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1.  Fractures of the cervical spine 
Clinics  2013;68(11):1455-1461.
The aim of this study was to review the literature on cervical spine fractures.
The literature on the diagnosis, classification, and treatment of lower and upper cervical fractures and dislocations was reviewed.
Fractures of the cervical spine may be present in polytraumatized patients and should be suspected in patients complaining of neck pain. These fractures are more common in men approximately 30 years of age and are most often caused by automobile accidents. The cervical spine is divided into the upper cervical spine (occiput-C2) and the lower cervical spine (C3-C7), according to anatomical differences. Fractures in the upper cervical spine include fractures of the occipital condyle and the atlas, atlanto-axial dislocations, fractures of the odontoid process, and hangman's fractures in the C2 segment. These fractures are characterized based on specific classifications. In the lower cervical spine, fractures follow the same pattern as in other segments of the spine; currently, the most widely used classification is the SLIC (Subaxial Injury Classification), which predicts the prognosis of an injury based on morphology, the integrity of the disc-ligamentous complex, and the patient's neurological status. It is important to correctly classify the fracture to ensure appropriate treatment. Nerve or spinal cord injuries, pseudarthrosis or malunion, and postoperative infection are the main complications of cervical spine fractures.
Fractures of the cervical spine are potentially serious and devastating if not properly treated. Achieving the correct diagnosis and classification of a lesion is the first step toward identifying the most appropriate treatment, which can be either surgical or conservative.
PMCID: PMC3812556  PMID: 24270959
Cervical Atlas; Cervical Vertebrae; Spinal Fractures; Classification; Therapeutics
2.  An intradural cervical chordoma mimicking schwannoma 
Journal of Injury and Violence Research  2012;4(3 Suppl 1): Paper No. 83.
Chordoma is a relatively rare tumor originating from the embryonic remnants of the notochord. This is an aggressive, slow growing and invasive tumor. It occurs mostly at the two ends of neuroaxis which is more frequent in the sacrococcygeal region. Chordoma in vertebral column is very rare. This tumor is extradural in origin and compresses neural tissues and makes the patient symptomatic. This tumor found extremely rare in the spinal region as an intradural tumor.
The present study reports a rare case of intradural chordoma tumor as well as its clinical manifestations and treatment options.
The patient was a 50-year-old female presented with 9 months history of progressively worsening neck pain, cervical spine chordoma resembling neurinoma and right arm numbness. Physical examination showed no weakness in her limbs, but she had upward plantar reflex and mild hyperreflexia. In a magnetic resonance imaging (MRI) scan of the cervical spine there was an ill-defined enhancing mass in the posterior aspect of C2-C3 body caused cord compression more severe in right side as well as foraminal scalloping. The patient underwent surgery and after midline posterior cervical incision and paravertebral muscle stripping a laminectomy was performed from C1 through C4 using a high speed drill. Needle biopsy revealed chordoma on frozen section and all of accessible parts of tumor were excised. The gross and microscopic histopathological appearance was consistent with chordoma.
Chordomas are malignant tumors that arise from remains of embryonic notochord. These ectopic rests of notochord termed “ecchordosis physaliphora “can be found in approximately 2% of autopsies. These are aggressive, slow growing, locally invasive and destructive tumors those occur in the midline of neuroaxis. They generally thought to account for 2% to 4% of all primary bone neoplasms and 1% to 4% malignant bone neoplasms. They are the most frequent primary malignant spinal tumors after plasmacytomas. The incidence has been estimated to be 0.51 cases per million. The most common location is sacrococcygeal region followed by the clivus. These two locations account for approximately 90% of chordomas. Of the tumors that do not arise in the sacrum or clivus, half occur in the cervical region, with the remainder found in the lumbar or thoracic region, in descending order of frequency. Cervical spine chordomas account for 6% of all cases. Distal metastasis most often occurs in young patients, those with sacrococcygeal or vertebral tumors, and those with atypical histological features. These tumors usually spread to contiguous anatomical structures, but they may be found in distant sites (skin, musculoskeletal system, brain, and other internal organs). Seeding of the tumor has also been reported, and the likely mechanism seems to be tumor cell of contamination during the surgical procedures. The usual radiological findings in chordomas of spine are destructive or lytic lesions with occasional sclerotic changes. They tend to lie anterolateral, rather than dorsal towards the cord, and reportedly known to invade the dura. The midline location, destructive nature, soft tissue mass formation and calcification are the radiological hallmarks of chordomas. Computed Tomography (CT) scan is the best imaging modality to delineate areas of osteolytic, osteosclerotic, or mixed areas of bone destruction.Chordoma is usually known as a hypovascular tumor which grows in a lobulated manner. Septal enhancement which reflects a lobulated growth pattern is seen in both CT and MRI and even in gross examination. Other epidural tumors include neurinoma, neurofibroma, meningioma, neuroblastoma, hemangioma, lymphoma and metastases. Their differentiation from chordoma may be difficult due to the same enhancement pattern on CT and MRI.
