neurological outcome.