SpineGateway

European Spine Journal: Growing rod concepts: state of the art

Yazici; Olgun — 2012-05-08

Type: Original Paper
Introduction

Early-onset spinal deformities present multiple challenges to the surgeon. They may be rapidly progressive and unresponsive to conservative treatment, necessitating surgical intervention at an early age.

Materials and methods

This text attempts to provide a review of current literature and to summarize the authors’ opinions.

Results

This paper attempts to concisely review available literature regarding the growing rod’s inception, evolution, technique, results, and complications and answers some of the controversy still surrounding it.

Conclusions

The growing rod is one of the first, most evolved, most popular and one of the most heatedly discussed technique of fusionless spinal instrumentation.

European Spine Journal: Clinical evaluation of the preliminary safety and effectiveness of a minimally invasive interspinous process device APERIUS® in degenerative lumbar spinal stenosis with symptomatic neurogenic intermittent claudication

Meirhaeghe; Fransen; Morelli; Craig; Godde; Mihalyi; Collignon — 2012-05-08

Type: Original Paper
Purpose

New interspinous process decompression devices (IPDs) provide an alternative to conservative treatment and decompressive surgery for patients with neurogenic intermittent claudication (NIC) due to degenerative lumbar spinal stenosis (DLSS). APERIUS^® is a minimally invasive IPD that can be implanted percutaneously. This multicentre prospective study was designed to make a preliminary evaluation of safety and effectiveness of this IPD up to 12 months post-implantation.

Methods

After percutaneous implantation in 156 patients with NIC due to DLSS, data on symptoms, quality of life, pain, and use of pain medication were obtained for up to 12 months.

Results

Early symptom and physical function improvements were maintained for up to 12 months, when 60 and 58 % of patients maintained an improvement higher than the Minimum Clinically Important Difference for Zurich Claudication Questionnaire (ZCQ) symptom severity and physical function, respectively. Leg, buttock/groin, and back pain were eased throughout, and the use and strength of related pain medication were reduced. Devices were removed from 9 % of patients due to complications or lack of effectiveness.

Conclusions

Overall, in a period of up to 12 months follow-up, the safety and effectiveness of the APERIUS^® offered a minimally invasive option for the relief of NIC complaints in a high proportion of patients. Further studies are underway to provide insight on outcomes and effectiveness compared to other decompression methods, and to develop guidance on optimal patient selection.

European Spine Journal: Clinical and radiological outcomes after conservative treatment of TB spondylitis: is the 15 years’ follow-up in the MRC study long enough?

Cheung; Luk — 2012-05-08

Type: Original Paper
Introduction

Tuberculosis of the spine is a still a common disease entity, not only in developing countries but is also returning in developed countries especially in the immune-compromised patients. Conservative treatment with chemotherapy is still the main stay of treatment. This article focuses on the clinical and radiological outcomes, and problems with conservative treatment.

Method

The available literature of anti-tuberculosis chemotherapy in managing spinal tuberculosis was reviewed. Data sources included relevant literature of the English language identified through Medline search from 1946 to 2011. Personal experience and unpublished reviews from the authors’ institution were also included.

Results

Although majority of patients respond well to anti-tuberculosis chemotherapy, about 15 % of them develop paradoxical response. The Medical Research Council (MRC) studies have shown that for patients without significant neurological deficits, operative and conservative treatment could produce the same clinical outcome at 15 years follow-up. Patients treated operatively with debridement and spinal fusion with strut graft had faster bony fusion and less kyphotic deformity. In contrast, those treated with drugs alone or with simple debridement without fusion may result in disease reactivation, severe kyphosis or late instability, which in turn may lead to late-onset Pott’s paraplegia, back pain, sagittal imbalance and compromised pulmonary function that are difficult or risky to treat.

Conclusion

Recognition of the clinical and radiologic features of these late sequels is important for the management. Prevention of deformity in the early disease has been added to the modern standard of treatment of TB spine.

European Spine Journal: Factors that influence current tuberculosis epidemiology

Millet; Moreno; Fina; Baño; Orcau; Olalla; Caylà — 2012-05-08

Type: Original Paper

According to WHO estimates, in 2010 there were 8.8 million new cases of tuberculosis (TB) and 1.5 million deaths. TB has been classically associated with poverty, overcrowding and malnutrition. Low income countries and deprived areas, within big cities in developed countries, present the highest TB incidences and TB mortality rates. These are the settings where immigration, important social inequalities, HIV infection and drug or alcohol abuse may coexist, all factors strongly associated with TB. In spite of the political, economical, research and community efforts, TB remains a major global health problem worldwide. Moreover, in this new century, new challenges such as multidrug-resistance extension, migration to big cities and the new treatments with anti-tumour necrosis alpha factor for inflammatory diseases have emerged and threaten the decreasing trend in the global number of TB cases in the last years. We must also be aware about the impact that smoking and diabetes pandemics may be having on the incidence of TB. The existence of a good TB Prevention and Control Program is essential to fight against TB. The coordination among clinicians, microbiologists, epidemiologists and others, and the link between surveillance, control and research should always be a priority for a TB Program. Each city and country should define their needs according to the epidemiological situation. Local TB control programs will have to adapt to any new challenge that arises in order to respond to the needs of their population.

European Spine Journal: Tuberculosis of spine: neurological deficit

Jain; Kumar — 2012-05-08

Type: Original Paper

The most dreaded neurological complications in TB spine occur in active stage of disease by mechanical compression, instability and inflammation changes, while in healed disease, these occur due to intrinsic changes in spinal cord secondary to internal salient in long standing kyphotic deformity. A judicious combination of conservative therapy and operative decompression when needed should form a comprehensive integrated course of treatment for TB spine with neurological complications. The patients showing relatively preserved cord with evidence of edema/myelitis with predominantly fluid collection in extradural space on MRI resolve on non-operative treatment, while the patients with extradural compression of mixed or granulomatous nature showing entrapment of spinal cord should be undertaken for early surgical decompression. The disease focus should be debrided with removal of pus caseous tissue and sequestra. The viable bone should only be removed to decompress the spinal cord and resultant gap should be bridged by bone graft. The preserved volume of spinal cord with edema/myelitis and wet lesion on MRI usually would show good neural recovery. The spinal cord showing myelomalacia with reduced cord volume and dry lesion likely to show a poor neural recovery. The internal kyphectomy is indicated for paraplegia with healed disease. These cases are bad risk for surgery and neural recovery. The best form of treatment of late onset paraplegia is the prevention of development of severe kyphosis in initial active stage of disease.

European Spine Journal: Epidemiology of tuberculosis in WHO European Region and public health response

Dara; Dadu; Kremer; Zaleskis; Kluge — 2012-05-08

Type: Original Paper
Purpose

To provide an overview of the tuberculosis (TB) and multi-drug resistant tuberculosis (MDR-TB) in the WHO European Region and evolution of public health response with focus on extra-pulmonary tuberculosis and Pott’s disease.

Methods

Authors reviewed regional strategic documents related to TB. The epidemiologic data were reviewed and analyzed.

Results

In the absence of associated pulmonary TB, Pott’s disease is reported as extra-pulmonary TB (up to 47 % of all TB cases in some settings). Due to limitations of the surveillance system, the epidemiology of Pott’s disease and its treatment success are unknown. The Stop TB Strategy and Consolidated Action Plan to Prevent and Combat M/XDR-TB provide comprehensive roadmaps to address all types of TB.

Conclusions

There is a need to further analyze country data to document the extent of Pott’s disease and develop specific guidelines for timely diagnosis and treatment of Pott’s disease.

European Spine Journal: Editor’s preface: the science of intervertebral disc replacement

Wilke; Ferguson — 2012-05-08

Type: Editorial Notes
No abstract available.

European Spine Journal: A tail of sacral agenesis: delayed presentation of meningocele in sacral agenesis

Gillis; Bader; Boyd — 2012-05-08

Type: Report
Introduction

Sacral agenesis is a congenital condition associated with multiple orthopedic, spinal, abdominal and thoracic organ deformities. Meningocele is commonly found among patients with sacral agenesis.

Description

We present the first case in the literature describing a delayed presentation of terminal (posterior) meningocele in an adult patient born with sacral agenesis.

Conclusion

Surgical repair was performed and is the best treatment option for significantly large lesions, with postoperative CSF leak being the main complication.

European Spine Journal: Erratum to: Chronic neck pain and treatment of cognitive and behavioural factors: results of a randomised controlled clinical trial

2012-05-08

Type: Erratum
No abstract available.

European Spine Journal: Thoracolumbar intramedullary subependymoma with multiple cystic formation: a case report and review

Iwasaki; Hida; Aoyama; Houkin — 2012-05-05

Type: Report
Background

An intramedullary subependymoma is rare, particularly in the thoracolumbar region. Moreover, a radiographical obvious cystic formation of subependymoma of spinal cord rarely occurs in comparison to ependymoma.

Case report

A 57-year-old woman presented with paraparesis. MRI revealed a multinodular and multicystic lesion in the spinal cord that was difficult to diagnose correctly. Intraoperative observation via midline myelotomy revealed a grayish, gelatinous solid mass with an eccentric localization. In addition, DREZtomy on the caudal side of the tumor revealed cystic formation. The cyst was punctured and xanthochromic fluid was collected. Attenuation of motor evoked potential (MEP) resulted in the partial removal of tumor. A pathological examination revealed the mass to be a subependymoma. The patient experienced transient worsening of symptoms, but improved gradually. No adjuvant radiosurgery was administered. Follow-up estimation 30 months after surgery revealed no evidences of regrowth.

Conclusions

This report presents this rare case, a review of the literature associated with thoracolumbar subependymomas, and a discussion of the clinical and radiographical characteristics.

European Spine Journal: Anular delamination strength of human lumbar intervertebral disc

Gregory; Bae; Sah; Masuda — 2012-05-01

Type: Original Paper
Introduction

Progression of intervertebral disc (IVD) herniation does not occur exclusively in a linear manner through the anulus fibrosus (AF), but can migrate circumferentially due to localized AF delamination. Consequently, resistance to delamination is an important factor in determining risk of herniation progression. The inter-lamellar matrix located between the AF layers is responsible for resisting this delamination; however, its mechanical properties are largely unknown. This study aimed to determine the mechanical properties of the inter-lamellar matrix in human AF samples via a peel test.

Materials and methods

Seventeen human IVDs (degeneration grades of 2–3) were obtained from six lumbar spines. From these 17 discs, 53 tissue samples were obtained from the superficial and deep regions of the anterior and posterior AF. Samples were dissected into a ‘T’ configuration to facilitate a T-peel test (or 180-degree peel test) by initiating delamination between the two middle AF layers.

Results

Peel strength was found to be 33 % higher in tissues obtained from the superficial AF region as compared with the deep region (p = 0.047).

Conclusion

This finding may indicate a higher resistance to delamination in the superficial AF, and as a result, delamination and herniation progression may occur more readily in the deeper layers of the AF.

European Spine Journal: A retrospective study of congenital osseous anomalies at the craniocervical junction treated by occipitocervical plate-rod systems

Ding; Abumi; Ito; Sudo; Takahata; Nagahama; Iwata — 2012-05-01

Type: Original Paper
Purpose

To evaluate the effectiveness of posterior occipitocervical reconstruction using the anchors of cervical pedicle screws and plate-rod systems for patients with congenital osseous anomalies at the craniocervical junction.

Methods

Twenty patients with congenital osseous lesions who underwent posterior occipitocervical fusion using the anchors of cervical pedicle screws and plate-rod systems for reduction and fixation from 1996 to 2009 were reviewed. The lesions included os odontoideum, occipitalization of the atlas, congenital C2–3 fusion, congenital atlantoaxial subluxation, congenital basilar invagination and combined anomalies. The clinical assessment and the measurements of the images were performed preoperatively, postoperatively and at most recent follow-up.

Results

The combined deformity of flexion of the occipitoatlantoaxial complex and invagination of the odontoid process associated with congenital osseous lesions at the craniocervical junction was corrected by application of combined forces of extension and distraction between the occiput and the cervical pedicle screws. Preoperative myelopathy improved in 94.7 % patients. The mean Ranawat value, Redlund-Johnnell value, atlantodental distance, occiput (O)–C2 angle, and C2–C7 lordosis angle improved postoperatively and was sustained at most recent follow-up. The mean cervicomedullary angle improved from 129.3° preoperatively to 153.3° postoperatively. The mean range of motion at the lower adjacent motion segment remained unchanged at most recent follow-up. The fusion rate was 95 %.

Conclusions

The results of the present study indicate that posterior occipitocervical reconstruction using the anchors of cervical pedicle screws and plate-rod systems is an effective technique for treatment of deformities and/or instability caused by congenital osseous anomalies at the craniocervical junction.

European Spine Journal: Abstracts for CSRS 2012

2012-05-01

Type: Events
No abstract available.

European Spine Journal: Improving successful rate of transcranial electrical motor-evoked potentials monitoring during spinal surgery in young children

Yang; Huang; Shu; Chen; Sun; Liu; Dou; Xie; Lin; Hu — 2012-05-01

Type: Original Paper
Introduction

This prospective study was to investigate the successful rate of intraoperative motor evoked potentials (MEP) monitoring for children (<12 years old) with congenital scoliosis.

Materials and methods

A consecutive series of 27 young children (7 girls and 20 boys; from 1 to 11 years old) between September 2007 and November 2009, were enrolled to this study. 12 patients received general anesthesia based on TIVA, induced with propofol 2–4 mg/kg and fentanyl 3–5 µg/kg followed by a continuous infusion of propofol (20–150 µg/kg/min, at mean of 71.7 µg/kg/min). The other 15 patients received combined inhalation and intravenous anesthesia, induced with sevoflurane and fentanyl 3–5 µg/kg and maintained by sevoflurane (0.5–1%). The maintenance of anaesthesia management was performed with stable physiological parameters during surgery.

Results

Intraoperative MEP monitoring was successfully performed in all patients, while SEP was successfully performed in 26 of 27 patients. There was no significant difference of successful rates between SEP and MEP monitoring (P > 0.05). As well, no difference in MEP successful rates was observed in two groups with different anesthetic techniques. No wake-up test and no post-operative neurological deficits occurred in this series of patients.

Conclusion

Low dose anesthesia by either TIVA with propofol or sevoflurane-based mixture anesthesia protocol can help the intraoperative spinal cord monitoring to successfully elicit MEP and perform reliable monitoring for patients below 12 years of age.

European Spine Journal: Blunt cerebrovascular injuries in acute trauma care: a screening protocol

2012-05-01

Type: Original Paper
Introduction

Blunt cerebrovascular injuries (BCVI) of the extra- or intracerebral vessels are frequently observed lesions which may lead to thrombembolic events with focal neurological deficits, stroke or death particularly in patients <60 years. However, a comprehensive standardised clinical algorithm for screening and management of these secondary injuries is still lacking.

Materials and methods

We developed a standardised screening protocol applicable for mild as well as severely injured patients. In this prospective cohort study, we evaluated the feasibility of this diagnostic algorithm in a level 1 trauma centre setting. Trauma patients who met the inclusion criteria underwent a computed tomographic angiography (CTA) as part of standard diagnostic procedure at admission. All suspicions or positive findings were reevaluated by a conventional four-vessel catheter angiography within the first 72 h after trauma. Within this period, anticoagulation with low-dose heparin was started. BCVI confirmation indicated a shift to systemic heparinisation with overlapping phenprocoumon therapy for at least 6 months. All patients were reevaluated after 6 months by another four-vessel angiography. Depending on the diagnostic findings, oral anticoagulation may be discontinued or continued for another 6 months.

Results

A total of 44 patients (8 male, 6 female, age range 19–95 years) were included in the study. 20 BCVIs were detected in 16 patients (36.3%). The most common injuries identified were Biffl Type II (40%) and Type IV lesions (30%). 86.4% of the patients received a CTA upon admission, 93.2% of which were conducted within 12 h posttrauma. None of the patients had a secondary thrombembolic neurological event during the hospital stay or within 3 months postdischarge.

Conclusion

Our results indicate that implementation of the screening protocol can prevent strokes in patients without primary thrombembolic neurological deficits.

European Spine Journal: Does it need to perform anterior column support after Smith-Petersen osteotomy for ankylosing spondylitis?

Kim; Jo; Lee; Park; Sin — 2012-05-01

Type: Original Paper
Purpose

The aim of this study was to determine whether anterior column support is required in Smith-Petersen osteotomy procedure with correction angles of more than 10°, while examining the subsequent healing patterns in relation to the disrupted area.

Methods

An analysis was done on 26 segments of 19 patients who showed a correction angle of more than 10° in the anterior opening after SPO. There were 17 male and two female patients with a mean age of 40 years (24–56 years). The mean follow-up period was 6.5 years (2–9.1 years). The patients were classified according to the site of the anterior opening, as the disc level, the lower end-plate of the upper body (upper body), or the upper end-plate of the lower body (lower body). The healing patterns of anterior opening and the radiological correction angles were evaluated relative to the opening site.

Results

In all cases, bony fusion was confirmed at a mean period of 5.6 months (3–6.7 months) after surgery and the anterior opening gap was healed in 18 segments (69.2%). For patients that developed an opening in the upper body, all of the gaps were healed. The gaps in the lower body opening group were healed in 85.7% of the cases, and for the opening at the disc level, the gaps were healed only in 12.5% of the cases. The least amount of correction was obtained when anterior opening occurred in disc level.

Conclusions

In our study of subjects presenting with anterior opening angles from 10° to 32°, we obtained successful fusion without the need for additional anterior interbody fusion. Improved gap healing and increased correction angles were obtained when the opening was present in the upper or lower body endplates compared to those at the disc space level.

European Spine Journal: Spinous process morphology: the effect of ageing through adulthood on spinous process size and relationship to sagittal alignment

Aylott; Puna; Robertson; Walker — 2012-05-01

Type: Original Paper
Study design

Blinded radiographic analysis of CT scans reformatted for precise lumbar spinous process (LSP) measurement.

Objective

To investigate the effect of ageing on LSP morphology and influence of LSP morphology on lumbar spine sagittal alignment.

Summary of background data

There is little data reporting the influence of ageing on spinous process size. There is data describing the increase in size of other body parts with age, such as the femur, ears, vertebral body, and nose. Several old cadaveric and radiographic studies have reported the formation of osseous spurs within the supraspinous and interspinous ligaments.

Method

200 abdominal CT scans taken for trauma and vascular investigation were reformatted to allow precise bony measurement of the lumbar spine. Two observers were blinded from the age and demographics of the patients. Sagittal and coronal plane projections were used to measure the height and width of the spinous processes (L1–L5), respectively. The relationship between spinous process size, age, and supine lordosis was investigated.

