Vertebral body compression fracture after percutaneous pedicle screw removal in a young man.

Hazards and potential complications associated with pedicle screw insertions have been reported. In contrast, complications due to implant removal are rarely described. An unreported case of acute vertebral body compression fracture following pedicle screw removal in a young man occurred during an episode of forceful coughing. Spinal implants need to be removed in cases of complications, pain or tissue irritation, and removal is mandatory when fixation involves L2 or the lower segments. Complications associated with spinal implant removal are rare but possible, and patients must be informed of this potential risk.

Posterior lumbar fusion by peek rods in degenerative spine: preliminary report on 30 cases.

PURPOSE: Pre-curved peek rods to support posterior lumbar fusion have been available in the market since 4 years. Potential advantages using this new technology are increased load sharing on the anterior column promoting interbody fusion, reduced stress on bone-screw interface decreasing the rate of screw mobilization and, in the long term, reduced incidence of adjacent level disc degeneration. METHODS: The authors retrospectively reviewed 30 cases in which posterior fusion was supported by peek rods, analyzing early complications, rate of fusion and clinical outcome. RESULTS: At an average follow-up of 18 months, both clinical and radiographic results were satisfactory with only one case requiring surgical revision for a mechanical complication. CONCLUSIONS: The semi-rigid systems can now be considered a viable option in the lumbar degenerative disease, although clinical evaluations are necessary in the longer term.

Ewing's sarcoma of the mobile spine.

OBJECTIVES: To evaluate the role of enbloc resection on the oncological outcome of patients with Ewing's sarcoma of the mobile spine treated with systemic multiagent chemotherapy combined with radiation therapy. While the role of chemotherapy and radiation therapy is well known and accepted in the treatment of Ewing sarcoma, there is no consensus on the role of enbloc resection in those tumors occurring in the mobile spine and, therefore, it can be difficult to conclude the decision making process, particularly if to achieve a tumor-free margin resection functionally relevant structures should be sacrificed. The study design of this work was the retrospective analysis of a series of 27 cases of Ewing sarcoma of the mobile spine homogeneously treated. METHODS: Twenty-seven patients with primary ES of the mobile spine were treated from 1979 to 2008 by the same multidisciplinary team. All the patients presented with pain. Motor deficits were present in 6 patients. All the patients were submitted to multiagent protocols of chemotherapy (always) and radiotherapy (alternative to surgery or associated to). Surgery was performed in 17 cases both for functional purpose (7 cases: intralesional piecemeal excision) both for curative purpose (10 cases: enbloc resection, resulting characterized by marginal/wide or intralesional margins). Patients were observed for a minimum of 2 years or until death. The mean follow-up time was 65 months (median 28 months; ranging 2 to 218 months). Neurological function, local recurrence, distant relapse, and treatment-related complications were evaluated. RESULTS: Three periods were considered according to the evolution of therapeutic strategies. Four patients were treated in the period 1979 to 1982. All were submitted to chemotherapy (REA-2) and radiation therapy (RT). Two of them were submitted to intralesional excision. All these patients died 2 to 29 months later without significant difference in the two groups. In the period 1983 to 1990 all patients were treated with chemotherapy (REN-1/2) and RT. Two were submitted to intralesional excision and had a worse evolution as died of the disease at 2 and 11 months follow up, while the patients who did not received surgery evolved more favourably: 1 died of the disease 57 months after the end of the treatment, 3 are continuously disease free at 130, 190, 290 months. The sixteen patients treated in the period 1991 to 2008 received chemotherapy (REN-3 and ISG-SSG) and RT, combined with intralesional excision in 3, with enbloc with intralesional margins in 4, enbloc with tumor-free margins (wide or marginal) in 6. Only one patient submitted to tumor-free margin enbloc resection had local recurrence and died 29 months after the treatment (biopsy was performed by open approach), the other surviving continuously disease free at 17 to 193 months follow-up (av. 76 months). All the patients submitted to intralesional excision and to enbloc resection resulting in margin violation had the same prognosis, as died of the disease 10 to 63 months after the treatment. Only one of the 3 patients who had no surgery died of the disease 8 months after the treatment, the other surviving 9 and 49 months follow-up. Among the seven patients who had neurological symptoms at the occurrence, just those with no metastasis and who underwent enbloc resection are alive. CONCLUSIONS: The current study seems to demonstrate that tumor-free margin enbloc resection provides better local control and longer survival, while the results after intralesional margin resection or piecemeal excision combined with chemotherapy and RT is less effective than chemotherapy and RT alone.

