Vertebroplasty combined with image-guided percutaneous cement augmented transpedicular fixation for the treatment of complex vertebral fractures in osteoporotic patients.

AIM: Surgical management of osteoporotic fractures constitutes a clinical challenge. The aim of this study was to evaluate feasibility and efficacy of navigated percutaneous screw fixation combined with multisegmental vertebroplasty for the treatment of osteoporotic fractures not suitable for monosegmental cement augmentation in patients with severe osteoporotic changes of the vertebral column and/or progressive kyphotic deformation. METHODS: Navigated percutaneous screw fixation and simultaneous augmentation with vertebroplasty was performed in 6 patients with lumbar and 4 patients with thoracic osteoporotic fractures. In all cases, significant vertebral body collapse, destruction of the endplates and multisegmental osteoporotic changes were radiologically confirmed. Postoperative images were obtained in all cases to analyze the position of each screw and to assess further deformity progression. Follow-up ranged between 12 and 18 months. RESULTS: There was no additional morbidity associated with screw or cement insertion. Cement leakage lateral to the vertebral body was observed in 4 cases. Mean total operation time (142 minutes) was prolonged due to intraoperative data acquisition for 15±6 minutes. In 2 cases a second data set had to be acquired due to poor image quality. Finally, mean intraoperative blood loss was 100ml. Clinical outcome was satisfactory in all cases. Radiological follow-up demonstrated loss of initial kyphosis correction in 8 cases. CONCLUSION: Navigated percutaneous screw fixation combined with multisegmental vertebroplasty is a technically feasible procedure. Despite the additional time needed for intraoperative data acquisition, total operation time was acceptable and intraoperative blood loss as well as muscle trauma were minimized compared to a standard open procedure. Despite good clinical outcome, the described construct failed to prevent further kyphotic deformation during the reported follow-up period.

The role of presurgical EEG parameters and of reoperation for seizure outcome in temporal lobe epilepsy.

PURPOSE: After surgery for intractable mesiotemporal lobe epilepsy (mTLE) seizures recur in 30-40%. One predictor for seizure recurrence is the distribution of seizure onset and interictal epileptiform discharges (IED). Our study focused on lateralization and extent of epileptiform activity regarding postoperative seizure persistence and the effect of reoperation. METHODS: This study comprises 426 consecutive patients operated for intractable mTLE. Impact of preoperative seizure onset and IED on the persistence of seizures and results of reoperation were analyzed. RESULTS: One year after surgery, 27% of patients with mTLE experienced persistent seizures (Engel II-IV). Preoperative bilateral seizure onset in EEG was predictive for postoperative seizure recurrence (Engel II-IV: 64%). Seizure foci and IED exceeding the temporal lobe in the ipsilateral hemisphere were not found to be associated with worse seizure outcome (Engel I: 72% and 75%) compared to patients with seizure foci confined to the ipsilateral temporal lobe (Engel I: 75% and 76%). Moreover, IED exceeding the affected temporal lobe in the ipsilateral hemisphere or even bilateral IED did not negatively affect seizure freedom if seizure onset was strictly limited to the affected temporal lobe (Engel I: 85% and 65%, respectively). 60% of patients reoperated in the ipsilateral temporal lobe for persistent seizures became seizure free. CONCLUSIONS: Preoperative bilateral ictal foci are a negative predictor for seizure outcome. Contrarily, IED exceeding the affected temporal lobe in the ipsilateral hemisphere or even bilateral IED had favorable seizure outcome if seizure onset is strictly limited to the affected temporal lobe. Reoperation for seizure persistence constitutes a promising therapeutic option.

Vesselplasty: a new minimally invasive approach to treat pathological vertebral fractures in selected tumor patients - preliminary results.