Results

LSP height increases by 0.03–0.07 mm/year (p < 10⁻³ to 10⁻⁸) and width by 0.05–0.06 mm/year (p < 10⁻¹¹ to 10⁻¹⁵). Lumbar lordosis decreases with increasing LSP height (p < 0.0004) but is not related to increasing LSP width (p = 0.195). Supine lordosis increases by 0.1°/year (p = 0.004).

Conclusions

This study demonstrates that the dimensions of the LSP change with age. Increases in LSP height and even more impressive increases in LSP width occur with advancing age. There is an inverse relationship between lumbar lordosis and LSP height.

European Spine Journal: Reviewer’s comment concerning “Spinous process morphology: the effect of ageing through adulthood on spinous process size and relationship to sagittal alignment” (doi:10.1007/s00586-011-2029-6 by C.E.W. Aylott, R. Puna, P.A. Robertson, C. Walker)

Schulitz — 2012-05-01

Type: Letter
No abstract available.

European Spine Journal: Autoreactivity against myelin basic protein in patients with chronic paraplegia

Zajarías-Fainsod; Carrillo-Ruiz; Mestre; Grijalva; Madrazo; Ibarra — 2012-05-01

Type: Original Paper
Introduction

Previous studies have shown the existence of either cellular or humoral MBP-reactive elements up to 5 years after spinal cord injury (SCI), but not the presence of both after 10 years.

Materials and methods

Twelve SCI patients, with more than 10 years of evolution, and 18 healthy blood donors were studied. Lymphocyte proliferation (colorimetric-BrdU ELISA assay) and antibody titers against MBP (ELISA Human IgG MBP-specific assay) were assessed.

Results

SCI patients presented a significant T-cell proliferation against MBP (lymphocyte proliferation index: 3.7 ± 1.5, mean ± SD) compared to control individuals (0.7 ± 0.3; P < 0.001). Humoral response analysis yielded a significant difference (P < 0.0001) between the antibody titers of controls and SCI patients. A significant correlation between cellular and humoral responses was observed. Finally, patients with an ASIA B presented the highest immune responses.

Conclusion

This work demonstrates, for the first time, the existence of both cellular and humoral responses against MBP in the chronic stages (>10 years) of injury.

European Spine Journal: Motor and bladder dysfunctions in patients with vertebral fractures at the thoracolumbar junction

Chen; Huang; Wei; Huang; Ho; Bih — 2012-05-01

Type: Original Paper
Objective

To present the motor deficits and type of neurogenic bladder dysfunction (NBD) in patients with vertebral fractures at thoracolumbar junction.

Methods

Fifty-two patients with single level vertebra fracture over T11–L2 with onset duration of longer than 3 years were enrolled. All participants provided basic demographic data, ambulatory status and received neurologic examination and urodynamic studies. The differences in distribution of NBD types, neurologic injury sites and functional walkers in patients with different levels of vertebral injury were analyzed. Receiver operating characteristic curve analysis was used to define the cutoff value of lower extremities motor score (LEMS) in functional walker and non-walker.

Results

Of the 52 patients, the injured levels were 3 (5.8%) in T11, 21 (40.4%) in T12, 22 (42.3%) in L1, and 6 (11.5%) in L2 vertebrae. Eight (15.4%) patients had upper lumbar cord lesions, 26 (50.0%) had epiconus and lumbar roots lesions, 18 (34.6%) had conus medullaris or/and cauda equina lesions. Mean LEMS was 0 ± 0, 5.4 ± 7.7, 11.1 ± 10.2, and 28.0 ± 11.0 for patients with T11, T12, L1, and L2 fractures, respectively. Patients with L2 fractures had higher LEMS than other levels (p < 0.001). The cutoff value of LEMS for functional walking was set at 20, and both the sensitivity and specificity was 100%. Thirty-one (59.6%) patients had spastic NBD, 18 (35.6%) had flaccid NBD, and 3 (5.8%) had mixed type NBD. Positive prediction value of ankle spasticity for bladder and sphincter spasticity was 95.2 and 100%, respectively.

Conclusion

Half of the patients had epiconus lesion following thoracolumbar junction fracture, and they had a clinical presentation of flaccid legs and spastic NBD. Patients with L2 fracture had higher LEMS than patients with T11, T12, and L1 fracture. Patients whose LEMS was higher than 20 could all walk functionally. Fracture at the thoracolumbar junction may cause spastic, flaccid, or mixed type NBD, and urodynamic study is an essential tool for the correct diagnosis and management. Ankle spasticity has a high positive predictive value for spastic bladder or sphincter.

European Spine Journal: Rigid cervical collar treatment for geriatric type II odontoid fractures

Molinari; Khera; Gruhn; McAssey — 2012-05-01

Type: Original Paper
Purpose

To evaluate fracture healing, functional outcomes, complications, and mortality associated with rigid cervical collars.

Methods

Thirty-four patients with <50% odontoid displacement were treated with a rigid cervical collar for 12 weeks (Average age = 84 years). Outcome scores were compared with a group of 40 age-matched control subjects (Average age 79.3).

Results

At average 14.9-month follow-up, only 6% demonstrated radiographic evidence of fracture healing and 70% had mobile odontoid nonunion. NDI scores indicated only mild disability, pain scores were low, and neither differed significantly from age-matched controls. Mobile odontoid nonunion was not associated with higher levels of disability or neck pain. Mortality rate was 11.8%. Treatment complications occurred in 6% of patients.

Conclusions

Odontoid nonunion and instability are high in geriatric patients treated with a rigid cervical collar. Fracture healing and stability did not correlate with improved outcomes. Outcomes did not differ significantly from age-matched cohorts.

European Spine Journal: Untreated Scheuermann’s disease: a 37-year follow-up study

Ristolainen; Kettunen; Heliövaara; Kujala; Heinonen; Schlenzka — 2012-05-01

Type: Original Paper
Introduction

There are only a few follow-up studies of untreated Scheuermann’s disease. The aim of this study was to investigate the relationship between vertebral changes, back pain, and disability in patients with untreated Scheuermann’s disease after a 37-year follow-up.

Materials and methods

Eighty patients responded to a postal questionnaire concerning back pain and disability and 49 of them had classic Scheuermann’s disease. Degree of kyphosis, lordosis, scoliosis, the number of affected vertebrae, and mean and maximum wedge angles were measured from radiographs. Back pain and disability scores were compared to a sample of the general Finnish population (n = 3,835).

Results

At follow-up, the patients were on average 59 (SD 8) years old (range 44–79 years), and the mean follow-up time was 37 (SD 7) years (26–54 years). The patients comprised more males than females (3.1:1). At follow-up, male patients were on average 3 cm taller than controls (p = 0.007). At age 20, female patients compared to controls were on average 6 kg heavier (p = 0.016) and had higher body mass index (BMI) (mean 23.9 kg/m² vs. 20.8 kg/m², p = 0.001). Scheuermann’s patients had 2.5-fold [odds ratio (OR); 95% confidence interval (CI); 1.4–4.5, p = 0.003] increased risk for constant back pain compared to controls. The risk for disability because of back pain during the past 5 years (OR 2.6; 95% CI 1.4–4.7, p = 0.002), risk for back pain during the past 30 days (OR 3.7; 95% CI 1.9–7.0, p < 0.001) and risk for sciatic pain (OR 2.3; 95% CI 1.3–4.3, p = 0.005) were higher compared to controls. Scheuermann’s patients had higher risk for difficulties in mounting stairs (OR 5.4; 95% CI 2.8–10.3, p < 0.001) and in carrying a 5 kg load for at least 100 m (OR 7.2; 95% CI 3.9–13.3, p < 0.001).

Conclusion

Scheuermann’s patients had a higher risk for back pain and disabilities during activities of daily living than controls. However, the degree of thoracic kyphosis among Scheuermann’s patients was not related to back pain, quality of life, or general health.

European Spine Journal: Posterior fixation and fusion of unstable Hangman’s fracture by using intraoperative three-dimensional fluoroscopy-based navigation

Tian; Weng; Liu; Li; Hu; Li; Liu; Sun — 2012-05-01

Type: Original Paper
Purpose

The purpose of this study was to assess the efficacy and accuracy of posterior screw fixation for unstable Hangman’s fracture using intraoperative 3D fluoroscopy-based navigation.

Methods

14 patients with unstable Hangman’s fractures (11 males and 3 females), ranging in age from 21 to 59 years, received posterior fixation assisted by an intraoperative 3D fluoroscopy-based navigation system: 11 Levine–Edwards type II and three type IIA cases. The American Spine Injury Association grade was D in 2 and E in 12 cases.

Results

Operation time was 110 min (range 90–140 min). Hospital stay was 7.6 days (range 5–12 days). All the patients were observed for an average of 28.8 months (range 15–50 months). No screw-related injury to nerve, or vertebral artery was observed intraoperatively. An average of four screws/patient were inserted. Pedicle screws were placed into C2 and C3, and 5 screws were into the lateral mass of C3. Screw placement accuracy was evaluated using postoperative CT, according to the modified classification of Gertzbein and Robbins; one screw was grade 2 in C2, and three screws were grade 2 in the pedicle of C3. No grade 3 misplacement or clinical deficits were noted. C3 lateral mass screws were successfully inserted. Neck pain was relieved in each case. Neurologic status improved from D to E in 2 cases. Solid fusion was demonstrated in all the cases by static and dynamic films during the final follow-up.

Conclusions

This case series demonstrates that intraoperative 3D fluoroscopy-based navigation is a safe, accurate, and effective tool for screw placement in patients with unstable Hangman’s fracture.

European Spine Journal: Three-dimensional kinematic analysis of the cervical spine after anterior cervical decompression and fusion at an adjacent level: a preliminary report

2012-05-01

Type: Original Paper
Purpose

Development of adjacent segment degeneration following anterior cervical decompression and fusion (ACDF) is still controversial, as adjacent-level kinematics is poorly understood. This study reports preliminary data from a high-accuracy 3D analysis technique developed for in vivo cervical kinematics.

Methods

From nine cervical spondylosis patients, four underwent single-level ACDF, and five underwent two-level ACDF using cylindrical titanium cage implant(s). Pre- and post-surgical CT scans were taken in flexion, neutral and extended positions, allowing us to compute segmental ranges of motion for rotation and translation, and 3D disc-height distributions. Differences in segmental motions and disc-height between fused and adjacent levels were analyzed with a Wilcoxon signed-rank test. Results are presented as mean ± SEM.

Results

The flexion/extension angular-ROM at the fusion level decreased after surgery (7.46 ± 1.17° vs. 3.14 ± 0.56°, p < 0.003). The flexion/extension angular-ROM at one caudal adjacent level to the fusion level (3.97 ± 1.29°) tended to be greater post-operatively (6.11 ± 1.44°, p = 0.074). Translation in the anterior-posterior direction during flexion/extension at the fusion level decreased after surgery (1.22 ± 0.20 mm vs. 0.32 ± 0.11 mm, p < 0.01). No differences were found in adjacent-level disc heights between both study time-points.

Conclusions

This study showed increased segmental motion in flexion/extension angular-ROM at one level adjacent to ACDF. However, increases in the rotational angular-ROM were not statistically significant when cranial/caudal adjacent levels were analyzed separately. This preliminary study highlighted the capabilities of a 3D-kinematic analysis method to detect subtle changes in kinematics and disc height at the adjacent levels to ACDF. Thus, reliable evidence related to ACDF’s influence on adjacent-level cervical kinematics can be collected.

European Spine Journal: Malignant peripheral nerve sheath tumours of the spine: clinical manifestations, classification, treatment, and prognostic factors

Zhu; Liu; Liu; Yang; Liao; Jiang; Wei — 2012-05-01

Type: Original Paper
Background and objectives

To summarise our experience treating patients with spinal malignant peripheral nerve sheath tumours (MPNSTs).

Methods

We retrospectively reviewed the records of patients diagnosed with spinal MPNSTs who received surgical treatment from January 1998 to December 2009.

Results

Postoperative follow-up data were available for 14/16 patients with spinal MPNSTs (7 men, 7 women; median age = 44 years [range: 23–68 years]). Eight of 14 (57.1%) patients had primary and 6/14 (42.9%) recurrent MPNSTs. A total of 12/14 (85.7%) patients underwent total tumour resection, whereas 2/14 (14.3%) patients underwent subtotal tumour resection. Malignancies were graded low in 4 (28.6%) and high in 10 (71.1%) cases. A total of 12/14 (85.7%) patients experienced tumour recurrence and 10/14 (71.4%) patients died during the course of follow-up. The 0.5- 1-, 3-, and 5-year survival rates were 64.3, 48.2, 32.1, and 21.4%, respectively. Overall survival was significantly associated with tumour malignant degree (P = 0.012).

Conclusion

Diagnosis of spinal MPNSTs should be made with reference to clinical, radiological, and pathological findings. Surgical resection is the best available option for treating spinal MPNST; however, postoperative prognosis is poor.

European Spine Journal: Reproducibility of the cervical range of motion (CROM) device for individuals with sub-acute whiplash associated disorders

Williams; Williamson; Gates; Cooke — 2012-05-01

Type: Original Paper
Purpose

The objective of this study was to evaluate the reproducibility of the cervical range of motion device when measuring both active and passive range of motion in a group of individuals with sub-acute Whiplash Associated Disorders (WAD).

Methods

Participants were recruited as part of a large multi-centre Randomised Controlled Trial from UK emergency departments. Experienced research physiotherapists measured active and passive cervical spine movements in all directions. Both intra- and inter-observer reliability and agreement were assessed using the intra-class correlation coefficient, standard error of measurement and limits of agreement methods.

Results

Different groups of 39 and 19 subjects were included in the intra and inter-observer studies, respectively. The CROM device demonstrated substantial intra- and inter-observer reliability and agreement for all the active and passive half-cycle movements (ICC range 0.82–0.99) with the exception of one (passive right lateral flexion for inter-observer; ICC 0.77).

Conclusions

The CROM device has proven to be a reproducible measurement method for a symptomatic WAD population using the measurement protocol described and can be used with confidence to differentiate individuals according to a single measurement.

European Spine Journal: Dural lesions in decompression for lumbar spinal stenosis: incidence, risk factors and effect on outcome

Strömqvist; Jönsson; Strömqvist — 2012-05-01

Type: Original Paper
Introduction

Decompression for lumbar spinal stenosis is one of the most frequent operations on the spine today. The most common complication seems to be a peroperative dural lesion. There are few prospective studies on this complication regarding incidence and effect on long-term outcome; this is the background for the current study.

Materials and methods

Swespine, the Swedish Spine Register documents the majority (>80%) of lumbar spine operations in Sweden today. Within the framework of this register, totally 3,699 operations for spinal stenosis during a 5-year period were studied regarding complications and 1-year postoperative outcome. Mean patient age was 66 (37–92) years and 44% were males. Fourteen percent were smokers and 19% had undergone previous lumbar spine surgery.

Results

The overall incidence of a peroperative dural lesion was 7.4%, 8.5% of patients undergoing decompressive surgery only and 5.5% of patients undergoing decompressive surgery + fusion (p < 0.001). A logistic regression analysis demonstrated that (high) age (p < 0.0004), previous surgery (p < 0.036) and smoking (p < 0.049) were significantly predictive factors for dural lesions. An odds ratio estimate demonstrated an age-related risk increase with 2.7% per year. The risk for dural lesions also increased with number of levels decompressed. The 1-year outcome was identical in the two groups with and without a dural lesion.

Conclusion

A dural lesion was seen in 7.4% of decompressive operations for spinal stenosis. High age, previous surgery and smoking were risk factors for sustaining a lesion, which, however, did not affect the 1-year outcome negatively.

European Spine Journal: Percutaneous augmented instrumentation of unstable thoracolumbar burst fractures

Rahamimov; Mulla; Shani; Freiman — 2012-05-01

Type: Original Paper
Background

Internal fixation of unstable thoracolumbar spine fractures requires correction of the lacking anterior column support. This usually entails insertion of a vertebral body replacement strut through an anterior approach, or a long posterior construct spanning at least two vertebrae above and two vertebrae below the fracture. Posterior short-segment pedicle instrumentation (SSPI)—one vertebra above and below—is suitable for approximately 40% of fractures, but not for all.

Methods

A total of 52 patients with unstable thoracolumbar burst fractures meeting our inclusion criteria were instrumented using a novel approach, combining percutaneous SSPI, pedicle screw augmentation with polymethyl methacrylate (PMMA) and fractured vertebra kyphoplasty. We retrospectively reviewed patient and fracture data, operative results and 1 year radiographic follow-up postoperatively in 40 of the patients. We reviewed operative complications of all 52 patients.

Results

Most fractures were AO/Magerl type A3.1, A3.2 and A3.3. They were instrumented within 72 h and ambulated without additional external bracing. Operative time averaged 2 h and blood loss was less than 50 cc in most cases. Complications were mostly related to PMMA leakage. On average, 3.3° (0–13) of correction was lost after 3 months, but remained constant afterward.

Conclusions

Percutaneous augmented short-segment pedicle instrumentation of unstable thoracolumbar fractures can be done with short operative times, minimal blood loss and a low complication rate. The radiographical results at 1 year are equal to anterior stabilization and are better than other posterior-only techniques.

European Spine Journal: Risk factors predicting the new symptomatic vertebral compression fractures after percutaneous vertebroplasty or kyphoplasty

Rho; Choe; Chun — 2012-05-01

Type: Original Paper
Introduction

Percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) are effective procedures to alleviate pain caused by osteoporotic vertebral compression fractures (VCFs). New vertebral compression fracture (NVCF) has been noted as a potential late sequela of the procedures. The incidence of NVCFs and affecting risk factors were investigated.

Materials and methods

The authors retrospectively analyzed the occurrence of NVCFs in 147 patients treated with PVP or PKP for osteoporotic VCFs. Possible risk factors, such as age, gender, body mass index, bone mineral density (BMD), location of treated vertebra, treatment modality, amount of bone cement injected, anterior–posterior ratio of the fractured vertebra, cement leakage into the disc space, and pattern of cement distribution, were assessed.

Results

Twenty-seven patients (18.4%) had subsequent symptomatic NVCFs with a median time to new fracture was of 70 days. The 1-year symptomatic fracture-free rate was 85.0% by the Kaplan–Meier estimate. Eighteen (66.7%) of the 27 patients had an NVCF on the adjacent vertebra. Significant differences (P < 0.05) were found between the NVCF and control groups in regard to age, treatment modality, BMD, and the proportion of cement leakage into the disc space. Discal cement leakage and low BMD affected on adjacent NVCFs.