A dumbbell-shaped chordoma is a rare pathogenic condition. The dumbbell shape is a characteristic finding of neurinomas in spine but in spinal neurinomas extention to transverse foramina has not yet been reported. Although our case mimicked a dumbbell shaped neurogenic tumor, its midline location and destructive pattern were characteristic feature indicating a clue to the diagnosis of chordoma that was already confirmed with histopathology.
This unusual behavior of tumor extension can be explained by the soft and gelatinous nature of the tumor enabling the mass to extend or creep into the existing adjacent anatomical structures.
Cervical Chordoma, Intradural, Computed tomography
PMCID: PMC3571609
3.  Clinical decision making in spinal fusion for chronic low back pain. Results of a nationwide survey among spine surgeons 
BMJ Open  2011;1(2):e000391.
To assess the use of prognostic patient factors and predictive tests in clinical decision making for spinal fusion in patients with chronic low back pain.
Design and setting
Nationwide survey among spine surgeons in the Netherlands.
Surgeon members of the Dutch Spine Society were questioned on their surgical treatment strategy for chronic low back pain.
Primary and secondary outcome measures
The surgeons' opinion on the use of prognostic patient factors and predictive tests for patient selection were addressed on Likert scales, and the degree of uniformity was assessed. In addition, the influence of surgeon-specific factors, such as clinical experience and training, on decision making was determined.
The comments from 62 surgeons (70% response rate) were analysed. Forty-four surgeons (71%) had extensive clinical experience. There was a statistically significant lack of uniformity of opinion in seven of the 11 items on prognostic factors and eight of the 11 items on predictive tests, respectively. Imaging was valued much higher than predictive tests, psychological screening or patient preferences (all p<0.01). Apart from the use of discography and long multisegment fusions, differences in training or clinical experience did not appear to be of significant influence on treatment strategy.
The present survey showed a lack of consensus among spine surgeons on the appreciation and use of predictive tests. Prognostic patient factors were not consistently incorporated in their treatment strategy either. Clinical decision making for spinal fusion to treat chronic low back pain does not have a uniform evidence base in practice. Future research should focus on identifying subgroups of patients for whom spinal fusion is an effective treatment, as only a reliable prediction of surgical outcome, combined with the implementation of individual patient factors, may enable the instalment of consensus guidelines for surgical decision making in patients with chronic low back pain.
Article summary
Article focus
What is the level of professional consensus among spine surgeons regarding spinal fusion surgery for chronic low back pain?
How are tests for patient selection appreciated and to what extent are they used in clinical practice?
Are prognostic patient factors incorporated in the process of surgical decision making for chronic low back pain?
Key messages
In clinical practice, there is no professional consensus on surgical treatment strategy for chronic low back pain.
Prognostic patient factors as well as tests for patient selection are not consistently used in clinical decision making for spinal fusion.
Because of a lack of consensus on spinal fusion strategy for chronic low back pain in clinical practice, no guidelines for proper patient counselling can be installed at present.
Strengths and limitations of this study
A survey among physicians provides valuable insight in the actual decision-making process in clinical practice. Understanding contributory factors in treatment strategy may help in the creation of consensus guidelines.
The introduction of an interviewer bias could be avoided by the use of a neutral intermediary instead of direct questions from peers in spine surgery.
This study focused on surgeon members of the Dutch Spine Society whose practice may not reflect that of all surgeons performing spinal fusion for chronic low back pain. Moreover, no information on conservative treatment options was acquired.
To define consensus, we chose for uniformity of opinion of at least 70%, which we considered to be sufficient for implementation in guidelines. Such a cut-off level remains arbitrary.