PURPOSE: To evaluate the effectiveness and safety of percutaneous vesselplasty in pathological vertebral fractures of the thoracolumbar spine in selected tumor patients. MATERIALS AND METHODS: Eleven pathological vertebral fractures in nine patients were treated with vesselplasty (Vessel-X®, MAXXSPINE). Nine of eleven vertebras (81.8 %) had major posterior wall deficiency (> 30 %). Clinical and radiological (CT) measures were obtained before and 3 months after the procedure. RESULTS: The mean VAS improved significantly from preoperative to postoperative (6.9 ± 2.2 to 3.7 ± 2.3; p < 0.05), as did the ODI (59.7 %± 19.2 % to 40.3 %± 24.0 %; p < 0.05). The physical component summary of the SF-36 was significantly improved by the operation (19.2 ± 8.0 to 31.0 ± 16.5; p < 0.05). Symptomatic cement leakage or other operation-associated complications were not observed. Three patients were primarily treated with concomitant minimally invasive stabilization via fixateur interne. One patient had to undergo minimally invasive stabilization via fixateur interne 4 months after vesselplasty due to further collapse of the treated vertebral body. CONCLUSION: From these preliminary results, vesselplasty appears to be a treatment option worth considering in pathological vertebral fractures, even in the case of posterior wall deficiency. Selected tumor patients might benefit from vesselplasty as a minimally invasive procedure for stabilization of the fractured vertebra, pain control, and improvement in body function and quality of life. Long-term prospective studies with a larger sample size are required to validate these results.

First experience using navigation-guided radiofrequency kyphoplasty for sacroplasty in sacral insufficiency fractures.

PURPOSE: To evaluate the efficacy and safety of navigation-guided radiofrequency kyphoplasty for sacroplasty in patients with sacral insufficiency fractures. METHODS: In this single-center retrospective observational study, four consecutive patients with sacral insufficiency fractures were treated with navigation-guided radiofrequency kyphoplasty for sacroplasty between April 2010 and May 2012. Symptom characteristics, pain duration and pain intensity were recorded for each patient. Cement extravasation was evaluated in thin-sliced and triplanar reconstructed CT scans of the sacrum. RESULTS: Four female patients with painful sacral insufficiency fractures and extensive osteopenic areas significantly improved from an average pre-treatment VAS score of 8.3 ± 0.5 to 2.3 ± 1.0 (p < 0.001) on the first postoperative day and to 1.3 ± 1.9 (p < 0.004) at follow-up (mean, 20.1 weeks). Slight cement extravasations were observed without evidence of being symptomatic. No major complications or procedure-related morbidity were noted. CONCLUSION: From the limited experience in four patients, navigation-guided radiofrequency kyphoplasty appears to be a safe and effective treatment option for sacral insufficiency fractures even though asymptomatic cement extravasation was noted. The use of navigation based on intraoperative 3 D images simplifies the positioning of the navigated bone needles via the long axis approach. The radiofrequency kyphoplasty system provides the possibility to administer a sufficient amount of bone cement with a well-defined viscosity over the entire period of the procedure leading to high security and low cement extravasation. Sacroplasty provides rapid and enduring pain relief and facilitates prompt mobilization.

Minimally invasive approach for the treatment of lateral lumbar disc herniations. Technique and results.

OBJECTIVE: This paper aims to demonstrate the feasibility and efficacy of a minimal invasive approach by using a muscle dilator system for the treatment of lateral lumbar disc herniations. METHODS: A retrospective analysis of 38 cases with lateral lumbar disc herniations that were treated the METRx-System was performed. Patients were assessed preoperatively and postoperatively with the visual analogue scale (VAS) for leg pain. Follow up ranged from 6 to 24 months. RESULTS: No intraoperative complications were observed. Operation time and intraoperative blood loss were minimized. In 37 cases VAS scores were significantly lower after the procedure. A single patient had to be reoperated due to insufficient removal of the herniated disc material. CONCLUSION: The reported minimal invasive technique is a safe and efficient alternative to conventional methods for the treatment of lateral lumbar disc herniations.