Conclusion

The most important risk factors affecting NVCFs were osteoporosis and intervertebral discal cement leakage.

European Spine Journal: The effectiveness of poloxamer 407-based new anti-adhesive material in a laminectomy model in rats

Yu; Lee; Baek; Nam — 2012-05-01

Type: Original Paper
Purpose

In the laminectomy model in rats, to verify anti-adhesive effectiveness of the new material, a mixture composed of poloxamer 407, calcium chloride, and xanthorrhizol, we compared it with that of commercially used solution form anti-adhesive agent GUARDIX-SL, Biorane.

Materials and methods

A total of 108 Sprague–Dawley rats (SD rats) were divided equally into three groups: negative control group (NCG), positive control group (PCG), and experimental group (EG). After exposing the dura on L4 level, we closed the wound shortly after hemostasis, after administering the anti-adhesive agent. To evaluate effectiveness, 18 SD rats from each group were killed after 1 week of rearing. Nine were examined by grading of gross adhesion and the other nine, by grading of histological adhesion. The degree of adhesion in the remainder of 18 SD rats in each group was examined with the same method after four weeks of rearing.

Results

Comparing the degree of adhesion after growth for 1 week, the gross and histological adhesion of the EG was lower than that of the NCG. There was no statistical significance in the gross score (P = 0.63), but there was statistical significance in the histological score (P = 0.04). The EG showed similar or improved degrees of adhesion in comparison with the PCG. In comparison after growth for 4 weeks, although gross adhesion of the EG was not significantly lower than the NCG, histological adhesion was remarkably low in the EG (P = 0.01). The EG showed similar or improved degrees of gross and histological adhesion in comparison to that of the PCG. (P = 0.20, 0.07).

Conclusion

The new anti-adhesive material showed similar or improved effectiveness with the existing agents for commercial use. This result suggests that the new anti-adhesive material will be a successful candidate as a future product for clinical use.

European Spine Journal: The effect of standard and low-modulus cement augmentation on the stiffness, strength, and endplate pressure distribution in vertebroplasty

Kinzl; Benneker; Boger; Zysset; Pahr — 2012-05-01

Type: Original Paper
Purpose

Vertebroplasty restores stiffness and strength of fractured vertebral bodies, but alters their stress transfer. This unwanted effect may be reduced by using more compliant cements. However, systematic experimental comparison of structural properties between standard and low-modulus augmentation needs to be done. This study investigated how standard and low-modulus cement augmentation affects apparent stiffness, strength, and endplate pressure distribution of vertebral body sections.

Methods

Thirty-nine human thoracolumbar vertebral body sections were prepared by removing cortical endplates and posterior elements. The specimens were scanned with a HR-pQCT system and loaded in the elastic range. After augmentation with standard or low-modulus cement they were scanned again and tested in two steps. First, the contact pressure distribution between specimen and loading plates was measured with pressure-sensitive films. Then, they were loaded again in the elastic range and compressed until failure. Apparent stiffness was compared before and after augmentation, whereas apparent strength of augmented specimens was compared to a non-augmented reference group.

Results

Vertebral body sections with fillings connecting both endplates were on average 33% stiffer and 47% stronger with standard cement, and 27% stiffer and 30% stronger with low-modulus cement. In contrast, partial fillings showed no significant strengthening for both cements and only a slight stiffness increase (<16%). The averaged endplate pressure above/below the cement was on average 15% lower with low-modulus cement compared to standard cement.

Conclusion

Augmentation connecting both endplates significantly strengthened and stiffened vertebral body sections also with low-modulus cement. A trend of reduced pressure concentrations above/below the cement was observed with low-modulus cement.

European Spine Journal: Treatment of MM-associated spinal fracture with percutaneous vertebroplasty (PVP) and chemotherapy

Yang; Tan; Xu; Sun; Xie; Zhao; Wang; Jiang — 2012-05-01

Type: Original Paper
Purpose

To investigate the effect of treatment of multiple myeloma (MM)-associated spinal fracture with percutaneous vertebroplasty (PVP) and chemotherapy.

Methods

Patients with MM-associated spinal fracture were randomly divided into combined (PVP and chemotherapy) treatment group (n = 38) and single chemotherapy group (n = 38). For the combined treatment group, bone cement was injected into vertebral body via DSA guided-percutaneous puncture. M2 scheme was used for both groups. And a 5-year follow-up was conducted for the study.

Results

At the 1-year follow-up visits, PVP combined with chemotherapy achieved complete remission (CR) in six patients (15.8%); near complete remission (nCR) in ten patients (26.30%); partial remission (PR) in nine patients (23.7%); minimal response (MR) in three patients (7.9%); no change (NC) in four patients (10.5%), and disease progression (DP) in five patients (13.2%). Only chemotherapy alone resulted in 3 CR (7.9%); 8 nCR (26.30%); 19 PR (77.5%); 4 MR (17.5%); 4 NC (17.5%), and 2 DP (5.0%). While the overall response rate (ORR) in the combined treatment group (65.8%) and the single chemotherapy group (50.0%) were significantly different, their visual analog pain scales (3.01 ± 0.62 and 5.97 ± 0.40, respectively) and Karnofsky performance scores (89.4 ± 6.3 and 80.3 ± 7.2, respectively) were significantly improved after treatment (P = 0.032 and P = 0.002, respectively). And the ORR between the two groups were significantly different (P = 0.001).

Conclusion

Percutaneous vertebroplasty is a minimally invasive surgery for MM-associated pathologic fracture. PVP had the characteristics of minimal trauma, easy operation and less complication. PVP can achieve long-term analgesic effect, and enhance the spinal stability.

European Spine Journal: Experimental in vivo acute and chronic biomechanical and histomorphometrical comparison of self-drilling and self-tapping anterior cervical screws

Porto; Silva; Rosa; Volpon; Shimano; Paula; Defino — 2012-05-01

Type: Original Paper
Purpose

Self-drilling screws (SDS) and self-tapping screws (STS) allow for quicker bone insertion and are associated with increased anchorage. This is an experimental in vivo comparison of anterior cervical SDS and STS in the post-insertion acute and chronic phases.

Methods

Thirty C2–C6 vertebrae from six Santa Inês hair sheep were used. Each screw design was randomly assigned to five of each spinal level. Insertion torque was measured using a torque device. Three animals were killed in each phase. Vertebrae were randomly assigned to pullout tests and histomorphometrical bone–screw interface evaluation (percent screw–bone contact and bone density inside and outside the threaded area). Statistical significance was set at P < 0.05.

Results

SDS insertion torque was greater than STS (P = 0.0001). SDS pullout strength was significantly greater than STS in the acute and chronic phases (P = 0.0001, 0.0003, respectively). SDS percent screw–bone contact and inside area bone density were significantly greater in both phases. No outside area bone density differences were observed in either phase.

Conclusions

SDS had higher insertion torque and better anchorage than STS in both phases. SDS percent bone–screw contact and inside area bone density were higher in both phases.

European Spine Journal: Less invasive approaches for the treatment of cervical schwannomas: our experience

Dehcordi; Marzi; Ricci; Di Cola; Galzio — 2012-05-01

Type: Review Paper
Purpose

The purpose of our paper is to illustrate our experience with minimally invasive approaches for the treatment of cervical schwannomas. Moreover, a brief review of the literature was conducted.

Methods

All data regarding patients treated for cervical schwannomas were retrospectively revised. Site, size and extension of the lesions and preoperative neurological status were obtained through re-examination of neuroimaging and clinical records. Postoperative clinical examinations and radiological images were available for all patients. The clinical course was documented using the visual analog scale (VAS), Karnofsky score (KPS) and the Klekamp–Samii score system.

Results

Sixteen patients harboring cervical schwannomas were treated from 2003 to 2009. Hemilaminectomy was performed in eight cases, subtotal hemilaminectomy in four cases, interlaminar fenestration in two cases, osteoplastic hemilaminotomy and laminoplasty in one case each. Postoperative neuroimaging revealed complete removal of the lesion and no signs of spinal instability. At discharge, neurological improvement was observed in 14 patients and all patients demonstrated reduction of VAS score and improvement of KPS and Klekamp–Samii’s score.

Conclusions

Minimal access procedures are increasingly gaining popularity but their use is poorly described in the treatment of cervical tumors. Less invasive approaches may effectively be used instead of traditional laminectomy in the treatment of cervical tumors, especially schwannomas, providing less iatrogenic traumatism and preventing postsurgical spinal instability. Modern neuroimaging allows adequate preoperative planning and microsurgical techniques provide adequate execution of the surgical act. The procedure has to be tailored case by case considering the specific lesional features and the individual anatomical situation.

European Spine Journal: Surgical management of U-shaped sacral fractures: a systematic review of current treatment strategies

König; Jehan; Boszczyk; Boszczyk — 2012-05-01

Type: Review Paper
Purpose

U-shaped sacral fractures usually result from axial loading of the spine with simultaneous sacral pivoting due to a horizontal fracture which leads to a highly unstable spino-pelvic dissociation. Due to the rarity of these fractures, there is lack of an agreed treatment strategy.

Methods

A thorough literature search was carried out to identify current treatment concepts. The studies were analysed for mechanism of injury, diagnostic imaging, associated injuries, type of surgery, follow-up times, complications, neurological, clinical and radiological outcome.

Results

Sixty-three cases were found in 12 articles. No Class I, II or III evidence was found in the literature. The most common mechanism of injury was a fall or jump from height. Pre-operative neurological deficit was noted in 50 (94.3%) out of 53 cases (not available in 10 patients). The most used surgical options were spino-pelvic fixation with or without decompression and ilio-sacral screws. Post-operative complications occurred in 24 (38.1%) patients. Average follow-up time was 18.6 months (range 2–34 months). Full neurological recovery was noted in 20 cases, partial recovery in 14 and 9 patients had no neurological recovery (5 patients were lost in follow-up). Fracture healing was mentioned in 7 articles with only 1 case of fracture reduction loss.

Conclusion

From the current available data, an evidence based treatment strategy regarding outcome, neurological recovery or fracture healing could not be identified. Limited access and minimal-invasive surgery focussing on sacral reduction and restoration seems to offer comparable results to large spino-pelvic constructs with fewer complications and should be considered as the method of choice. If the fracture is highly unstable and displaced, spino-pelvic fixation might offer better stability.

European Spine Journal: Biomechanical evaluation of a posterior non-fusion instrumentation of the lumbar spine

Schmoelz; Erhart; Unger; Disch — 2012-05-01

Type: Original Paper
Purpose

Numerous posterior non-fusion systems have been developed within the past decade to resolve the disadvantages of rigid instrumentations and preserve spinal motion. The aim of this study was to investigate the effect of a new dynamic stabilization device, to measure the screw anchorage after flexibility testing and compare it with data reported in the literature.

Methods

Six human lumbar spine motion segments (L2–5) were loaded in a spine tester with pure moments of 7.5 Nm in lateral bending, flexion/extension and axial rotation. Specimens were tested intact, after instrumentation of the intact segment, after destabilization by a nucleotomy and after instrumentation of the destabilised segment with the new non-fusion device (Elaspine). After flexibility testing all screws were subjected to a pull-out test.

Results

Instrumentation of the intact segment significantly reduced the RoM (p < 0.002) in flexion, extension and lateral bending to 49.7, 44.6 and 53% of the intact state, respectively. In axial rotation, the instrumentation resulted in a non-significant RoM reduction to 95% of the intact state. Compared to the intact segment, instrumentation of the destabilized segment significantly (p < 0.05) reduced the RoM to 69.8, 62.3 and 79.1% in flexion, extension and lateral bending, respectively. In axial rotation, the instrumented segment showed a significantly higher RoM than the intact segment (137.6% of the intact state (p < 0.01)). The pull-out test showed a maximum pull-out force of 855.1 N (±334) with a displacement of 6.1 mm (±2.8) at maximum pull-out force.

Conclusions

The effect of the investigated motion preservation device on the RoM of treated segments is in the range of other devices reported in the literature. Compared to the most implanted and investigated device, the Dynesys, the Elaspine has a less pronounced motion restricting effect in lateral bending and flexion/extension, while being less effective in limiting axial rotation. The pull-out force of the pedicle screws demonstrated anchorage comparable to other screw designs reported in the literature.

European Spine Journal: Paget disease of the spine: an evaluation of 101 patients with a histomorphometric analysis of 29 cases

Pestka; Seitz; Zustin; Püschel; Amling; Barvencik — 2012-05-01

Type: Original Paper
Introduction

Paget’s disease of bone (PDB) is the second most frequent metabolic bone disease with the spine being a common site of manifestation. Still, neither the disease’s etiology nor reasons for its manifestation at preferred skeletal sites are understood. The aim of the current study was therefore to perform a histologic and histomorphometric analysis of PBD biopsies of the spine to achieve a more detailed understanding concerning PDB activity and characteristics.

Materials and methods

Out of 754 cases with histologically proven PDB, 101 cases were identified to have involvement of the spine. A total of 29 individual vertebral body biopsies were available for histologic and histomorphometric analysis and were compared to age- and sex-matched spinal bone specimens obtained from skeletal-intact individuals at autopsy. Histomorphometric results were correlated with vertebral body height, disease location and iliac crest biopsies.

Results

In the majority of patients, PDB was located in the lumbar spine (62.2%). The cervical spine was affected in 8.2% of all cases with involvement of the second vertebral body (C2) in every other case. In comparison to age-matched individuals, histomorphometric analysis of vertebral body biopsies revealed a significant increase both in trabecular bone volume as well as osteoid parameters. In comparison to histomorphometric data obtained for extra-spinal skeletal locations affected by PDB (iliac crest), no differences in bone micro-architecture or disease activity were observed.

Conclusion

Disease activity in terms of osteoblast and osteoclast number does not appear to be significantly associated with disease location when spinal and iliac bone biopsies are compared. However, a positive correlation between vertebral body height and density in skeletal-intact individuals and disease incidence was observed leading to the conclusion that vertebral body height and possibly at least the spine bone volume together with bone density might play an important role in the incidence of PDB.

European Spine Journal: Knowledge transfer of spinal manipulation skills by student-teachers: a randomised controlled trial

2012-05-01

Type: Original Paper
Purpose

To assess the use of peer-assisted learning (PAL) of complex manipulative motor skills with respect to gender in medical students.

Methods

In 2007–2010, 292 students in their 3rd and 4th years of medical school were randomly assigned to two groups [Staff group (SG), PAL group (PG)] led by either staff tutors or student-teachers (ST). The students were taught bimanual practical and diagnostic skills (course education module of eight separate lessons) as well as a general introduction to the theory of spinal manipulative therapy. In addition to qualitative data collection (Likert scale), evaluation was performed using a multiple-choice questionnaire in addition to an objective structured clinical examination (OSCE).

Results

Complex motor skills as well as palpatory diagnostic competencies could in fact be better taught through professionals than through ST (manipulative OSCE grades/diagnostic OSCE score; SG vs. PG; male: P = 0.017/P < 0.001, female: P < 0.001/P < 0.001). The registration of theoretical knowledge showed equal results in students taught by staff or ST. In both teaching groups (SG: n = 147, PG: n = 145), no significant differences were observed between male and female students in matters of manipulative skills or theoretical knowledge. Diagnostic competencies were better in females than in males in the staff group (P = 0.041) Overall, students were more satisfied with the environment provided by professional teachers than by ST, though male students regarded the PAL system more suspiciously than their female counterparts.

Conclusions

The peer-assisted learning system does not seem to be generally qualified to transfer such complex spatiotemporal demands as spinal manipulative procedures.

European Spine Journal: Continuing conservative care versus crossover to radiofrequency kyphoplasty: a comparative effectiveness study on the treatment of vertebral body fractures

Bornemann; Hanna; Kabir; Goost; Wirtz; Pflugmacher — 2012-05-01

Type: Original Paper
Background

There is controversy about how to treat vertebral fractures. Conservative care is the default approach. Radiofrequency kyphoplasty uses ultrahigh viscosity cement to restore spinal posture and stabilize the fracture. The aims of this study were to compare radiofrequency kyphoplasty to conservative care and assess the usual algorithm of starting all patients on conservative care for 6 weeks before offering surgery.

Methods

Elderly patients with painful osteoporotic vertebral compression fractures were all treated with 6 weeks of conservative care (analgesics, bracing, and physiotherapy). They were then offered the choice of continuing conservative care or crossing over to radiofrequency kyphoplasty, at 6 and 12 weeks. Clinical success was defined as: (1) VAS pain improvement ≥2, (2) final VAS pain ≤5, (3) no functional worsening on ODI.

Results

After the initial 6 weeks of conservative care, only 1 of 65 patients met the criteria for clinical success, and median VAS improvement was 0. After 12 weeks of conservative care, only 5 of 38 patients met the criteria for clinical success, and median VAS improvement was 1. At the 6-week follow-up after radiofrequency kyphoplasty, 31 of 33 surgery patients met the criteria for clinical success, and median VAS improvement was 5.

Conclusion

For the vast majority of patients with a VAS ≥5, conservative care did not provide meaningful clinical improvement. In contrast, nearly all patients who underwent radiofrequency kyphoplasty had rapid substantial improvement. Surgery was clearly much more effective than conservative care and should be offered to patients much sooner.

European Spine Journal: Cervical neural space narrowing during simulated rear crashes with anti-whiplash systems

Ivancic — 2012-05-01

Type: Original Paper
Purpose

Chronic radicular symptoms have been documented in whiplash patients, potentially caused by cervical neural tissue compression during an automobile rear crash. Our goals were to determine neural space narrowing of the lower cervical spine during simulated rear crashes with whiplash protection system (WHIPS) and active head restraint (AHR) and to compare these data to those obtained with no head restraint (NHR). We extrapolated our results to determine the potential for cord, ganglion, and nerve root compression.

Methods

Our model, consisting of a human neck specimen within a BioRID II crash dummy, was subjected to simulated rear crashes in a WHIPS seat (n = 6, peak 12.0 g and ΔV 11.4 kph) or AHR seat and subsequently with NHR (n = 6, peak 11.0 g and ΔV 10.2 kph with AHR; peak 11.5 g and ΔV 10.7 kph with NHR). Cervical canal and foraminal narrowing were computed and average peak values statistically compared (P < 0.05) between WHIPS, AHR, and NHR.

Results

Average peak canal and foramen narrowing could not be statistically differentiated between WHIPS, AHR, or NHR. Peak narrowing with WHIPS or AHR was 2.7 mm for canal diameter and 1.6 mm, 2.7 mm, and 5.9 mm² for foraminal width, height and area, respectively.