PMCID: PMC3278483  PMID: 22189352
4.  Metastatic non-Hodgkin lymphoma presenting as low back pain and radiculopathy: a case report 
Journal of Chiropractic Medicine  2012;11(3):202-206.
The purpose of this case report is to describe a case of metastatic non-Hodgkin lymphoma in the lumbar spine presenting as lumbar radiculopathy.
Clinical Features
A 46-year-old man sought care from his doctor of chiropractic for low back pain and right leg radiculopathy. The patient was referred for a magnetic resonance imaging (MRI) scan to evaluate for a suspected disk herniation. The MRI scan revealed 2 lumbar pathologic compression fractures with cauda equina compression, and MRI short tau inversion recovery (STIR) sagittal image of the lumbar spine showed high signal in T12 and S2.
Intervention and Outcome
The patient was referred for an immediate consultation with his medical physician with the preliminary diagnosis of metastatic bone lesions or primary bone lesions of unknown etiology. The patient underwent bone biopsy, computed tomography, and positron emission tomography scanning and was diagnosed with small cell non-Hodgkin lymphoma with osseous metastasis. The patient underwent chemo- and radiation therapy, and the lymphoma is now in remission 18 months later.
This case describes the presentation of metastatic non-Hodgkin lymphoma as a possible contributing cause in a patient presenting with lumbar radiculopathy, a common musculoskeletal condition. As well, this case highlights the importance of STIR sequences as part of a routine lumbar spine MRI examination. Without the STIR sequences, the additional deposits in T12 and S1 would not have been readily appreciated. Although metastatic non-Hodgkin lymphoma of the spine is rare, it should be remembered in the differential diagnoses.
PMCID: PMC3437349  PMID: 23449990
Non-Hodgkin lymphoma; Spine; Radiculopathy; Magnetic resonance imaging; Metastasis; Chiropractic
5.  Clinical presentation of a traumatic cervical spine disc rupture in alpine sports: a case report 
Isolated non-skeletal injuries of the cervical spine are rare and frequently missed. Different evaluation algorithms for C-spine injuries, such as the Canadian C-spine Rule have been proposed, however with strong emphasis on excluding osseous lesions. Discoligamentary injuries may be masked by unique clinical situations presenting to the emergency physician. We report on the case of a 28-year-old patient being admitted to our emergency department after a snowboarding accident, with an assumed hyperflexion injury of the cervical spine. During the initial clinical encounter the only clinical finding the patient demonstrated, was a burning sensation in the palms bilaterally. No neck pain could be elicited and the patient was not intoxicated and did not have distracting injuries. Since the patient described a fall prevention attempt with both arms, a peripheral nerve contusion was considered as a differential diagnosis. However, a high level of suspicion and the use of sophisticated imaging (MRI and CT) of the cervical spine, ultimately led to the diagnosis of a traumatic disc rupture at the C5/6 level. The patient was subsequently treated with a ventral microdiscectomy with cage interposition and ventral plate stabilization at the C5/C6 level and could be discharged home with clearly improving symptoms and without further complications.
This case underlines how clinical presentation and extent of injury can differ and it furthermore points out, that injuries contracted during alpine snow sports need to be considered high velocity injuries, thus putting the patient at risk for cervical spine trauma. In these patients, especially when presenting with an unclear neurologic pattern, the emergency doctor needs to be alert and may have to interpret rigid guidelines according to the situation. The importance of correctly using CT and MRI according to both – standardized protocols and the patient's clinical presentation – is crucial for exclusion of C-spine trauma.
PMCID: PMC2596173  PMID: 19014511
6.  Principles of management of osteometabolic disorders affecting the aging spine 
European Spine Journal  2003;12(Suppl 2):S113-S131.