Management of bone metastases.

Bone metastases are only apparently similar lesions, considering the large varieties of istotypes and the spread of the primary tumour. Although these metastases develop early and are not terminal events, they have to be considered as severe complications. When possible, surgical treatment can improve the history of the patient in terms of life expectancy and quality of life. The approach to these lesions should be multidisciplinary in collaboration with oncologists and radiotherapists. In fact the average of survival of these patients has increased in recent years. The evolution of anesthesiological techniques permits surgical treatments that once were considered prohibitive. The application of new adjuvant therapies increases the effectiveness for surgical treatment. Controversy exists over the most appropriate treatment for patients with bone metastatic disease. The purpose was to determine the best sequential process to arrive at the most appropriate treatment considering the individual general conditions and the parameters of the metastases. As the number of treatment options for metastatic bone disease has grown, it has become clear that effective implementation of these treatments can only be achieved by a multidisciplinary approach.

Minimally invasive percutaneous fixation in the treatment of thoracic and lumbar spine fractures.

We studied 51 patients with 64 fractures of the thoracolumbar and lumbar spine undergoing the surgical treatment by percutaneous trans-pedicular fixation and stabilization with minimally invasive technique. Patient follow-up ranged from 6 to 28 months (mean 14.2 months) and the patients were assessed by clinical and radiographic evaluation. The results show that percutaneous trans-pedicular fixation and stabilization with minimally invasive technique is an adequate and satisfactory procedure to be used in specific type of the thoracolumbar and lumbar spine fractures.

Spinal metastasis: a retrospective study validating the treatment algorithm.

A retrospective clinical study was conducted to validating the treatment algorithm in patients with spinal metastasis. The study participants were 43 patients with spinal metastasis from carcinoma. Since most interventions are palliative we had to seek for clear definitions to describe the results, aiming to increase the quality of life. To this purpose, we would introduce the concept of "target achievement". We presume that the target is achieved when all the following findings are present: a survival rate which is not inferior to the average, improvement or the maintenance of the neurological condition and achievement of local control. The results of this study demonstrate that performing the treatment suggested by the algorithm, the majority of the patients have a good residual quality of life. Worse results are obtained when a more aggressive treatment is selected.

[The surgical treatment of renal cell carcinoma metastases to the vertebrae: intra-operative anesthesia related problems]. / Il trattamento chirurgico delle metastasi vertebrali da carcino- ma renale: problematiche anestesiologiche intraoperatorie.

AIMS: Analysis of the intra-operative anesthesia related problems were compared during intra-lesional or extra-lesional surgeries for patients with metastatic renal cell carcinoma to the spine. MATERIALS AND METHODS: We retrospectively collected and analyzed the hemodynamic data on 30 patients who had undergone surgical intervention. Twenty patients had an intra-lesional excision of the metastatic lesion in the vertebra, whereas for the rest, an en-bloc wide or marginal margin resection was carried out. RESULTS: The surgical time for the en-bloc resections was much longer, and thus also the exposure to the anesthesia, but lesser variability within the data on blood pressure and pulse as compared with intra-lesional curettage. There was also more blood loss with the intra-lesional surgeries. CONCLUSIONS: En-bloc resections of the vertebral tumors not only give better oncological local control, but also have less compromising effects on the patient, especially with respect to the intra-operative hemodynamics. In selected cases, en-bloc resections present a good option of treatment in vertebral metastases, and especially in highly vascular tumors such as the renal cell carcinoma metastases.

Vertebroplasty in the treatment of vertebral metastases: clinical cases and review of the literature.

Bone metastases are the most common tumours affecting the musculoskeletal system. The most frequently affected area of the skeleton is the spine. The vertebral bodies are reached largely via the bloodstream and neoplastic substitution of the bone tissue causes progressive structural destruction leading to loss of stability and compression of the intracanal nerve structures. The treatment of bone metastases in the spine is different and controversial, mostly because of the wide spectrum of clinical and radiographic pattern of the local and systemic disease. Percutaneous vertebroplasty is emerging as one of the most promising new interventional procedures for relieving (or reducing) pain and improve stability. In this article we review indications, contraindications, technique, and complications of percutaneous vertebroplasty in spine metastases.