Conclusions

While lower cervical spine cord compression during a rear crash is unlikely in those with normal canal diameters, our results demonstrated foraminal kinematics sufficient to compress spinal ganglia and nerve roots. Future anti-whiplash systems designed to reduce cervical neural space narrowing may lead to reduced radicular symptoms in whiplash patients.

European Spine Journal: Sagittal endplate morphology of the lower lumbar spine

Lakshmanan; Purushothaman; Dvorak; Schratt; Thambiraj; Boszczyk — 2012-05-01

Type: Original Paper
Summary of background data

The sagittal profile of lumbar endplates is discrepant from current simplified disc replacement and fusion device design. Endplate concavity is symmetrical in the coronal plane but shows considerable variability in the sagittal plane, which may lead to implant–endplate mismatch.

Objective

The aim of this investigation is to provide further analysis of the sagittal endplate morphology of the mid to lower lumbar spine study (L3–S1), thereby identifying the presence of common endplate shape patterns across these levels and providing morphological reference values complementing the findings of previous studies.

Study design

Observational study

Methods

A total of 174 magnetic resonance imaging (MRI) scans of the adult lumbar spine from the digital archive of our centre, which met the inclusion criteria, were studied. Superior (SEP) and inferior (IEP) endplate shape was divided into flat (no concavity), oblong (homogeneous concavity) and ex-centric (inhomogeneous concavity). The concavity depth (ECD) and location of concavity apex (ECA) relative to endplate diameter of the vertebrae L3–S1 were determined.

Results

Flat endplates were only predominant at the sacrum SEP (84.5%). The L5 SEP was flat in 24.7% and all other endplates in less than 10%. The majority of endplates were concave with a clear trend of endplate shape becoming more ex-centric from L3 IEP (56.9% oblong vs. 37.4% ex-centric) to L5 IEP (4% oblong vs. 94.3% ex-centric). Ex-centric ECA were always found in the posterior half of the lumbar endplates. Both the oblong and ex-centric ECD was 2–3 mm on average with the IEP of a motion segment regularly possessing the greater depth. A sex- or age-related difference could not be found.

Conclusion

The majority of lumbar endplates are concave, while the majority of sacral endplates are flat. An oblong and an ex-centric endplate shape can be distinguished, whereby the latter is more common at the lower lumbar levels. The apex of the concavity of ex-centric discs is located in the posterior half of the endplate and the concavity of the inferior endplate is deeper than that of the superior endplate. Based on the above, the current TDR and ALIF implant design does not sufficiently match the morphology of lumbar endplates in the sagittal plane.

European Spine Journal: Asymmetric osteotomy of the spine for coronal imbalance: a technical report

Thambiraj; Boszczyk — 2012-05-01

Type: Original Paper
Study design

Technical report on the surgical technique of asymmetric osteotomy of the spine for coronal imbalance.

Objective

To describe a successful method of performing asymmetrical pedicle subtraction osteotomy (APSO) through a posterior only approach.

Summary of background

Rigid coronal deformity of the spine can be sharply angulated and can create significant coronal imbalance. Surgical correction is the only definitive treatment of restoring the balance as bracing is unhelpful. Corrective surgery can be anterior or posterior. The literature on the methods of surgical correction of rigid coronal deformities of the spine is limited. Unlike osteotomies for sagittal imbalance, blunt dissection of the anterior cortex is necessary in asymmetrical osteotomy to allow resection of the anterior cortex for closure of the wedge. We describe a method by which we performed this in the thoracic and lumbar spine with case examples.

Method

After insertion of pedicle screws, laminectomy and unilateral facetectomy of the proposed level of osteotomy is performed. Next, dissection lateral to the pedicle and vertebral body is performed bluntly with mastoids to reach the front of the anterior cortex and confirmed with fluoroscopy. An oblique osteotomy including the lateral and posterior cortex is performed above and below the pedicle under imaging. The osteotomy site is closed through unilateral compression.

Conclusion

Satisfactory correction of coronal deformity can be achieved with APSO from an isolated posterior approach. In contrast to sagittal osteotomies, blunt dissection along the anterior cortex is necessary to allow safe resection of anterior cortical bone for closure of the wedge.

European Spine Journal: Intra-operative localisation of thoracic spine level: a simple “‘K’-wire in pedicle” technique

Thambiraj; Quraishi — 2012-05-01

Type: Original Paper
Purpose of study

To describe a simple and reliable method of intra-operative localisation of thoracic spine in a single surgical setting.

Summary of background

Intra-operative localisation of thoracic spine levels can be difficult due to anatomical constraints, such as scapular shadow, patient’s size and poor bone quality. This is particularly true in cases of thoracic discectomies in which the vertebral bodies appear normal. There are several methods described in recent literature to address this. Many of them require a separate procedure which was performed often the previous day. We report a technique which addresses the issue of localising thoracic level intra-operatively.

Materials and methods

After induction of general anaesthesia, the patient was placed prone and the pedicle of interest was identified using fluoroscopy. A K-wire was then inserted percutaneously into this pedicle under image guidance [confirmed in the antero-posterior (AP) and lateral views]. The wire was then cut close to the skin after bending it. The patient was now positioned laterally and the intended procedure performed through an anterior trans-thoracic approach. The ‘K’ wire was removed at the end of the procedure.

Results and conclusion

We routinely used this technique in all our thoracic discectomies (four cases in 2 years). There were no intra-operative complications. This method is simple, avoids the patient undergoing two procedures and requires no more ability than placing an implant in the pedicle under fluoroscopy. Placing the ‘K’ wire into a fixed point like the pedicle facilitates rapid intra-operative viewing of the level of interest and is removed easily at the conclusion of surgery.

European Spine Journal: A comparative evaluation of the small leucine-rich proteoglycans of pathological human intervertebral discs

Brown; Melrose; Caterson; Roughley; Eisenstein; Roberts — 2012-05-01

Type: Original Paper
Purpose

Proteoglycans are important to the functioning of the intervertebral disc. In addition to aggrecan there are the small leucine-rich proteoglycans (SLRPs). These are less common but in other locations their functions include collagen organisation, sequestering growth factors and stimulating inflammation. We have performed a comparative analysis of the SLRP core protein species present in intervertebral discs with various pathologies.

Methods

Eighteen intervertebral discs from patients with scoliosis (n = 7, 19–53 years), degenerative disc disease (n = 6, 35–51 years) and herniations (n = 5, 33–58 years) were used in this study. Proteoglycans were dissociatively extracted from disc tissues and the SLRPs (biglycan, decorin, fibromodulin, keratocan and lumican) assessed by Western blotting following deglycosylation with chondroitinase ABC and keratanase.

Results

Intact SLRP core proteins and a number of core protein fragments were identified in most of the discs examined. Biglycan and fibromodulin were the most extensively fragmented. Keratocan generally occurred as two bands, one representing the intact core protein, the other a smaller fragment. The intact core protein of lumican was detected in all samples with fragmentation evident in only one of the older scoliotic discs. Decorin was less obvious in the disc samples and showed little fragmentation.

Conclusion

In this cohort of pathological intervertebral discs, fragmentation of certain SLRP core proteins was common, indicating that some SLRPs are extensively processed during the pathological process. Identification of specific SLRP fragments which correlate with disc pathology may not only help understand their aetiopathogeneses, but also provide biomarkers which can be used to monitor disease progression or to identify particular disc disorders.

European Spine Journal: A pilot investigation into the effects of different office chairs on spinal angles

Annetts; Coales; Colville; Mistry; Moles; Thomas; Deursen — 2012-05-01

Type: Original Paper
Purpose

To investigate the effects of four office chairs on the postural angles of the lumbopelvic and cervical regions.

Research question

Which chair(s) produce an “ideal” spinal posture?

Methods

An experimental same subject design was used involving healthy subjects (n = 14) who conducted a typing task whilst sitting on four different office chairs; two “dynamic” chairs (Vari-Kneeler and Swopper), and two static chairs (Saddle and Standard Office with back removed). Data collection was via digital photogrammetry, measuring pelvic and lumbar angles, neck angle and head tilt which were then analysed within MatLab. A repeated measures ANOVA with Bonferroni corrections for multiple comparisons was conducted.

Results

Statistically significant differences were identified for posterior pelvic tilt and lumbar lordosis between the Vari-Kneeler and Swopper chairs (p = 0.006, p = 0.001) and the Vari-Kneeler and Standard Office chairs (p = 0.000, 0.000); and also for neck angle and head tilt between the Vari-Kneeler and Swopper chairs (p = 0.000, p = 0.000), the Vari-Kneeler and Saddle chairs (p = 0.002, p = 0.001), the Standard Office and Swopper chairs (p = 0.000, p = 0.000), and the Standard Office and Saddle chairs (p = 0.005, p = 0.001). This study confirms a within region association between posterior pelvic tilt and lumbar lordosis, and between neck angle and head tilt. It was noted that an ideal lumbopelvic position does not always result in a corresponding ideal cervical position resulting in a spinal alignment mismatch.

Conclusion

In this study, the most appropriate posture for the lumbopelvic region was produced by the Saddle chair and for the cervical region by both the Saddle and Swopper chairs. No chair consistently produced an ideal posture across all regions, although the Saddle chair created the best posture of those chairs studied. Chair selection should be based on individual need.

European Spine Journal: High-grade spondylolisthesis: gradual reduction using Magerl’s external fixator followed by circumferential fusion technique and long-term results

Karampalis; Grevitt; Shafafy; Webb — 2012-05-01

Type: Original Paper
Purpose

To report the results of a cohort of patients treated with this technique high lighting radiological and functional outcomes, discussing also benefits arising from a gradual reduction procedure compared with other techniques.

Methods

We evaluated nine patients who have undergone high-grade listhesis reduction and circumferential fusion at our institution from 1988 to 2006. Average length of follow-up was 11 years (5–19). Functional outcomes and radiological measurements were recorded and reported.

Results

Slip magnitude was reduced by an average of 2.9 grades (Meyerding classification). Slip angle improved by an average of 66% (p = 0.0001), lumbosacral angle by 47% (p = 0.0002), sacral rotation by 51% (p = 0.0068) and sacral inclination by 47% (p = 0.0055). At the latest follow-up 88.9% had achieved solid fusion. Post-operative 10-point Visual Analogue Score (VAS) for back pain had improved by 70% (p < 0.001) and that for leg pain by 76% (p < 0.001) compared with pre-operative score. Average postoperative Oswestry Disability Index for all patients was 8% (range 0–16%) and that for Low Back Outcome Scores was 56.6 (range 44–70). All components of Short Form 36 Health Survey were greater than 80%. Overall patients’ expectations were met in 100%.

Conclusions

This is an effective and safe technique which addresses the lumbosacral kyphosis and cosmetic deformity without the neurological complications which accompany other reduction and fusion techniques for high-grade spondylolisthesis.

European Spine Journal: Safety of fluoroscopy guided percutaneous access to the thoracic spine

Clamp; Bayley; Ebrahimi; Quraishi; Boszczyk — 2012-05-01

Type: Original Paper
Background

Fluoroscopy-guided percutaneous access to thoracic vertebrae is technically demanding due to the complex radiological anatomy and close proximity of the spinal cord, major vessels and pleural cavity. There is a trend towards computed tomography (CT) guidance due to a perceived reduction in the risk of spinal canal intrusion by instrumentation causing neurological injury. Due to limited access to CT guidance, there is a need for safe fluoroscopy-guided percutaneous access to the thoracic spine.

Purpose

To evaluate the safety of a strict radio-anatomical protocol in avoiding access-related neurological complications due to tool misplacement in fluoroscopy-guided percutaneous procedures on the thoracic spine.

Method

A combined two-surgeon prospective case series of 444 procedures (biopsy, vertebroplasty or kyphoplasty) covering all thoracic vertebral levels T1–T12. Clinical examination and routine observations were used to identify access-related complications including neurological, vascular and visceral injury using physiological parameters.

Results

No patient in our series was identified to have sustained a neurological deficit or deterioration of preoperative neurological status.

Conclusion

Percutaneous access to the thoracic spine using fluoroscopic guidance is safe. The crucial step of the protocol is not to advance the tool beyond the medial pedicle wall on the anterior–posterior projection until the tip of the instrument has reached the posterior vertebral cortex on the lateral projection.

European Spine Journal: Malpractice litigation and the spine: the NHS perspective on 235 successful claims in England

Quraishi; Hammett; Todd; Bhutta; Kapoor — 2012-05-01

Type: Original Paper
Purpose

The objective of this study was to evaluate the overall incidence and total burden of successful litigation relating to the management of spinal disease across the National Health Service (NHS) in England.

Methods

The study design comprised a retrospective review of the NHS Litigation Authority (NHSLA) database, retrieving all successful claims relating to spinal disease between 2002 and 2010—a total of 235 (144 acute, 91 elective).

Results

The general trend for successful claims with relation to spinal surgery has actually been decreasing steadily over the last few years. The total value of these claims during the period was £60.5 million, comprising £42.8 million (£28.6 million relating to acute diagnoses, £16.1 million for elective) in damages and £17.7 million in legal costs (31% relating to NHS legal costs, the remainder claimants costs).

Conclusions

Spinal litigation remains a source of significant cost to the NHS. The complexity of resolving these cases is reflected in the associated legal costs.

European Spine Journal: Single level cervical fusion by an anterior approach using autologous bone graft influences the adjacent levels degenerative changes: clinical and radiographic results at 10-year minimum follow-up

Faldini; Miscione; Acri; Leonetti; Nanni; Chehrassan; Giannini — 2012-05-01

Type: Original Paper
Introduction

Cervical degenerative pathology can produce pain and disability and, in case of failure of conservative treatment surgery is indicated.

Materials and methods

107 patients affected by single level cervical degenerative pathology were surgically treated by Cloward procedure. On radiographs, the sagittal segmental alignment (SSA) of the affected level and sagittal alignment of the cervical spine were measured.

Results

Preoperatively, mean SSA was 0.6° and at the last follow-up 1.8°. In particular, adjacent-level degeneration occurred more frequently in Group A than in Group B.

Conclusion

Lordotic SSA angle can be considered a protective factor against adjacent-level degeneration.

European Spine Journal: Atlantoaxial rotatory dislocation (AARD) in pediatric age: MRI study on conservative treatment with Philadelphia collar—experience of nine consecutive cases

Landi; Pietrantonio; Marotta; Mancarella; Delfini — 2012-05-01

Type: Original Paper
Purpose

Atlantoaxial rotatory fixation and atlantoaxial rotatory subluxation are the most frequent manifestations of atlantoaxial rotatory dislocation (AARD) in pediatric population and are often treated conservatively. The objective of this study is to correlate the changes highlighted on MRI T2-weighted and STIR sequences with the duration of conservative treatment.

Methods

We analyzed nine consecutive patients treated surgically between 1 Jan 2006 and 1 Jan 2010 at the Policlinico Umberto I of Rome. All patients underwent cervical X-ray, computed tomography and magnetic resonance imaging (MRI) (T1 and T2-weighted, STIR, angio MRI). All patients were treated with bed rest, muscle relaxants and cervical collar, and radiological follow-up with MRI and cervical X-ray was performed.

Results

According to Fielding’s classification, we observed seven patients with a type 1 subluxation and two patients with a type II subluxation. In type 1, STIR and T2 sequences showed a hyperintensity in the alar and capsular ligaments and in the posterior ligamentous system, with integrity of the transverse ligament (LTA). In type 2, the hyperintensity also involved the LTA. During the follow-up, MRI showed a progressive reduction until the disappearance of the hyperintensity described, which was followed by a break with orthotic immobilization.

Conclusions

MRI with STIR sequences appears to be useful in addressing the duration of conservative treatment in AARD.

European Spine Journal: Direct lateral access lumbar and thoracolumbar fusion: preliminary results

Berjano; Balsano; Buric; Petruzzi; Lamartina — 2012-05-01

Type: Original Paper
Purpose

To describe the clinical outcomes and complications in a consecutive series of extreme lateral interbody fusion cases.

Methods

Retrospective cohort review of 97 consecutive patients from three centers with minimum 6-month follow-up (mean 12 months). Functional status was evaluated by preoperative and last follow-up Oswestry Disability Index score. Leg and back pain were evaluated by visual analog scales. Complications were recorded and permanent complications and neurological impairment was actively investigated at last follow-up.

Results

No permanent neurological impairment, vascular or visceral injuries were observed. Transient neurological symptoms presented in 7% of cases, all resolved within 1 month from surgery. Transient thigh discomfort was observed in 9%. Clinical success was recorded in 92% of cases.

Conclusions

Extreme lateral interbody fusion is a safe and effective technique for anterior interbody fusion.

European Spine Journal: Free-hand pedicle screws insertion technique in the treatment of 120 consecutive scoliosis cases operated without use of intraoperative neurophysiological monitoring

Crostelli; Mazza; Mariani — 2012-05-01

Type: Original Paper
Purpose

We present 120 patients (37 males, 83 females) affected by thoracic lumbar scoliosis, treated by posterior instrumented arthrodesis with the insertion of pedicle screws by “free hand technique”, without any image guided system, radioscopy use during insertion or intraoperative neurophysiological monitoring.

Methods

Seventy-two (60%) patients have been treated by hybrid instrumentation with lumbar and thoracic screws, hooks and wires at thoracic levels, while the remaining 48 (40%) patients have used only lumbar and thoracic pedicle screws. Mean Cobb grades value of the main scoliotic curve was 73° before surgery in patients treated by hybrid instrumentation, reduced to 37.5° after surgery. In patients treated only by screws, mean Cobb grades value of the main scoliotic curve was 65°, reduced to 16° after surgery.

Results

Minimum follow up has been 3 years; mean patient age at surgery was 15 years and 4 months. We placed a total number of 1,004 pedicle screws, 487 of which at thoracic level. In 12 patients (10%) a total number of 20 screws were misplaced at postoperatory exam, without any clinical complication for the patients or consequences on the arthrodesis or on maintaining the correction of the curve.

Conclusions

In our experience pedicle screws is the method that leads to best correction and balance on vertebral bodies, with best results at distance concerning correction maintaining. Our experience shows that even at thoracic level, pedicle screws insertion by free-hand technique is safe and reliable.

European Spine Journal: Posterior lumbar fusion by peek rods in degenerative spine: preliminary report on 30 cases

Iure; Bosco; Cappuccio; Paderni; Amendola — 2012-05-01

Type: Original Paper
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.