Osteoporosis is the most common contributing factor of spinal fractures, which characteristically are not generally known to produce spinal cord compression symptoms. Recently, an increasing number of medical reports have implicated osteoporotic fractures as a cause of serious neurological deficit and painful disabling spinal deformities. This has been corroborated by the present authors as well. These complications are only amenable to surgical management, requiring instrumentation. Instrumenting an osteoporotic spine, although a challenging task, can be accomplished if certain guidelines for surgical techniques are respected. Neurological deficits respond equally well to an anterior or posterior decompression, provided this is coupled with multisegmental fixation of the construct. With the steady increase in the elderly population, it is anticipated that the spine surgeon will face serious complications of osteoporotic spines more frequently. With regard to surgery, however, excellent correction of deformities can be achieved, by combining anterior and posterior approaches. Paget's disease of bone (PD) is a non-hormonal osteometabolic disorder and the spine is the second most commonly affected site. About one-third of patients with spinal involvement exhibit symptoms of clinical stenosis. In only 12–24% of patients with PD of the spine is back pain attributed solely to PD, while in the majority of patients, back pain is either arthritic in nature or a combination of a pagetic process and coexisting arthritis. In this context, one must be certain before attributing low back pain to PD exclusively, and antipagetic medical treatment alone may be ineffective. Neural element dysfunction may be attributed to compressive myelopathy by pagetic bone overgrowth, pagetic intraspinal soft tissue overgrowth, ossification of epidural fat, platybasia, spontaneous bleeding, sarcomatous degeneration and vertebral fracture or subluxation. Neural dysfunction can also result from spinal ischemia when blood is diverted by the so-called "arterial steal syndrome". Because the effectiveness of pharmacologic treatment for pagetic spinal stenosis has been clearly demonstrated, surgical decompression should only be instituted after failure of antipagetic medical treatment. Surgery is indicated as a primary treatment when neural compression is secondary to pathologic fractures, dislocations, spontaneous epidural hematoma, syringomyelia, platybasia, or sarcomatous transformation. Five classes of drugs are available for the treatment of PD. Bisphosphonates are the most popular antipagetic drug and several forms have been investigated.
PMCID: PMC3591829  PMID: 14505119
Osteoporosis; Fractures; Neurological deficit; Deformity; Paget's disease; Back pain; Spinal stenosis; Myelopathy; Treatment
7.  Spinal cord injury and its association with blunt head trauma 
Severe and moderate head injury can cause misdiagnosis of a spinal cord injury, leading to devastating long-term consequences. The objective of this study is to identify risk factors involving spine trauma and moderate-to-severe brain injury.
A prospective study involving 1617 patients admitted in the emergency unit was carried out. Of these patients, 180 with moderate or severe head injury were enrolled. All patients were submitted to three-view spine series X-ray and thin cut axial CT scans for spine trauma investigations.
112 male patients and 78 female patients, whose ages ranged from 11 to 76 years (mean age, 34 years). The most common causes of brain trauma were pedestrians struck by motor vehicles (31.1%), car crashes (27.7%), and falls (25%). Systemic lesions were present in 80 (44.4%) patients and the most common were fractures, and lung and spleen injuries. 52.8% had severe and 47.2% moderate head trauma. Fourteen patients (7.8%) suffered spinal cord injury (12 in cervical spine, one in lumbar, and one thoracic spine). In elderly patients, the presence of associated lesions and Glasgow Coma Scale (GCS) < 9 were statistically significant as risk factors (P < 0.05) for spine injury.
Spinal cord injury related to moderate and severe brain trauma usually affects the cervical spine. The incidence of spinal lesions and GCS < 9 points were related to greater incidence of spinal cord injury.
PMCID: PMC3177586  PMID: 21941446
head injury; spine trauma; risk factors
8.  Spine and Pain Clinics Serving North Carolina Patients With Back and Neck Pain 
Spine  2009;34(6):615-622.
Study Design
Cross-sectional survey.
Our primary objective was to describe spine and pain clinics serving North Carolina residents with respect to organizational characteristics. Our secondary objective was to assess the multidisciplinary nature of the clinics surveyed.
Summary of Background Data
Pain clinics have become common in the United States, and patients with chronic back pain have increasingly been seeking services at these clinics. Little is known about the organizational characteristics of spine and pain clinics.
We identified and surveyed spine and pain clinics serving North Carolina residents with chronic back and neck pain. Practice managers at 46 clinics completed a 20-minute questionnaire about the characteristics of their clinic, including providers on staff and services offered. Descriptive and exploratory analyses were conducted to summarize the data. Several variables were constructed to assess the multidisciplinary nature of the clinics.