Solitary plasmacytoma of the spine: a 22 years follow-up case report.

BACKGROUND AND OBJECTIVES: Plasmacytoma is a systemic malignancy and it is the most frequent primary tumor affecting the skeleton. Progression from solitary plasmacytoma to systemic diffusion is reported to be 65-100% in 15 years. A case report of a rare 22-year follow-up of a thoracic solitary plasmacytoma is here presented. MATERIAL AND METHODS: Clinical case analysis, radiographs, magnetic resonance images and histological sections of the lesion are discussed. Repeated surgical interventions were required due to progression and local recurrence of disease. RESULTS: Although the inadequate surgical treatment, low response to chemotherapy and radiation therapy, and many local recurrences, no systemic diffusion of the disease was observed in 22 years. DISCUSSION: Aggressive surgery may be indicated in young patients with isolated lesion and good prognostic factors. Palliative surgery remains necessary in order to decompress the cord and to stabilize the spine.

Three years experience with the new intragastric balloon, and a preoperative test for success with restrictive surgery.

BACKGROUND: The BioEnterics Intragastric Balloon (BIB) is a smooth, spherical, saline-filled, silicone elastomer with a black radiopaque filling valve, intended to induce weight loss by limiting food consumption. This can be considered a "restrictive" procedure, and by using this balloon, we can assess the patient's eligibility for a restrictive surgical procedure (the BIB-Test). METHODS: From May 1997 to May 2000, 87 BIB were inserted in 77 moderately to severely obese patients (4 BIB in 1 patient, 2 BIB in 7 patients). 64 patients completed the treatment. Out of these, 18 (16 female, 2 male) underwent laparoscopic gastric banding after BIB removal. RESULTS: After the treatment (3-6 months), weight loss results were as follows: WL 14.3 kg, %EWL 23.5 and loss in BMI 5.3. 12 patients after the preliminary BIB, have been followed > or = 6 months after gastric banding, and have significant further weight loss. CONCLUSIONS: BIB appears to have good results. A supervised nutritional and behavioral regimen is mandatory. The balloon may be indicated to: 1) induce weight loss in patients whose obesity is not severe enough to warrant surgery; 2) reduce the surgical risk in those who are massively obese; 3) select patients for gastric restrictive surgery if they lose weight with the balloon. The data showed that patients who had good results with the BIB (positive BIB-Test) are still losing weight after subsequent gastric banding.

Spinal metastases: treatment evaluation algorithm.

Spinal metastases are only apparently similar lesions, considering the large varieties of istotypes and the spread of the primary tumor. These metastases develop early and are not terminal events, they have to be considered as severe complications because, when possible, surgical treatment can improve the history of the patient in terms of life expectancy and quality of life. The approach to these lesions should be multidisciplinary in collaboration with oncologists and radiotherapists, in fact the average of survival of these patients has increased in recent years. The evolution of anesthaesiological techniques that permit surgical treatments that were once considered prohibitive. The application of new adjuvant therapy increases the effectiveness for surgical treatment. Controversy exist over the most appropriate treatment for patients with metastatic disease of the vertebral column. The purpose of this article was to determine the best sequential process to arrive at the most appropriate treatment considering the individual general conditions and the parameters of the metastases. We review 269 cases in 182 patients suffering from spinal metastases from a solid tumour treated between 1996 and 2002. As the number of treatment options for metastatic spinal disease has grown, it has become clear that effective implementation of these treatments can only be achieved by multidisciplinary approach.

Symptomatic vertebral hemangioma: the treatment of 23 cases and a review of the literature.