European Spine Journal: Endoscopic transnasal odontoid resection to decompress the bulbo-medullary junction: a reliable anterior minimally invasive technique without posterior fusion

2012-05-01

Type: Original Paper
Purpose

Anterior decompression of the craniovertebral junction is reserved to patients with irreducible ventral bulbo-medullary lesions and rapidly deteriorating neurological functions. Classically performed through the transoral approach, the exposure of this region can be now achieved by a minimally invasive endonasal endoscopic approach (EEA).

Methods

Four patients with irreducible, anterior bulbo-medullary compression due to rheumatoid pannus and basilar invagination were enrolled. The imaged-guided EEA was used to resect the odontoid process, trying to preserve the C1 anterior arch.

Results

Neurological improvement and adequate bulbo-medullary decompression were obtained in all patients. In two cases, anterior C1 ring was preserved. These patients did not required a posterior fusion.

Conclusions

Compared with the standard transoral technique, the EEA provides the same good exposure but with potentially less complications. The preservation of the anterior C1 arch can contribute to avoid cranial settling and posterior fusion with its related risk of subaxial instability.

European Spine Journal: Cement leakage: safety of minimally invasive surgical techniques in the treatment of multiple myeloma vertebral lesions

La Maida; Giarratana; Acerbi; Ferrari; Mineo; Misaggi — 2012-05-01

Type: Original Paper
Purpose

To evaluate and address the safety of vertebroplasty (VP) and kyphoplasty (KP) in terms of rate and type of cement leakage in the treatment of Multiple Myeloma (MM) vertebral fractures.

Methods

A total number of 37 treated vertebrae were evaluated post-operatively by using standard X-rays and CT scan looking for a cement leakage. VP was done using a monoportal approach in all cases (18 treated levels, group A), while KP was done using a monopedicular approach in 9 levels (group B1) and using a bipedicular approach in the remaining 10 levels (group B2). A computed tomography was used to establish the presence of any cement leakage and to determine its localization.

Results

Vertebral augmentation through VP and KP provides immediate pain relief and an improvement of the quality of life of patients affected by MM but it is gravated by high risk of cement leakage. Cement extravasation occurred in 27.7% of total VP procedures and in 21.05% of total KP procedures, but considering the whole number of treated levels, it was more common in multi-level VP and in bipedicular KP, in which a higher quantity of cement was employed.

Conclusions

KP procedure in these patients is slightly less risky but we suggest doing it with a monopedicular approach. It’s mandatory to use an high viscosity cement and we suggest not to use an amount of PMMA over 2 cc and a previous treatment with bone marrow transplant is related to a lower risk of cement leakage.

European Spine Journal: Treatment of kyphotic deformities in adults: our experience

Finocchiaro; Nena; Scalzo; Monterumici — 2012-05-01

Type: Original Paper
Purpose

Many degenerative phenomena frequently result into kyphotic lumbar and thoracic deformities or cause their progression combined with deformities on the frontal plane of the spine. In these patients, the progression of the sagittal imbalance may lead to a series of disabling functional and painful consequences. The analysis of the spinopelvic parameters biases the choice of the correction surgical strategy aimed at restoring a good tri-dimensional and sagittal balance of the spine.

Materials and methods

Sample included 62 patients treated in our Operation Unit that were enrolled for evaluation; they were affected with prevailing sagittal deformities.

Results

Clinical results were evaluated through the administration of SF-36, Oswestry Disability Index (ODI), Roland Morris (RM), and visual analogical scale (VAS).

Conclusions

In our experience, patients with sagittal imbalance and short fusion areas show a higher risk of correction loss; the arthrodesis area must include the thoracolumbar junction, and it is often necessary to include the whole thoracic spine in the arthrodesis area. This is to avoid any loss of correction, implants mobilization, and proximal hyperkyphosis.

European Spine Journal: Treatment of typical amyelic somatic fractures with kyphoplasty and calcium phosphate cement: a critical analysis

Gioia; Mandelli; Gogue — 2012-05-01

Type: Original Paper
Purpose

Vertebroplasty and more recently kyphoplasty are recognized as techniques in the treatment of osteoporotic vertebral fractures and in case of pathological fracture like in secondary tumors. The recent introduction of calcium phosphate cement (CPC) that offers, at least theoretically, an osteointegrative capacity, absent in polymethyl methacrylate (PMMA), has generated interest for its use in the treatment of traumatic fractures (type A) even in young patients.

Methods

In this study, type A fractures without neurological signs were treated. A total of six male patients, of age between 21 and 55 years (mean age 38 years), were included. Fracture treatment was performed with kyphoplasty with balloon (Kyphon) and injection of calcium phosphate cement for a total of seven procedures.

Results

The results were evaluated according to the regional kyphosis angle and the local kyphosis angle. The postoperative X-ray control showed an average improvement of the regional kyphosis angle of 7.4°; however, this value was reduced by an average of 6.6° after 45 days with regard to the postoperative control. The local kyphosis angle showed an average improvement of 9° at the postoperative control with an average worsening of 9.2° in the control after 45 days.

Conclusions

While kyphoplasty with the use of CPC in the treatment of type A traumatic fractures was effective in the treatment of pain, it has not been so far effective concerning the maintenance of the reduction obtained intra-operatively and its osteointegrative effect.

European Spine Journal: Neurological L5 burst fracture: posterior decompression and lordotic fixation as treatment of choice

Ramieri; Domenicucci; Cellocco; Raco; Costanzo — 2012-05-01

Type: Original Paper
Purpose

We report our experience and literature review concerning surgical treatment of neurological burst fractures of the fifth lumbar vertebra.

Materials and methods

Nineteen patients with L5 neurological burst fractures were consecutively enrolled; 6 patients had complete motor deficits, and 12 had sphincter dysfunction. We performed 18 posterior and one combined approaches. To avoid kyphosis, posterior internal fixation was achieved by positioning patients on the operating table with hips and knees fully extended. At the latest follow-up (mean 22 months, range 10–66), neurological recovery, canal remodeling and L4–S1 angle were evaluated.

Results

Vertebral body replacement was difficult, which therefore resulted in an oblique position of the cage. Vertebral bodies still remained deformed, even though fixation allowed for an acceptable profile (22°, range 20–35). We observed three cases of paralysis, five complete, and three incomplete recoveries. In the remaining eight patients, sphincter impairment was the only finding. In 15 patients, pain was absent or occasional; in four individuals, it was continuous but not invalidating. Remodeling was visible by X-ray and/or CT, without significant secondary stenosis.

Conclusions

The L5 burst fractures are rare and mostly due to axial compression. Cauda and/or nerve root injuries are absolute indications for surgery. If an anterior approach is technically difficult, laminectomy can allow for decompression, and it can be easily combined with transpedicular screw fixation. Posterior instrumented fusion, also performed with the aim to restore sagittal profile, when associated with an accurate spinal canal exploration and decompression, may be looked at as an optimal treatment for neurological L5 burst fractures.

European Spine Journal: Diffusion-weighted MR imaging in differentiation between osteoporotic and neoplastic vertebral fractures

Pozzi; Garcia Parra; Stradiotti; Tien; Luzzati; Zerbi — 2012-05-01

Type: Original Paper
Purpose

To assess the usefulness of magnetic resonance imaging (MRI) with spin-echo echo-planar diffusion-weighted imaging (SE-EPI-DWI) in differentiation between vertebral osteoporotic fractures and pathological neoplastic fractures.

Materials and methods

Thirty-three patients with both osteoporotic or neoplastic vertebral fractures diagnosed with X-ray or TC were studied with MRI exam, (1.5 T unit) with DWI sequences. DWI sequences were qualitatively analyzed. Apparent diffusion coefficient (ADC) values were also determined and compared to the definitive histologic diagnosis.

Results

DWI of neoplastic lesions showed hyperintensity signal in 22 out of 23 cases. Mean ADC value of neoplastic fractures was 1.241 ± 0.4 × 10⁻³ mm²/s; mean ADC value of osteoporotic fractures was 0.646 ± 0.368 × 10⁻³ mm²/s. Neoplastic fractures showed ADC values significantly higher than osteoporotic ones (p < 0.001). DWI imaging and histology showed a significant correlation.

Conclusion

DWI provides reliable information to support MRI diagnosis of neoplastic versus osteoporotic fractures. ADC value appears as a useful adjunctive parameter.

European Spine Journal: Transdiscal L5-S1 screws for the treatment of adult spondylolisthesis

Logroscino; Tamburrelli; Scaramuzzo; Schirò; Sessa; Proietti — 2012-05-01

Type: Original Paper
Purpose

The aim of the study was to evaluate clinical and radiographic outcome of patients treated with a modified Grob technique analysing the advantages related to increased mechanical stability.

Methods

30 patients that underwent “in situ” fusion for L5-S1 spondylolisthesis were evaluated. All patients presented a low-dysplastic developmental L5-S1 spondylolisthesis. Patients were divided into two groups: A, in which L5-S1 pedicle instrumentation associated with transsacral screw fixation was performed, and B, in which L5-S1 pedicle instrumentation associated with a posterolateral interbody fusion (PLIF) was performed.

Results

Patients treated with transdiscal L5-S1 fixation observed a faster resolution of the symptoms and a more rapid return to daily activities, especially at 3–6 months’ follow-up. The technique is reliable in giving an optimal mechanical stability to obtain a solid fusion.

Conclusions

The advantages of this technique are lower incidence of neurologic complications, speed of execution and faster return to normal life.

European Spine Journal: Assessment of prognostic factors in patients with metastatic epidural spinal cord compression (MESCC) from solid tumor after surgery plus radiotherapy: a single institution experience

2012-05-01

Type: Original Paper
Purpose

To identify potential prognostic factors predicting functional outcome and survival after surgery followed by radiotherapy for metastatic spinal cord compression due to solid tumors.

Methods

531 consecutive patients with metastatic epidural spinal cord compression (MESCC) were treated at our institution. Surgery followed by radiation therapy was performed in 151 patients (30%) with various histological diagnoses. Three different surgical procedures were performed: minimal resection with or without instrumented fixation, curettage, and total tumorectomy. Within 1 month after surgery, RT was performed, delivering a total dose of 30–36 Gy (3 Gy per fraction). Ten potential prognostic factors were investigated for relationship with functional outcome and survival.

Results

Clinical remission of pain was obtained in 91% of patients and 94 (62.5%) had recovery of neurological deficit. Recurrence in the same site of treatment occurred in nine (6%) patients. Median survival was 14 months (range 0–52 months); OS at 1, 2, and 3 years was 43.6, 37, and 21.5%, respectively. Survival was significantly associated with the histology of primary tumor (P < 0.001) and visceral metastases (P < 0.001) in the whole group; for histology, the prognostic factors statistically significant were other bone metastases in breast cancer, control of primary tumor, and the absence of visceral metastases in NSCLC and kind of surgery in the other.

Conclusions

The key element for successful treatment of MESCC is multidisciplinary care of the patient, which includes all of those prognostic factors that have been, until now, analyzed and compared. In our set of patients treated for vertebral metastases, PS, time to development of symptoms, and the presence of visceral metastases affected functional outcome and survival.

European Spine Journal: Ex vivo observation of human intervertebral disc tissue and cells isolated from degenerated intervertebral discs

2012-05-01

Type: Original Paper
Purpose

Disc degeneration, and associated low back pain, are a primary cause of disability. Disc degeneration is characterized by dysfunctional cells and loss of proteoglycans: since intervertebral tissue has a limited capacity to regenerate, this process is at present considered irreversible. Recently, cell therapy has been suggested to provide more successful treatment of IVD degeneration. To understand the potential of cells to restore IVD structure/function, tissue samples from degenerated IVD versus healthy discs have been compared.

Methods

Discal tissue from 27 patients (40.17 ± 11 years) undergoing surgery for degenerative disc disease (DDD), DDD + herniation and congenital scoliosis, as controls, was investigated. Cells and matrix in the nucleus pulposus (NP) and annulus fibrosus (AF) were characterized by histology. AF- and NP-derived cells were isolated, expanded and characterized for senescence and gene expression. Three-dimensional NP pellets were cultured and stained for glycosaminoglycan formation.

Results

Phenotypical markers of degeneration, such as cell clusters, chondrons, and collagen disorganization were seen in the degenerate samples. In severe degeneration, granulation tissue and peripheral vascularization were observed. No correlation was found between the Pfirrmann clinical score and the extent of degeneration.

Conclusion

The tissue disorganization in degenerate discs and the paucity of cells out of cluster/chondron association, make the IVD-derived cells an unreliable option for disc regeneration.

European Spine Journal: Bioactive electrospun scaffold for annulus fibrosus repair and regeneration

Vadalà; Mozetic; Rainer; Centola; Loppini; Trombetta; Denaro — 2012-05-01

Type: Original Paper
Purpose

Annulus fibrosus (AF) tissue engineering is gathering increasing interest for the development of strategies to reduce recurrent disc herniation (DH) rate and to increase the effectiveness of intervertebral disc regeneration strategies. This study evaluates the use of a bioactive microfibrous poly(l-lactide) scaffold releasing Transforming Growth Factor (TGF)-β1 (PLLA/TGF) for the repair and regeneration of damaged AF.

Methods

The scaffold was synthesized by electrospinning, with a direct incorporation of TGF-β1 into the polymeric solution, and characterized in terms of morphology and drug release profile. Biological evaluation was performed with bovine AF cells (AFCs) that were cultured on the scaffold up to 3 weeks to quantitatively assess glycosaminoglycans and total collagen production, using bare electrospun PLLA as a control. Histological evaluation was performed to determine the thickness of the deposited neo-ECM.

Results

Results demonstrated that AFCs cultured on PLLA/TGF deposited a significantly greater amount of glycosaminoglycans and total collagen than the control, with higher neo-ECM thickness.

Conclusions

PLLA/TGF scaffold induced an anabolic stimulus on AFCs, mimicking the ECM three-dimensional environment of AF tissue. This bioactive scaffold showed encouraging results that allow envisaging an application for AF tissue engineering strategies and AF repair after discectomy for the prevention of recurrent DH.

European Spine Journal: Criteria to restore the sagittal balance in deformity and degenerative spondylolisthesis

2012-05-01

Type: Original Paper
Purpose

To present in a single source the relevant information needed to assess spinopelvic balance and alignment, and to estimate the amount of correction needed in a patient during surgical treatment.

Methods

Narrative literature review

Results

Sagittal balance can be evaluated by global balance estimates (sagittal vertical axis and T1 tilt). Other important parameters are the relationship between pelvic incidence and lumbar lordosis (spinopelvic harmony), between pelvic incidence and difference of thoracic kyphosis and lumbar lordosis (spinopelvic balance), excess of pelvic tilt, knee flexion and thoracic compensatory hypokyphosis. Different methods to calculate the amount of surgical correction needed in patients with sagittal imbalance have been based on combinations of these parameters.

Conclusions

Relevant parameters of sagittal imbalance have been identified and correlated with clinical outcomes. Methods for calculation of surgical correction of imbalance have been proposed, but not validated in patients with mid-term follow-up.

European Spine Journal: Sagittal profile control in patients affected by neurological scoliosis using Universal Clamps: a 4-year follow-up study

La Rosa; Giglio; Oggiano — 2012-05-01

Type: Original Paper
Purpose

Patients affected by cerebral palsy often develop progressive scoliosis that can results in trunk instability with an impairment of both coronal and sagittal balance. The aim of this retrospective study was to demonstrate the ability of UC to control the sagittal profile in a consecutive series of patients affected by neurological scoliosis.

Methods

From 2006 to 2008, 84 patients (57 F, 27 M) affected by neurological scoliosis were treated surgically. Mean age was 14 years (range 10–17). The etiology was mainly cerebral palsy. The average pre-operative Cobb angle was 73° ± 16°. Patients were divided into three groups according to the pre-operative presence of: physiological kyphosis (mean 29° ± 8°), thoracic lordosis (mean 10° ± 6°) and hyperkyphosis (51° ± 8°). A posterior access was performed in all patients using thoracic UC associated with transpedicular lumbar screws and a conventional claw at the upper extremity of the construct.

Results

The average percentage of coronal correction was 72%. In all three groups, we observed a common trend toward maintaining or restoring the physiological values. Mean follow-up time was 36 months. At the 1-year follow-up, the mean loss of correction was 7° ± 2° in the coronal plane and 2° ± 1° in the sagittal plane with no other change thereafter.

Conclusions

The hybrid construct using UC appears effective in neurological scoliosis treatment, providing a good correction of the deformity in both coronal and sagittal planes. In the present series, physiological thoracic kyphosis has been restored in all patients, providing better sitting tolerance in wheelchair-bound patients, and retaining standing and walking abilities in ambulatory patients.

European Spine Journal: The anterior stand-alone approach (ASAA) during the acute phase of spondylodiscitis: results in 40 consecutively treated patients

D’Aliberti; Talamonti; Villa; Debernardi — 2012-05-01

Type: Original Paper
Purpose

Spondylodiscitis mainly affects the anterior part of the spine. In this paper, we retrospectively analyze our experience with the anterior stand-alone approach (ASAA) in the treatment of spinal infections.

Methods

Forty consecutive patients with severe spondylodiscitis underwent the ASAA during the acute infective phase. Treatment consisted of disease debridement, vertebral body reconstruction using titanium expandable prostheses and anterior fixation.

Results

There was neither mortality nor major morbidity. Successful arthrodesis was achieved in 39 out of 40 patients who remained disease free throughout the follow-up period. Six months after treatment, one patient experienced pseudarthrosis and required supplemented posterior spinal fixation for vertebral instability. However, adequate arthrodesis was eventually obtained even in this patient.

Conclusions

ASAA with spine reconstruction using synthetic materials during the acute infection phase was safe and effective. The infections were rapidly defeated, the patients were allowed to stand up early after the procedure and the length of hospital stay was significantly reduced.

European Spine Journal: Spine surgery in Italy between neuro and ortho surgeons

Lamartina — 2012-05-01

Type: Editorial Notes
No abstract available.

European Spine Journal: Reviewer’s comment concerning “Continuing conservative care versus cross-over to radiofrequency kyphoplasty: a comparative effectiveness study on the treatment of vertebral body fractures” (doi:10.1007/s00586-012-2148-8 by R. Bornemann, M. Hanna, K. Kabir, H. Goost, D. C. Wirtz, R. Pflugmacher)

Alvarez Galovich — 2012-05-01

Type: Letter
No abstract available.

European Spine Journal: Prospective study of a new dynamic stabilisation system in the treatment of degenerative discopathy and instability of the lumbar spine

Zagra; Minoia; Archetti; Corriero; Ricci; Teli; Giudici — 2012-05-01

Type: Original Paper
Introduction

Posterior dynamic stabilisation (PDS) aims at relieving lumbar discogenic pain and preserving adjacent levels from accelerated degeneration.

Purpose

To evaluate the results of a novel PDS system in 32 adult patients affected by chronic low back pain (CLBP) due to degenerative lumbar spine instability (DLSI).

Method

A progressive follow-up for 12 months of 32 patients, with collection of complete clinical (ODI and VAS back + leg) and radiological data (resting + functional radiographs and MRI).

Results

Mean ODI scores improved from 49 to 6%, VAS back from 5 to 1 and VAS leg from 7 to 2. Twenty-two patients underwent fusion of a lower lumbar segment and stabilisation of an upper segment (hybrid fusion) whereas ten underwent dynamic stabilisation. In 16/32 patients, decompression was added to treat radicular pain. Motion in non-fused instrumented levels was unrestricted on functional X-rays and MRIs did not show significant morphologic changes. Four patients (12.5%) had unchanged functional and pain scores while two (6.3%) suffered worsening low back pain necessitating implant removal and spinal fusion. No infection, no new neurologic deficit or implant failure was recorded.

Conclusions

The 1 year follow-up shows that the tested PDS system is able to provide a significant improvement in pain and disability scores when applied to patients affected by DLSI. The system does not provide better clinical results when compared to similar trials on posterior fusion. Further follow-up is ongoing to investigate the potential preservation of adjacent levels from accelerated degeneration.

European Spine Journal: “In situ” fusion or reduction in high-grade high dysplastic developmental spondylolisthesis (HDSS)

Martiniani; Lamartina; Specchia — 2012-05-01

Type: Original Paper
Purpose

To assess if the evaluation of the spino-pelvic balance can be effective in the surgical decision making of the high-grade high dysplastic developmental spondylolisthesis (HDDS).

Methods

Sixteen patients affected with high-grade HDDS (6 treated with “in situ” fusion, and 10 with reduction and fusion) were retrospectively evaluated. A clinical and radiological assessment of the deformity correction was carried out, with a minimum follow-up of 2 years. The differences between the pre- and postoperative measures were statistically analyzed using a two-tailed, paired t test.

Results

The six patients treated with “in situ” fusion showed no statistically significant change at the last follow-up relative to pelvic tilt (PT), sacral slope (SS), and grade, while the 10 patients treated with reduction showed significant changes: PT significantly decreased following surgery, while SS and grade significantly increased.

Conclusions

The analysis of the spino-pelvic sagittal balance allows to identify two types of HDDS: the balanced deformities, which do not need reduction, and the unbalanced deformities, in which correction is needed.

European Spine Journal: Electromyographic analysis of trunk-muscle activity during stable, unstable and unilateral bridging exercises in healthy individuals

Feldwieser; Sheeran; Meana-Esteban; Sparkes — 2012-05-01

Type: Original Paper
Background

Spinal pain can result in unilateral atrophy of spinal muscles. Understanding side-to-side muscle activity during exercises can help clinicians address these deficits. This study determined if variations of bridging exercises specifically activated side-to-side trunk-muscle activity.

Method

Using surface electromyography on 20 healthy subjects (16 females), age 25.45 (±3.57) years, height 166 (±0.8) cm, weight 63.35 (±12.70) kg, muscle activity of left and right lumbar multifidus, iliocostalis lumborum thoracis (ICLT), rectus abdominis (RA) and external oblique (EO) was recorded during eight bridging exercises with stable, unstable and unilateral (left-leg off the ground) conditions.

Results

There were significant side-to-side differences in abdominal-muscle activity during all unstable exercises (mean difference range from 3.10 %MVC for RA to 9.86 %MVC for EO), and during all unilateral exercises (mean difference range from 3.22 %MVC for RA to 9.41 %MVC for EO), with the exception of RA in exercise-7. For the back muscles, there were significant side-to-side differences for multifidus during all unilateral exercises (mean difference range 5.35 %MVC to 11.72 %MVC), with the exception of exercise-5. None of the bilateral exercises (stable or unstable) produced side-to-side differences for multifidus. For ICLT only exercise-3 produced significant side-to-side differences with a mean difference of 5.5 %MVC. In all cases where significant differences were noted, the left side of the muscles demonstrated the higher values.

Conclusion

The results suggest that specific exercises (unilateral/unstable) can target specific sides of trunk muscles.

European Spine Journal: Human mesenchymal stem cells and biomaterials interaction: a promising synergy to improve spine fusion

Barbanti Brodano; Mazzoni; Tognon; Griffoni; Manfrini — 2012-05-01

Type: Original Paper
Purpose

Spine fusion is the gold standard treatment in degenerative and traumatic spine diseases. The bone regenerative medicine needs (i) in vitro functionally active osteoblasts, and/or (ii) the in vivo induction of the tissue. The bone tissue engineering seems to be a very promising approach for the effectiveness of orthopedic surgical procedures, clinical applications are often hampered by the limited availability of bone allograft or substitutes. New biomaterials have been recently developed for the orthopedic applications. The main characteristics of these scaffolds are the ability to induce the bone tissue formation by generating an appropriate environment for (i) the cell growth and (ii) recruiting precursor bone cells for the proliferation and differentiation. A new prototype of biomaterials known as “bioceramics” may own these features. Bioceramics are bone substitutes mainly composed of calcium and phosphate complex salt derivatives.

Methods

In this study, the characteristics bioceramics bone substitutes have been tested with human mesenchymal stem cells obtained from the bone marrow of adult orthopedic patients.

Results

These cellular models can be employed to characterize in vitro the behavior of different biomaterials, which are used as bone void fillers or three-dimensional scaffolds.

Conclusions

Human mesenchymal stem cells in combination with biomaterials seem to be good alternative to the autologous or allogenic bone fusion in spine surgery. The cellular model used in our study is a useful tool for investigating cytocompatibility and biological features of HA-derived scaffolds.

European Spine Journal: Lumbar spinal stenosis treatment with aperius perclid interspinous system

Surace; Fagetti; Fozzato; Cherubino — 2012-05-01

Type: Original Paper
Purpose

The purpose of this study is to report clinical outcome and imaging changes of percutaneous Aperius stand-alone implant in patients with degenerative lumbar spinal stenosis and neurogenic intermittent claudication, which did not respond to conservative treatment.

Method

Between January 2008 and July 2010, 37 patients (20 males and 17 females) with mean age of 64.3 years underwent surgery for the onset of claudicatio spinalis with Aperius PercLID interspinous device (Medtronic). In all patients, the diagnosis was: foraminal stenosis, in one case (2.7 %) it was associated to a degenerative anterior listhesis (I grade), in three cases (8.1 %) it was associated to an intraforaminal disc herniation. The mean follow-up was of 18 months (range 2–35 months). The patients were evaluated through the Oswestry disability index, Zurich Claudication Questionnaire (ZCQ), VAS scales. In all cases were obtained preoperative and in postoperative radiographs and magnetic resonance imaging.

Results

The VAS score decreased significantly after surgery: the patients presented a mean VAS of seven preoperatively and two postoperatively (p < 0.001).

The ZCQ score significantly decreased postoperatively, with an average reduction of 21.89 % (p < 0.001).

The ODI score as well showed a significant reduction postoperatively of an average 26.09 % (p < 0.001).

Conclusion

Despite of the brief follow up, the preliminary results are encouraging, showing a significantly decrease of the disability parameters, a marked improvement of the function with the vanishing of the claudicatio spinalis and the following increase of the free interval during the walk. Aperius PercLID system seems to offer an alternative to the traditional decompression surgery.

European Spine Journal: How well do observed functional limitations explain the variance in Roland Morris scores in patients with chronic non-specific low back pain undergoing physiotherapy?

Caporaso; Pulkovski; Sprott; Mannion — 2012-05-01

Type: Original Paper
Purpose

Self-rated activity limitations in patients with non-specific chronic low back pain (cLBP) do not correlate well with performance in traditional tests of impairment (e.g. back strength, ROM, etc.). Tests using more “functional activities” have therefore been recommended as alternative “objective” outcome measures. We examined the relationship between a battery of such tests and self-reported activity limitations, before and in response to physiotherapy, and the influence of psychological factors on the relationship.

Methods

37 patients with cLBP took part (45 ± 12 years; 23 female, 14 male); 32 completed 9 weeks’ physiotherapy. Before and after therapy, the patients completed the Roland Morris (RM) disability questionnaire and questionnaires to assess fear avoidance beliefs, catastrophising and psychological disturbance. They also performed eight simple functional tests (stair climb, prolonged flexion, stand to floor, lift test, sock test, roll-up test, pick-up test, fingertip-to-floor test).

Results

Baseline RM scores were significantly (p < 0.05) correlated with all but one of the functional test scores (ranging from r = −0.34 (half-flexion) to 0.56 (pick-up test), and with a functional test index score for all tests together (r = 0.60, p < 0.0001). The correlation between the change-scores (after treatment) for RM and for the functional test index was 0.55 (p = 0.001). Psychological factors explained 7–23 % variance in RM scores (baseline, post-therapy, and change scores), beyond that which was explained by the functional tests. Effect sizes for patients with a self-rated “good global outcome” were 1.23 for RM and 0.75 for the functional test index; for those with a “poor outcome”, they were −0.08 and 0.23, respectively.

Conclusion

Moderately high correlations (for both absolute and change scores) were observed between the subjective and observed measures of activity limitation. This indicates that to some extent they are assessing the same underlying construct, but it also suggests that each is delivering a certain amount of unique information. Psychological factors explained some of the discrepancy between the two types of measure. Both were responsive to therapy, and their change scores reflected well the patients’ global outcome ratings. The two methods of assessing activity limitations should serve to complement one another in the assessment of treatment outcome.

European Spine Journal: Anterior thoracic foraminotomy through mini-thoracotomy for the treatment of giant thoracic disc herniations

Russo; Balamurali; Nowicki; Boszczyk — 2012-05-01

Type: Original Paper
Study design

A retrospective review of a case series.

Objectives

Giant thoracic disc herniations remain a surgical challenge and historically have been associated with significant complications. While neurological outcomes have improved with the abandonment of decompressive laminectomy, the attempt to minimize surgical complications and associated morbidities continues through less-invasive approaches. With the current study, we describe a surgical technique to treat giant thoracic disc herniations while minimizing approach-related morbidity.

Methods

Demographic and radiographic data; clinical outcome and perioperative complications were retrospectively analysed for patients with single-level giant thoracic disc herniations who underwent mini-thoracotomy and selective microsurgical anterior spinal cord decompression without instrumented fusion.

Results

Between 2007 and 2012, 7 consecutive patients with giant thoracic disc herniations were treated (average age of 53 years; range 45–66 years). The average canal encroachment was 73.2 % (range 40–92 %) with 5 grossly calcified discs of which 3 had transdural components. All patients had gradual myelopathic progression. The average Nurick grade was 3.5 (range 2–5). All patients were successfully treated with anterior microsurgical decompression without instrumentation. Uninstrumented fusion with rib graft was performed only in one patient with advanced degenerative changes. Average time of surgery was 337.8 min (range 220–450 min). The average length of hospital stay was 7.4 days (range 6–11 days). The average neurological status at follow-up (average 23.5 months; range 9–36 months) using the modified Nurick grading scale was 1.28. No vertebral collapse or loss of spinal alignment developed. There were no neurological complications. One patient developed an acute headache and diplopia, 10 days after surgery, following sneezing associated with a post-operative thoracic cerebrospinal fluid leakage requiring revision. Two patients suffered an approach-related complication in form of intercostal neuralgia; one was persistent.

Conclusions

Anterior decompression using a mini-transthoracic approach provides sufficient exposure for microsurgical decompression of giant thoracic disc herniations without disrupting the stability of the spine. Microsurgical decompression without instrumentation does not appear to lead to vertebral collapse or spinal malalignment.

European Spine Journal: Bridging the channel: the first British Isles supplement of the European Spine Journal

Boszczyk; Sell — 2012-05-01

Type: Editorial Notes
No abstract available.

European Spine Journal: Introducing the Society for Back Pain Research

McGregor; O’Dowd — 2012-05-01

Type: Editorial Notes
No abstract available.

European Spine Journal: Editorial: Spinal education, training and research in the UK

Wardlaw; Cole — 2012-05-01

Type: Editorial Notes
No abstract available.

European Spine Journal: Effectiveness of a bone substitute (CERAMENT™) as an alternative to PMMA in percutaneous vertebroplasty: 1-year follow-up on clinical outcome

Marcia; Boi; Dragani; Marini; Marras; Piras; Anselmetti; Masala — 2012-05-01

Type: Original Paper
Purpose

The aim of the study was to evaluate the efficacy of an injectable and partly absorbable calcium bone cement (CERAMENT™, Bone Support, Sweden) in the treatment of osteoporotic or traumatic vertebral fractures by percutaneous vertebroplasty.

Methods

From March 2009 to October 2010 an open, prospective study in two centres was performed. 33 patients with symptomatic vertebral fractures were enrolled. Patients were included based on evaluation by X-ray, CT, and MRI. Clinical evaluation by Visual Analogue Scale (VAS, 0–10) and Oswestry Disability index test (ODI, 0–100 %) was performed before the operation as well as 1, 6 and 12 months after the procedure. Radiology assessment post-procedure was carried out by X-ray, CT, and MRI at 1, 6 and 12 months post-op. Intake of analgesic medications pre- and post-procedure was monitored.

Results

66 vertebral bodies underwent percutaneous vertebroplasty. VAS score demonstrated a significant decrease from 8.61 (SD 19.8) pre-operatively to 2.48 (SD 2.36) at 1 month. The score was 2.76 (SD 2.68) at 6 months and 1.36 (SD 1.33) at the latest follow up. ODI score dropped significantly from 58.86 pre-op to 26.94 at 6 months and further down to 7.61 at 12 months. No re-fractures or adjacent level fractures were reported.

Conclusion

Data show that CERAMENT can be a substitute of PMMA in the treatment of osteoporotic and traumatic vertebral fractures, especially in young patients.

European Spine Journal: Bisphosphonate therapy in multiple myeloma in preventing vertebral collapses: preliminary report

Tamburrelli; Proietti; Scaramuzzo; Stefano; Logroscino — 2012-05-01

Type: Original Paper
Purpose

The aim of the study was to report and discuss the preliminary data obtained in a homogeneous series of 50 patients affected by multiple myeloma treated with bisphosphonates.

Methods

Patients were followed for a minimum of 1 year. Main orthopaedic data were recorded. Visual Analogue Score and QLQ-C30 and MY 20 were used to assess the quality of life.

Results

Statistical analysis showed less lytic lesions in the group with zoledronate therapy and stable primary disease compared with a greater number of lesions in the non-treated group. Results regarding VAS score and QLQ-C30 and MY were statistically better in the first group than in the second.

Conclusions

Our results confirm the efficacy of zoledronate in ensuring an acceptable quality of life restraining the aggressiveness of the myeloma on bone tissue, especially in spine although further prospective studies have to be conducted to determine its correct use in myeloma patients.

European Spine Journal: Abstracts for the Britspine Meeting, Newcastle 2–4 May 2012

2012-05-01

Type: Events
No abstract available.

European Spine Journal: Abstracts for Poster Presentations for EuroSpine 2012, May Amsterdam

2012-05-01

Type: Events
No abstract available.

European Spine Journal: Author Index Eurospine 2012

2012-05-01

Type: Events
No abstract available.

European Spine Journal: Abstracts for Oral Presentations for EuroSpine 2012, May Amsterdam

2012-05-01

Type: Events
No abstract available.

European Spine Journal: Announcements for 21-5-2012

2012-05-01

Type: Announcement
No abstract available.

European Spine Journal: Comparative evaluation of a novel measurement tool to assess lumbar spine posture and range of motion

Consmüller; Rohlmann; Weinland; Druschel; Duda; Taylor — 2012-04-29

Type: Original Paper
Purpose

The diagnosis of low back pain pathology is generally based upon invasive image-based assessment of structural pathology, but is limited in methods to evaluate function. The accurate and robust measurement of dynamic function may assist in the diagnosis and monitoring of therapy success. Epionics SPINE is an advanced strain-gauge measurement technology, based on the two sensor strips SpineDMS system, which allows the non-invasive assessment of lumbar and thoraco-lumbar motion for periods of up to 24 h. The aim of this study was to examine the reliability of Epionics SPINE and to collect and compare normative data for the characterisation of spinal motion in healthy subjects. Furthermore, the identification of parameters that influence lumbar range of motion (RoM) was targeted.

Methods

Spinal shape was measured using Epionics SPINE in 30 asymptomatic volunteers during upright standing, as well as maximum flexion and extension, to check intra-rater reliability. Furthermore, back shape was assessed throughout repeated maximum flexion and extension movements in 429 asymptomatic volunteers in order to collect normative data of the lordosis angle and RoM in different gender and age classes.

Results

The lordosis angle during standing in the healthy collective measured with Epionics SPINE was 32.4° ± 9.7°. Relative to this standing position, the average maximum flexion angle was 50.8° ± 10.9° and the average extension angle 25.0° ± 11.5°. Comparisons with X-ray and Spinal Mouse data demonstrated good agreement in static positions. Age played a larger role than gender in influencing lumbar posture and RoM.

Conclusions

The Epionics SPINE system allows the practical and reliable dynamic assessment of lumbar spine shape and RoM, and may therefore provide a clinical solution for the evaluation of lower back pain as well as therapy monitoring.

European Spine Journal: Comparing effects of kyphoplasty, vertebroplasty, and non-surgical management in a systematic review of randomized and non-randomized controlled studies

2012-04-29

Type: Original Paper
Purpose

To determine if differences in safety or efficacy exist between balloon kyphoplasty (BKP), vertebroplasty (VP) and non-surgical management (NSM) for the treatment of osteoporotic vertebral compression fractures (VCFs).

Methods

As of February 1, 2011, a PubMed search (key words: kyphoplasty, vertebroplasty) resulted in 1,587 articles out of which 27 met basic selection criteria (prospective multiple-arm studies with cohorts of ≥20 patients). This systematic review adheres to preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines.

Results

Pain reduction in both BKP (−5.07/10 points, P < 0.01) and VP (−4.55/10, P < 0.01) was superior to that for NSM (−2.17/10), while no difference was found between BKP/VP (P = 0.35). Subsequent fractures occurred more frequently in the NSM group (22 %) compared with VP (11 %, P = 0.04) and BKP (11 %, P = 0.01). BKP resulted in greater kyphosis reduction than VP (4.8º vs. 1.7°, P < 0.01). Quality of life (QOL) improvement showed superiority of BKP over VP (P = 0.04), along with a trend for disability improvement (P = 0.08). Cement extravasation was less frequent in the BKP (P = 0.01). Surgical intervention within the first 7 weeks yielded greater pain reduction than VCFs treated later.