It is the purpose of this study to analyze a group of 23 patients affected with hemangioma in one or more metameres of the vertebral column. On the basis of clinical examination and instrumental testing in time (minimum follow-up 12 months, maximum 217 months) the following treatment options are discussed: medical treatment and clinical monitoring closer in time; palliative surgical treatment whether or not associated with embolization of vascular afferences of the lesion and adjuvant treatment; intralesional surgical treatment whether or not associated with embolization of the vascular afferences of the lesion and adjuvant treatment. Skeletal hemangioma is a hamartomatous proliferation of vascular tissue, more precisely of endothelial tissue. This is demonstrated by its anatomical identity with other tissues and the existence of exceptional skeletal and multiple tissue hemangiomatosis that begin during childhood. Hemangioma is the benign tumor that is most frequently localized in the spine, involving about 10% of the world population, as reported in the literature on autoptic studies. It is often a solitary lesion, usually localized in the vertebral body, although it may extend to the posterior arch. There is predilection for the thoracic region of the spine, while it less frequently occurs in the cervical and lumbar spines. Generally, it remains asymptomatic throughout the entire life of the subject, so much so that it is often difficult to establish the onset of the lesion. Symptomatic hemangiomas (less than 1% of all hemangiomas) are those that are accidentally discovered via radiograms; they are most often observed during adult age. The most common treatment used for vertebral hemangioma associated with pain is radiotherapy, even if clinical observation represents a reasonable choice. Surgical treatment, preceded when possible by embolization of the vascular afferences of the lesion, is often associated with radiation therapy in cases where there is neurologic compression in addition to pain. It was the purpose of this study to analyze the long-term results obtained in a group of 23 patients affected with symptomatic vertebral hemangioma.

Giant cell tumor of the upper cervical spine: transmandibular-translingual access. Clinical case.

The authors describe the clinical case of a patient aged 18 years affected with giant cell tumor (GCT) at C3 who came to the surgical unit of Orthopaedics and Traumatology at the Ospedale Maggiore in Bologna after being treated by surgery elsewhere. Particular attention is paid to surgical access by means of median transmandibuloglossotomy used in order to obtain a sufficiently wide surgical field that can adequately expose the vertebral segment affected by neoplastic disease. In particular, possible complications that may be observed postsurgery can be compared to other surgical approaches to the upper cervical spine and above all that there are no permanent clinical sequelae.

Two cases of Brown-Séquard syndrome in penetrating spinal cord injuries.

INTRODUCTION: Brown-Séquard syndrome due to a stab injuries is uncommon and results from a lesion in one half of the spinal cord. BACKGROUND: The role of surgery in the treatment of penetrating spinal injury often remain controversial. AIM: To discuss the current diagnostic and therapeutic approach for these types of injuries. MATERIALS AND METHODS: The Authors describe two rare cases of Brown-Séquard syndrome due to civilian stab injuries differently treated. Mechanism of damage, clinical features and neurological outcome are reported. RESULTS: The recovery of neurological function in the first case indicates that the spinal tracts were injured by a contusion, rather than by a direct injury as in the second case. Moreover, surgery was required in the second patient to remove the weapon and to stabilize the spine, presenting bony and ligamentous instability. DISCUSSION: The diagnostic and therapeutic management are debated. An overview on clinical research in sperimental medical treatment of spinal cord injury was considered to evaluate future possible approaches to these injuries. CONCLUSIONS: As the neurologic improvement depends on the type and severity of the spinal cord damage, the indications for acute surgical management are limited and conservative management should be preferred.

Solitary necrotic nodule of the liver misinterpreted as malignant lesion: considerations on two cases.

In our experience, we document 2 cases of a rare and non-tumoral lesion of the liver misinterpreted as necrotic tumor: necrotic solitary nodule. In the first clinical case, ultrasound (US) showed a polylobated lesion (35 x 35 x 38 mm) at segment 8. Color-doppler identified a compression of celiac axis (Dunbar syndrome). Arteriography revealed a subtotal stenosis of celiac tripod soon after the emergence of the left gastric artery. FNAB-CT showed a highly cellulated tissue with a necrotic core surrounded by a fibersclerotic tissue. The patient underwent surgery: cholecystectomy and correction of Dunbar syndrome. US follow-up showed a progressive reduction in diameter of the lesion (24 x 25 x 25 mm at 24 months), suggesting in this case the role of ischemic injury in the pathogenesis of the lesion. In the second clinical case, a hypoechoic lesion (32 x 32 x 30 mm) of segment 6 as occasional US finding during the staging for prostate cancer was shown. FNAC-CT showed a positive result for necrotic cells. Surgical treatment consisted in a wide excision of the lesion. Histologically the lesion was solitary necrotic nodule. The diagnosis of this rare lesion is accidental. In accordance with the literature (50% of cases), we founded an associated tumor. Radiology doesn't differentiate solitary necrotic nodule and other solid lesions. Diagnosis is histological (in our second case, FNAC-CT misinterpreted the tumor as a malignant lesion, while histology showed the real nature of it).