Conclusions

BKP/VP provided greater pain relief and fewer subsequent fractures than NSM in osteoporotic VCFs. BKP is marginally favored over VP in disability improvement, and significantly favored in QOL improvement. BKP had a lower risk of cement extravasation and resulted in greater kyphosis correction. Despite this analysis being restricted to Level I and II studies, significant heterogeneity suggests that the current literature is delivering inconsistent messages and further trials are needed to delineate confounding variables.

European Spine Journal: Resistive straight leg raise test, resistive forward bend test and heel compression test: novel techniques in identifying secondary gain motives in low back pain cases

Kumar; Wijerathne; Lim; Barry; Nath; Liang — 2012-04-29

Type: Original Paper
Purpose

‘Low back pain’ (LBP) is a prevalent condition with a majority showing no specific organic pathology. Distinguishing ‘secondary gain motives (SGM)’ from organic causes is imperative in clinical practice. We describe here, three new tests—resistive straight leg raise test (rSLRT), resistive forward bend test (rFBT) and heel compression test (HCT) to help differentiate patients with ‘SGM’ from those without. We conducted a prospective study to validate the above tests in predicting non-organic causes as a reason for LBP.

Methods

200 patients presenting with low back pain at the senior author’s outpatient orthopaedic clinic from Jan 2009 to Nov 2010 were studied. Patients were separated into two groups—‘SGM group’ (n = 100) and ‘non-SGM group’ (n = 100). ‘SGM group’ patients had a history of work-related accidents, road traffic accidents or assault, with a background of ongoing litigation issues or compensation benefits. rSLRT, rFBT, HCT, Schober’s test and Waddell’s five signs were performed on them. Statistical analysis was done to identify correlations between test results, MRI findings and ‘SGM’ status.

Results

Statistically significant differences were observed between the SGM and non-SGM group (p < 0.0005) for all tests studied. In predicting SGM status, rSLRT showed highest specificity (0.94) and highest positive predictive value (0.925) while HCT showed the highest negative predictive value (0.859). Positive rSLRT was found to be strongly correlated with ≥3 positive Waddell’s signs. SGM patients with positive rSLRT tended to show resistance ≤45°.

Conclusions

rSLRT, rFBT and HCT (NK triad) are highly practical tests which strongly predict SGM status in patients.

European Spine Journal: Expert’s comment concerning Grand Rounds case entitled “Management of cervical myelopathy due to ossification of posterior longitudinal ligament in a patient with Alström syndrome” (by Bronek M. Boszczyk, Rishi Mugesh Kanna and Daniela Gradil)

Yuan — 2012-04-28

Type: Original Paper
No abstract available.

European Spine Journal: Schmorl’s nodes

Kyere; Than; Wang; Rahman; Valdivia–Valdivia; La Marca; Park — 2012-04-28

Type: Original Paper
Introduction

First described in 1927, a Schmorl’s node (SN) is the herniation of nucleus pulposus (NP) through the cartilaginous and bony end plate into the body of the adjacent vertebra. SNs are common findings on imaging, and although most SNs are asymptomatic, some have been shown to become painful lesions. In this manuscript, we review the literature regarding the epidemiology, clinical presentation, pathogenesis, imaging, and management of SNs.

Materials and methods

Using databases from the US National Library of Medicine and the National Institutes of Health, relevant articles were identified.

Results

While several theories regarding the pathogenesis of SNs have been proposed, an axial load model appears to have the greatest supporting evidence. Symptomatic SNs are thought to be due to the inflammatory response solicited by the herniation of NP into the well-vascularized vertebral body. Management options for symptomatic SNs vary, ranging from medical management to surgical fusion.

Conclusion

SNs are common lesions that are often asymptomatic. In certain cases, SNs can cause back pain. No consensus on pathogenesis exists. There is no established treatment modality for symptomatic SNs.

European Spine Journal: Loading rate patterns in scoliotic children during gait: the impact of the schoolbag carriage and the importance of its position

Gelalis; Ristanis; Nikolopoulos; Politis; Rigas; Xenakis — 2012-04-28

Type: Original Paper
Purpose

Concerns have been raised regarding the effects of schoolbag carriage on adolescent schoolchildren and particularly those with a pre-existing spinal deformity. The purpose of this study was to determine the effect of school backpack loads in scoliotic and healthy school-age children during walking, in terms of peak vertical ground reaction forces and loading rates. We hypothesized that walking with a loaded backpack would have a greater effect on gait kinetics of scoliotic compared to healthy.

Methods

Eight children with idiopathic scoliosis and eight healthy children were assessed. Kinetic data were collected using two AMTI OR6-7 force-plates, while the subjects walked freely along a 6-m walkway under three walking conditions: (1) without a schoolbag, (2) carrying a schoolbag bilaterally (over both shoulders—symmetrical load) and (3) carrying a schoolbag unilaterally (over each shoulder—asymmetrical load). Kinetic data were collected and four parameters were calculated; peak ground reaction force at the first maximum force peak (F1), time needed to reach F1 (T1), loading rate of F1 (LRF1) and total contact time (T2).

Results

We found no significant differences between the scoliotic and healthy children for any of the kinetic variables examined. In addition, the position of the bag did not seem to have any effect on loading rate.

Conclusions

The results of this study indicate that in terms of kinetic parameters during normal gait, the schoolbag load (symmetrical or asymmetrical) does not have a different effect on children with mild adolescent idiopathic scoliosis compared to normal controls.

European Spine Journal: Long fusions to the sacrum in elderly patients with spinal deformity

Crawford; Carreon; Bridwell; Glassman — 2012-04-27

Type: Original Paper
Purpose

Long spinal deformity fusions in elderly patients continue to be controversial. However, there is a growing population of elderly patients with spinal deformities that may be optimally treated by reconstructive surgery requiring a long fusion to the sacrum. This study evaluated clinical outcomes in elderly (>65) adult deformity patients who underwent posterior instrumented reconstruction consisting of fusion from the thoracic spine to the sacrum with iliac fixation.

Methods

Patients in a prospective database for adult spinal deformity who had a posterior reconstruction with an instrumented fusion from the thoracic spine to the sacrum that included iliac fixation with minimum 2-year follow-up were identified. Two cohorts were compared: patients 65 years and older and patients 55 years and younger. Student’s t test for independent groups was used to determine any significant differences between continuous variables. Chi-square was used to compare categorical demographic variables between the two groups.

Results

The 65 and older group consisted of 15 patients with an average age of 71 years (range 65–78 years). The 55 and younger group consisted of 25 patients with an average age of 45 years (range 30–55 years). The older group had a worse mean co-morbidity score (4.6 vs. 2.1). Baseline SRS scores were similar between groups. Baseline SF-12 data showed worse PCS (22.1 vs. 32.0, p = 0.009) yet better MCS (63.6 vs. 48.4, p < 0.0001) in the older group. Although major curve magnitude was similar (47.1° vs. 42.6°), the older group had more positive sagittal imbalance at baseline (115.7 vs. 54.2 mm, p = 0.02). Number of levels fused, operative time, blood loss, and incidence of complications were similar between groups. Two-year improvements in SRS subscores, SF-12 PCS, and MCS were not significantly different between groups.

Conclusions

Properly selected patients 65 years of age and older who have substantial sagittal imbalance, a considerable disease burden, and a lesser degree of mental distress can obtain as much clinical benefit as their younger counterparts (≤55 years of age) 2 years following spinal deformity surgery that requires fusion from the thoracic spine to the sacrum with segmental instrumentation and iliac fixation.

European Spine Journal: Pulmonary function after anterior double thoracotomy approach versus posterior surgery with costectomies in idiopathic thoracic scoliosis

Bullmann; Schulte; Schmidt; Gosheger; Osada; Liljenqvist — 2012-04-26

Type: Original Paper
Introduction

The surgical approach in the treatment of idiopathic thoracic scoliosis depends on the type of curve involved. In anterior correction, the rib hump is corrected by derotating the thoracic spine. In posterior scoliosis surgery, additional rib hump resection is sometimes necessary to achieve an optimal cosmetic result. The aim of this study was to compare pulmonary function in these two patient groups.

Materials and methods

Forty patients in the anterior group (A) were treated with standard double thoracotomy, with an anterior derotation spondylodesis and a primary stable dual-rod system. The posterior group (P) included 29 patients who were treated with a pedicle screw-based posterior instrumentation spondylodesis, with additional rib hump resection. Pulmonary function was evaluated preoperatively, on the 12th postoperative day, and at 3, 6, 12 and 24 months during the follow-up.

Results

The patients’ mean age was 15 years in group A and 19 in group P with a standard deviation 8.7 years and a significant difference. With regard to body height or weight there were no significant differences between the two groups. In group A, the deterioration in pulmonary function immediately after the operation (from $$ V_{{{\text{c}}_{\max } }} /{\text{FEV}}_{1} $$ 75.3 %/71.3 % preoperatively to 38.5 %/36.1 % postoperatively) was clearer than in group P ($$ V_{{{\text{c}}_{\max } }} /{\text{FEV}}_{ 1} $$ 71.6 %/65.7 % preoperatively to 47.7 %/48.4 % postoperatively). During a follow-up period of 3 months, the values improved in both groups in comparison with the values immediately after the operation. Up to the 2 year follow-up, pulmonary function in the posterior and anterior groups corresponded to the preoperative values, with no significant differences. There was a trend toward moderately increased values in the posterior group and moderately decreased values in the anterior group at the 2-year follow-up examination, in comparison with the preoperative baseline, but without a statistically significant difference. Two major complications occurred in the anterior group, with reintubation and several bronchoscopy examinations due to atelectasis.

Conclusion

The severe deterioration in group A is caused by the substantial trauma with double thoracotomy in contrast to rib hump resection. For patients with severe restrictive pulmonary distress, posterior instrumentation in combination with rib hump resection would be preferable to an anterior procedure involving double thoracotomy. Respiratory physiotherapy exercise should be administered in order to minimise postoperative pulmonary distress. In conclusion opening of the chest wall leads to deterioration of pulmonary function with improvement to the preoperative values after 6 months in the posterior and after 24 months in the anterior group.

European Spine Journal: Temporary occipito-cervical stabilization of a unilateral occipital condyle fracture

Schnake; Pingel; Scholz; Kandziora — 2012-04-25

Type: Original Paper
Introduction

Injuries of the occipital condyles are rare. While the majority of occipital condyle fractures can be treated conservatively, surgery is recommended in craniocervical misalignment and instability. Open reduction and temporary occipito-cervical stabilization might be an alternative to fusion or halo treatment.

Materials and methods

This Grand Round case presentation describes temporary C0–C3 stabilization in a 29-year-old man who was involved in a car accident. Radiological examination revealed a rotational burst fracture (type AO C3.1) of C7, and a slight displaced right occipital condyle fracture (Anderson/Montesano type III) with rotational misalignment of the C0–C2 complex.

Results

The C7 fracture was stabilized and fused from anterior and posterior. The occipital condyle fracture was reduced and temporarily stabilized from C0–C3 from posterior. Bony healing occurred after 6 months and consequently the internal fixator was removed to preserve upper cervical mobility.

European Spine Journal: Injection of a polymerized hyaluronic acid/collagen hydrogel matrix in an in vivo porcine disc degeneration model

Omlor; Nerlich; Lorenz; Bruckner; Richter; Pfeiffer; Gühring — 2012-04-25

Type: Original Paper
Introduction

Disc degeneration and re-herniation after nucleotomy procedures are common problems. Simultaneous application of hyaluronic acid (HA)-based matrix has been proposed to limit disc degeneration. This, however, is hampered by loss of the substituted matrix out of the disc. Hence, in situ polymerization of the injected matrix with ultraviolet light (UVL) directly used after injection may be useful. Therefore, this study evaluates a new HA/collagen hydrogel matrix with in situ polymerization after implantation in an established porcine nucleotomy model.

Materials and methods

12 mature minipigs were used. A total of 60 lumbar discs were analyzed. 36 discs underwent partial nucleotomy with a 16G biopsy needle. Of those, 24 discs received matrix (porcine nucleus pulposus collagenous scaffold component and chemically modified HA) which was in situ polymerized using UVL immediately after transplantation. 12 nucleotomized discs and 24 non-nucleotomized discs served as controls. After 24 weeks, animals were killed. X-rays, MRIs, histology, and gene expression analysis were done.

Results

Disc height was reduced equally after sole nucleotomy and nucleotomy with HA treatment and in MRIs signal intensity decreased. For both nucleotomy groups, the nucleus histo-degeneration score showed a significant increase compared to controls. In histology, HA treatment resulted in more scarring and inflammation in the annulus. Gene expression of catabolic MMPs was up-regulated, whereas IFN-gamma, IL-6, and IL-1b were unchanged.

Conclusion

Although nucleotomy and administration of the implant material did not cause generalized inflammation of the disc, localized annular damage with annulus inflammation and scarring resulted in detrimental degenerative disc changes. As a result, therapeutic strategies should strongly focus on the prevention of annular damage or techniques for annular repair to remain disc integrity.

European Spine Journal: Isolated atypical spinal tuberculosis mistaken for neoplasia: case report and literature review

Yu; Wang; Du; Yuan; Ni; Chen — 2012-04-25

Type: Original Paper
Introduction

We report a case of isolated intra-spinal tuberculosis in a 45 year-old woman. The uncommon findings in MRI were more suggestive of tumor lesion.

Materials and methods

After 3 month history of low back pain and 2 weeks radiated pain of right lower extremity, an operation was performed and the total intra-spinal mass was resected. Histological examination revealed a granulomatous necrosis with caseum. Symptoms were greatly improved postoperatively and then the patient was treated with four anti-tuberculosis drugs.

Conclusion

This case indicated the complexity of differentiating atypical spinal tuberculosis from disease which could cause spinal cord and cauda equina compression.

European Spine Journal: Lack of uniform diagnostic criteria for cervical radiculopathy in conservative intervention studies: a systematic review

Thoomes; Scholten-Peeters; Boer; Olsthoorn; Verkerk; Lin; Verhagen — 2012-04-25

Type: Review Paper
Purpose

Cervical radiculopathy (CR) is a common diagnosis. It is unclear if intervention studies use uniform definitions and criteria for patient selection. Our objective was to assess the uniformity of diagnostic criteria and definitions used in intervention studies to select patients with CR.

Methods

We electronically searched the Cochrane Controlled Trials Register, MEDLINE, EMBASE and CINAHL. Studies were included when evaluating conservative interventions in randomised clinical trials (RCTs) in patients with CR. Selection criteria and definitions for patients with CR were extracted and evaluated on their uniformity.

Results

Thirteen RCTs were included. Pain was used as an inclusion criterion in 11 studies. Inclusion based on the duration and location of pain varied between studies. Five studies used sensory symptoms in the arm as inclusion criterion. Four studies used cervical range of motion and motor disturbances as inclusion criteria, while reflex changes were used in two studies. Three studies included patients with a positive Spurling’s test and two studies used it within a cluster of provocation tests.

Conclusions

Criteria used to select patients with CR vary widely between different intervention studies. Selection criteria and test methods used are poorly described. There is consensus on the presence of pain, but not on the exact location of pain.

European Spine Journal: Spontaneous lumbar curve correction in selective anterior instrumentation and fusion of idiopathic thoracic scoliosis of Lenke type C

Liljenqvist; Halm; Bullmann — 2012-04-25

Type: Original Paper
Background

Posterior pedicle screw instrumented correction and fusion have become the gold standard in the surgical treatment of thoracic scoliosis. However, in thoracic Lenke type C curves selective posterior fusion of the thoracic curve may lead to spinal imbalance. The aim of the study was to analyse the radiological results of selective anterior thoracic fusion using a standard open dual rod technique with special respect to spontaneous lumbar curve correction (SLCC).

Methods

Twenty-eight patients (26 patients with Lenke 1C and 2 patients with Lenke 2C curves) with an average age of 15 years were surgically treated with an anterior dual rod system through a standard open double thoracotomy approach. Average clinical and radiological follow-up was 4 years (24–84 months).

Results

Fusion was carried out mostly from end-to-end vertebra. The primary curve was corrected from 61.6° (average correction on reverse bending films 42.9 %) to 27.1° (56.0 % correction) with an average loss of correction of 2.2°. The secondary lumbar curve measured 47.7° preoperatively (40–56°, average correction on reverse bending films 66.2 %) and corrected spontaneously to 30.1° (36 % SLCC) and remained stable without any cases of deterioration or decompensation during follow-up. Lumbar apical vertebral translation increased minimally by an average of 4 mm directly, postoperatively, and returned to an average of preoperative values during follow-up. All but two curves remained as type C lumbar modifier at follow-up. Preoperatively, three patients showed a marked coronal imbalance of more than 3 cm (all left, average 4.0 cm); at follow-up, two patients were still out of balance by more than 3 cm (all to the left, average 3.4 cm). Preoperatively, a marked shoulder imbalance of more than 1.0 cm was found in 11 patients; this was corrected in all patients to <1.0 cm at follow-up. The apical vertebral rotation measured according to Perdriolle was corrected from 23.5° to 15.0° in the thoracic spine (36.2 % correction) with an average clinical reduction of the rib hump of 63.2 %. In the lumbar spine, there was no relevant radiological derotation; however, clinically, the lumbar hump corrected spontaneously by 44.3 %. Thoracic kyphosis measured 28.5° preoperatively and 32.3° at follow-up. All six patients with a preoperative hypokyphosis (<20°) of an average of 9.5° were successfully corrected to an average thoracic kyphosis of 23.8° at follow-up. There were no cases of junctional thoracolumbar kyphosis. There were neither reoperations nor implant failures with pseudarthrosis.

Conclusion

Selective anterior correction and fusion in primary thoracic curves with lumbar modifier type Lenke C resulted in a reliable and satisfactory SLCC. Advantages of anterior versus posterior techniques are the true segmental derotation with excellent rib hump correction and a superior restoration of thoracic kyphosis.

European Spine Journal: Pedicle screw instrumentation and spinal deformities: have we gone too far?

McCormick; Aebi; Toby; Arlet — 2012-04-25

Type: Original Paper
Introduction

Placement of pedicle screws within the thoracic and lumbar spine has become the “state of the art” for the treatment of spinal deformities. Newly trained surgeons are often trained only with the placement of pedicle screws within the thoracic and lumbar spine and not with hooks or other means of fixation. However, if the benefits of pedicle screw instrumentation in terms of correction ability cannot be questioned on some issues pertaining to their safety, their rationale for all situations as well as their long-term adverse consequence and or early or late complications start to arise.

Materials and methods

We therefore present four case examples that illustrate the advantages, questions and complications inherent to pedicle screw instrumentation in spinal deformities. These four cases serve as discussion supported by a review of the literature. The literature search was performed to include pedicle screws associated risks, costs and complications. Articles focusing on instrumentation of the thoracic and lumbar spine for the treatment of adult and pediatric scoliosis were reviewed.

Results

Pedicle screw instrumentation in the treatment of spinal deformity is here to stay, however a fair number of issues have come up since their widespread use that started 10 years ago: these include their misplacement with the inherent risks to the vascular or neurologic structures, the rate of misplaced pedicle screw not per number of screws inserted, but per patient operated, the number of screws really necessary to achieve a satisfactory outcome while maintaining costs, their contraindications in some very challenging deformities where the risks clearly outweigh their advantage compared to hooks. At last, the use of pedicle screw instrumentation has driven many centers in increasing the safety of such procedures using intraoperative spinal cord monitoring as well as improved imaging technologies.

Conclusion

To answer our provocative title “Pedicle screw instrumentation have we gone too far?” Definitively we can answer that for some spinal deformities instrumented with all-pedicle-screw instrumentation, we have observed cases where the surgeons have gone way too far; in other cases, where such instrumentation was used in a comprehensive and rational manner, the answer to “Have we gone too far” is no, and such use of pedicle screw has improved outcome with minimum complications.

European Spine Journal: Kinematic evaluation of one- and two-level Maverick lumbar total disc replacement caudal to a long thoracolumbar spinal fusion

Zhu; Itshayek; Jones; Schwab; Larson; Lenke; Cripton — 2012-04-25

Type: Original Paper
Purpose

Adjacent level degeneration that occurs above and/or below long fusion constructs is a documented clinical problem that is widely believed to be associated with the considerable change in stiffness caused by the fusion. Some researchers have suggested that early degeneration at spinal joints adjacent to a fusion could be treated by implanting total disc replacements at these levels. It is thought that further degeneration could be prevented through the disc replacement’s design aims to reproduce normal disc heights, kinematics and tissue loading. For this reason, there is a clinical need to evaluate if a total disc replacement can maintain both the quantity of motion (i.e. range) and the quality of motion (i.e. center of rotation and coupling) at segments adjacent to a long spinal fusion. The purpose of this study was to experimentally evaluate range of motion (ROM—the intervertebral motion measured) and helical axis of motion (HAM) changes due to one- and two-level Maverick total disc replacement (TDR) adjacent to a long spinal fusion.

Methods

Seven spine specimens (T8–S1) were used in this study (66 ± 19 years old, 3F/4 M). A continuous pure moment of ±5.0 Nm was applied to the specimen in flexion–extension (FE), lateral bending (LB) and axial rotation (AR), with a compressive follower preload of 400 N. The 5.0 Nm data were analyzed to evaluate the operated segment biomechanics at the level of the disc replacements. The data were also analyzed at lower moments using a modified version of Panjabi’s proposed “hybrid” method to evaluate adjacent segment kinematics (intervertebral motion at the segments adjacent to the fusion) under identical overall (T8–S1) specimen rotations. The motion of each vertebra was monitored with an optoelectronic camera system. The biomechanical test was completed for (1) the intact condition and repeated after each surgical technique was applied to the specimen, (2) capsulotomy at L4–L5 and L5–S1, (3) T8–L4 fusion and capsulotomy at L4–L5 and L5–S1, (4) Maverick at L4–L5, and (5) Maverick at L5–S1. The capsulotomy was performed to allow measurement of facet joint loads in a companion study. Paired t tests were used to determine if differences in the kinematic parameters measured were significant. Holm–Sidak corrections for multiple comparisons were applied where appropriate.

Results

Under the 5.0 Nm loads, L4–L5 ROMs tended to decrease in all directions following L4–L5 Maverick replacement (mean = 22 %, compared to the fused condition). Two-level Maverick implantation also tended to reduce L4–S1 ROM (mean 18, 7 and 31 % in FE, LB and AR, respectively, compared to the fused condition without TDR). Following TDR replacement, the HAM location tended to shift posteriorly in FE (at L5–S1), anteriorly in AR, and inferiorly in LB. However, although the above-mentioned trends were observed, neither one- nor two-level TDR replacement showed statistically significant ROM or HAM change in any of the three directions. At the identical T8–S1 posture identified by the modified hybrid analysis, the L4–L5 and L5–S1 levels underwent significant larger motions, relative to the overall specimen rotation, after fusion. In the hybrid analysis, there were no significant differences between the ROM after fusion with intact natural discs at L4–L5 and L5–S1 and the motions at those levels with one or two TDRs implanted.

Conclusions

The present results demonstrated that one or two Maverick discs implanted subjacent to a long thoracolumbar fusion preserved considerable and intact-like ranges of motion and maintained motion patterns similar to the intact specimen, in this ex vivo study with applied pure moments and compressive follower preload. The hybrid analysis demonstrated that, after fusion, the TDR-implanted levels are required to undergo large rotations, relative to those necessary before fusion, in order to achieve the same motion between T8 and S1. Additional clinical and biomechanical research is necessary to determine if such a kinematic demand would be made on these levels clinically and the biomechanical performance of these implants if it were.

European Spine Journal: Is the development of Modic changes associated with clinical symptoms? A 14-month cohort study with MRI

Jensen; Leboeuf-Yde; Wedderkopp; Sorensen; Jensen; Manniche — 2012-04-24

Type: Original Paper
Purpose

Modic changes (MCs) have been suggested to be a diagnostic subgroup of low back pain (LBP). However, the clinical implications of MCs remain unclear. For this reason, the aims of this study were to investigate how MCs developed over a 14-month period and if changes in the size and/or the pathological type of MCs were associated with changes in clinical symptoms in a cohort of patients with persistent LBP and MCs.

Methods

Information on LBP intensity and detailed information from MRI on the presence, type and size of MCs was collected at baseline and follow-up. Changes in type (Type I, II, III and mixed types) and size of MCs were quantified at both time points according to a standardised evaluation protocol. The associations between change in type, change in size and change in LBP intensity were calculated using odds ratios (ORs).

Results

Approximately 40 % of the MCs followed the expected developmental path from Type I (here Type I or I/II) to Type II (here Type II or II/III) or Type I to Type I/II. In general, the bigger the size of the MC at baseline, the more likely it was that it remained unchanged in size after 14 months. Patients who had MC Type I at both baseline and 14-month follow-up were less likely to experience an improvement in their LBP intensity as compared to patients who did not have Type I changes at both time points (OR 7.2, CI 1.3–37). There was no association between change in size of MCs Type I and change in LBP intensity.

Conclusions

The presence of MCs Type I at both baseline and follow-up is associated with a poor outcome in patients with persistent LBP and MCs.

European Spine Journal: Currarino’s triad diagnosed in an adult woman

Berghauser Pont; Dirven; Dammers — 2012-04-24

Type: Report
Purpose

To report on a female patient diagnosed with Currarino’s triad in adulthood.

Case report

This case presents an adult patient with a medical history of a congenital anal atresia, a partial sacral agenesis, and a surgically treated ectopic anus. After a coincidentally observed presacral mass by MRI, due to unexplained constipation later in adulthood, Currarino’s triad was suspected in this patient. This triad consists of anorectal malformation(s), sacrococcygeal defects and a presacral mass of various origin. Further investigation confirmed the mass to be a meningocele, and showed a tethered cord and a syrinx.

Conclusions

In (young) patients with anorectal malformations, although having no other symptoms, further examination might be required to exclude Currarino’s triad. Importance of early diagnosis and multidisciplinary assessment is recommended to establish adequate treatment if needed.

European Spine Journal: Lumbar instrumented posterolateral fusion in spondylolisthetic and failed back patients: a long-term follow-up study spanning 11–13 years

Turunen; Nyyssönen; Miettinen; Airaksinen; Aalto; Hakumäki; Kröger — 2012-04-24

Type: Original Paper
Introduction and materials

We examined lumbar transpedicular instrumented posterolateral fusion patients operated on between 1992 and 1997 presenting: degenerative spondylolisthesis with spinal stenosis; adult isthmic spondylolisthesis; failed back syndrome after one to five discectomies; and failed back syndrome after one to three laminectomy operations (Groups 1–4, respectively).

Methods

They were examined by an independent orthopedic surgeon, completed the Oswestry Disability Index (ODI) and visual analog scale (VAS) questionnaires and their outcome was evaluated.

Results

The overall patient satisfaction at follow-up (mean 11.7 years) was 82.1 %. The reoperation rate was 15.1 % (7.5 % due to adjacent segment disease).

Conclusion

Group 1 showed the greatest improvements in ODI and VAS values, Group 2 the lowest and Group 3 the highest preoperative values, and Group 4 the second highest improvements. Patient satisfaction scores were 90.3, 69.7, 63.6 and 80.0 %, respectively, and unplanned reoperation rates were 6.5, 9.1, 31.8 and 20.0 %. Thus, long-term outcomes of lumbar instrumented posterolateral fusion (rarely previously studied) were satisfactory for >80 % of patients, but varied among groups.

European Spine Journal: Posterior lumbar spinal fusion and instrumentation in morbidly obese patients using the Synframe retractor system: technical note

Vaidya; Sethi; Lee; Bartol; Onwudiwe; Aebi — 2012-04-24

Type: Original Paper
Purpose

Lumbar spine surgery in morbidly obese patients is a challenge to the operating surgeon. The aim of the study was to evaluate the surgical experience in this group of patients using the Synframe retractor system (Synthes, Paoli, PA, USA) as a tool for improved surgical access.

Methods

An Institutional Review Board approved retrospective study was conducted on 43 morbidly obese patients undergoing posterior lumbar decompression instrumentation and fusion. Patient selection was based on a BMI of >40. Information acquired included BMI, set up time, procedure time, ASA, intraoperative blood loss and the number of preoperative co-morbidities of each patient. Postoperative complications, length of stay, and pre-operative and postoperative Oswestry disability index (ODI) and visual analogue scale (VAS) were recorded at each postoperative visit. They were compared to 45 age matched controls from our spine database.

Results

The average set-up time (73.5 min), amount of blood loss (average 1,040 mL), length of incision (10.3–14.5 cm) and length of hospital stay (5.4 days) were recorded. The average surgical time was dependent on the procedure and number of levels fused and ranged from 164 to 245 min. These parameters were compared with normal weight patients and noted to be higher.

Conclusion

The surgical experience determined that the Synframe retractor system provided a stable and well-illuminated operative field. It minimized the number of personnel required for assistance and improved surgical access. As may be expected, all the above recorded parameters were greater in the morbidly obese group.

European Spine Journal: Etanercept treatment enhances clinical and neuroelectrophysiological recovery in partial spinal cord injury

Bayrakli; Balaban; Ozum; Duger; Topaktas; Kars — 2012-04-21

Type: Original Paper
Purpose

To investigate the effect of an anti-TNF-α agent (etanercept) on recovery processes in a partial spinal cord injury (SCI) model using clinical and electrophysiological tests.

Methods

Twenty-four New Zealand rabbits were divided into three groups: group 1 [SCI + 2 ml saline intramuscular (i.m.), n = 8], group 2 (SCI + 2.5 mg/kg etanercept, i.m., 2–4 h after SCI, n = 8) and group 3 (SCI + 2.5 mg/kg etanercept, i.m., 12–24 h after SCI, n = 8). Rabbits were evaluated before SCI, immediately after SCI, 1 week after, and 2 weeks after SCI, clinically by Tarlov scale and electrophysiologically by SEP.

Results

Tarlov scores of groups 2 and 3 were significantly better than group 1, 2 weeks after SCI. SEP recovery was significantly better in groups 2 and 3 than group 1, 2 weeks after SCI.

Conclusions

These results show that blocking TNF-α mediated inflammation pathway by an anti-TNF-α agent enhances clinical and electrophysiological recovery processes in partial SCI model.

European Spine Journal: Comparison of the aorta impingement risks between thoracolumbar/lumbar curves with different convexities in adolescent idiopathic scoliosis: a computed tomography study

Qiao; Zhu; Xu; Zhu; Qian; Liu; Qiu — 2012-04-20

Type: Original Paper
Purpose

To compare the positions of the aorta relative to vertebral bodies and the potential risk of the aorta impingement for pedicle screw (PS) placement between right-sided and left-sided thoracolumbar/lumbar curves of adolescent idiopathic scoliosis (AIS).

Methods

Thirty-nine AIS patients with a main thoracolumbar or lumbar curve were recruited. The Lenke’s classification was type 5C in all patients. According to the convexity of the thoracolumbar or lumbar curves, the patients were divided into either group R or Group L. The patients in Group R had a main right-sided thoracolumbar/lumbar curve, and the patients in Group L had a main left-sided thoracolumbar/lumbar curve. Axial CT images from T12 to L4 at the midvertebral body level were obtained to evaluate Aorta-vertebra angle (α), Vertebral rotation angle (β), Lefty safety distance (LSD), and Right safety distance (RSD). The risks of the aorta impingement from T12 to L4 were calculated and then compared between the two groups.

Results

The α increased from T12 through L4 in Group R, increased from T12 through L1, and then decreased from L1 through L4 in Group L. The β decreased from T12 through L4 in both groups. The LSD constantly increased from T12 through L4 in Group R, increased from T12 through L3, and then decreased from L3 through L4 in Group L. The RSD increased from T12 through L3 and then decreased from L3 through L4 in both groups. With the increment of the lengths of the simulated screws, the aorta impingement risks were constantly elevated at all levels in both groups. The aorta was at a high risk of impingement from left PS regardless of the diameters of the simulated screws in Group R (80–100 % at T12 and 53.3–100 % at L1). In Group L, the aorta was completely safe when using 35 mm (0 at all levels) PS and at high risks of the aorta impingement on the right side from 45 mm PSs (31.8–72.7 %). In all, the risks of the aorta impingement were mainly from left PS in Group R and from right PS in Group L, and the risk of the aorta impingement from PS placement was generally higher in right thoracolumbar or lumbar curves when compared with that of the left.

Conclusions

The present study illustrated different changed positions of the aorta relative to vertebrae between thoracolumbar/lumbar curves with different convexities. In right-sided curve, the risks of the aorta impingement were mainly from left PS while in left-sided curves, from right PS. The aorta was more proximal to entry points in right-sided lumbar curve when compared with left-sided curve; thus placing PS carries more risks in right-sided thoracolumbar/lumbar curve. Surgeons should be more cautious when placing PSs on the concave sides of T12 and L1 vertebrae of right-sided thoracolumbar/lumbar curves.

European Spine Journal: Quantitative MRI analysis of the surface area, signal intensity and MRI index of the central bright area for the evaluation of early adjacent disc degeneration after lumbar fusion

Fan; Zhou; Hu; Fang; Zhao; Zhang — 2012-04-20

Type: Original Paper
Purpose

The aim of this study was to evaluate early ASD at short-term follow-up in fused and unoperated patients with degenerative disc disease, using quantitative magnetic resonance imaging (MRI) analysis of the area, signal intensity and their product, i.e., MRI index of the central bright area of the disc as well as measures of intervertebral disc height and Pfirrmann grading scale. The further purpose was to determine whether fusion accelerates ASD compared with non-surgical treatment in short-term follow-up.

Methods

One hundred and eight chronic low back patients diagnosed as L4/L5 degeneration undertook either one-level instrumented posterior lumbar interbody fusion or conservative treatment. They were followed up for about 1 year. Finally 46 fused and 45 conservatively treated patients with MRI follow-up were included. Pre- and post-treatment MRIs were compared to determine the progression of disc degeneration at the two cranial adjacent segments.

Results

The area, signal intensity and MRI index of the central bright area of the adjacent discs decreased in the operated and unoperated groups from pre-treatment to follow-up, except for an insignificant decrease of signal intensity at the second adjacent segment in the unoperated group. The changes in these parameters were statistically greater at the first than the second adjacent segment in the fused group, but not in the unoperated group. And the changes in the fused group were more pronounced than those at both neighbouring levels in the unoperated group. However, the Pfirrmann grading scale and intervertebral disc height did not detect any changes at adjacent discs in either group.

Conclusions

Decrease in the parameters of quantitative MRI analysis indicated early degeneration at discs adjacent to lumbar spinal fusion. Fusion had an independent effect on the natural history of ASD during short-term follow-up. Continued longitudinal follow-up is required to determine whether these MRI changes lead to pathologic changes.

European Spine Journal: Ethnic differences in pedicle and bony spinal canal dimensions calculated from computed tomography of the cervical spine: a review of the English-language literature

Chazono; Tanaka; Kumagae; Sai; Marumo — 2012-04-19

Type: Original Paper
Purpose

The aims of this study were to review published data on pedicle dimensions and bony spinal canal diameters calculated from CT examinations of the cervical spine through the English-language literature and analyze these data for ethnic disparities and similarities.

Materials and methods

The authors reviewed the literature on “pedicle” and “spinal canal” by conducting a bibliographic search using PubMed, Ovid MEDLINE, and Science Direct from January 1985 to December 2010. After evaluating all of the selected abstracts, we ultimately selected 19 studies involving living subjects: 12 studies on pedicle dimensions and 7 on spinal canal diameters. The four parameters, pedicle width (PW), pedicle transverse angle (PTA), anterior-posterior diameter of the spinal canal (APD), and transverse diameter of the spinal canal (TD), were analyzed at the relevant levels from C3 to C7. In addition, the values for pedicle dimensions and spinal canal diameters in the European/American populations were compared using the data from Asian populations as a baseline.

Results

The smallest mean PW was found at C4 in the male (5.1 mm) and female populations (4.1 mm); the largest mean PW was found at C7 in both male (7.7 mm) and female populations (7 mm). The PW in males was greater than in females at the majority of levels. The smallest mean PTA was found at C7 in both male (33.4°) and female populations (33°); the largest mean PTA was found at C4 in both male (53.2°) and female populations (52.1°). The overall PW, PTA, APD, and TD ratio of European/American to Asian populations was 91.4–98.8, 99.6–106.2, 110.7–122, and 100–108.3 %, respectively.

Conclusion

Although our cervical spine CT data were suggestive of possible ethnic differences in spinal canal morphology, our analysis failed to identify significant ethnic disparity in pedicle dimensions despite potential differences in physique between populations.

Alert: 5th German Spine Congress

2010-05-10

Type: Alert

Alert: Eurospine 2010

2009-11-11

Type: Alert

Alert: European Spine Journal

2009-11-11

Type: Alert