The response rate was 75%. There was marked heterogeneity among the clinics surveyed. Fifty-nine percent of practices were free-standing (n = 27) and 61% were physician-owned (n = 28). Twenty-five clinics (54%) had an anesthesiologist. Other common physician providers were physiatrists and surgeons. Less than one third of sites had mental health providers (n = 12; 26%); only 26% employed physical therapists. Seventy-six percent of sites offered epidural injections, 74% long-term narcotic prescriptions, and 67% antidepressants. The majority of clinics (30 of 33) prescribing narcotics provided monitoring of therapy using periodic urine toxicology testing. Forty-eight percent of sites (n = 22) offered exercise instruction. Few clinics were multidisciplinary in nature. Only 3 (7%) met the criteria of having a medical physician, registered nurse, physical therapist, and mental health specialist.
Clinics varied widely in their organizational characteristics, including providers and scope of services available. Few clinics were multidisciplinary in nature. This information should be used to determine how pain clinics can better serve patients and improve outcomes.
PMCID: PMC2757449  PMID: 19282742
chronic low back pain; chronic neck pain; organization and administration; health services research; multidisciplinary pain clinics
9.  Surgical treatment of a patient with lung cancer metastasized to the spine with EGFR mutation: A case report 
The prognosis of patients with lung cancer metastasis to the spine is not very promising and a palliative approach is often suggested by scales such as the Tomita score. The choice of surgery for these patients is questionable based on the aggressiveness of the disease. However, certain patient characteristics can be sought out to determine if surgery is indicated.
Here, we present a case of a 59 year old male which consulted for back pain, numbness of the upper left thigh, and weakness corresponding to an L2 lesion. It was later discovered that he was suffering from non small cell lung cancer (adenocarcinoma) with a single metastasis to the spine at the level of L2. The patient also presented an EGFR mutation. Thus, the patient presented two good prognosis characteristics: adenocarcinoma and an EGFR mutation.
An aggressive treatment was chosen. This included an EGFR inhibitor, surgical treatment, and radiotherapy thereafter. The patient had no complications due to surgery and to date, the patient has survived over 12 months and is free of any symptoms. This case demonstrates that surgical intervention can be considered for certain patients with lung cancer metastasized to the spine.
This case demonstrates that surgical intervention can be considered for certain patients with lung cancer metastasized to the spine. We hope spine surgeons in general will start verifying the EGFR mutation status of adenocarcinoma lung cancer patients to determine if surgery is indicated.
PMCID: PMC3421144  PMID: 22858793
EGFR mutation; Spine surgery; Lung cancer; Metastasis; Adenocarcinoma
10.  Biphasic Synaptic Ca Influx Arising from Compartmentalized Electrical Signals in Dendritic Spines 
PLoS Biology  2009;7(9):e1000190.
Dendritic spines compartmentalize synaptically-evoked biochemical signals. The authors show that electrical compartmentalization provided by a spine endows the associated synapse with additional modes of calcium signaling by shaping the kinetics of synaptic calcium currents.
Excitatory synapses on mammalian principal neurons are typically formed onto dendritic spines, which consist of a bulbous head separated from the parent dendrite by a thin neck. Although activation of voltage-gated channels in the spine and stimulus-evoked constriction of the spine neck can influence synaptic signals, the contribution of electrical filtering by the spine neck to basal synaptic transmission is largely unknown. Here we use spine and dendrite calcium (Ca) imaging combined with 2-photon laser photolysis of caged glutamate to assess the impact of electrical filtering imposed by the spine morphology on synaptic Ca transients. We find that in apical spines of CA1 hippocampal neurons, the spine neck creates a barrier to the propagation of current, which causes a voltage drop and results in spatially inhomogeneous activation of voltage-gated Ca channels (VGCCs) on a micron length scale. Furthermore, AMPA and NMDA-type glutamate receptors (AMPARs and NMDARs, respectively) that are colocalized on individual spine heads interact to produce two kinetically and mechanistically distinct phases of synaptically evoked Ca influx. Rapid depolarization of the spine triggers a brief and large Ca current whose amplitude is regulated in a graded manner by the number of open AMPARs and whose duration is terminated by the opening of small conductance Ca-activated potassium (SK) channels. A slower phase of Ca influx is independent of AMPAR opening and is determined by the number of open NMDARs and the post-stimulus potential in the spine. Biphasic synaptic Ca influx only occurs when AMPARs and NMDARs are coactive within an individual spine. These results demonstrate that the morphology of dendritic spines endows associated synapses with specialized modes of signaling and permits the graded and independent control of multiple phases of synaptic Ca influx.
Author Summary
The vast majority of excitatory synapses in the mammalian central nervous system are made onto dendritic spines, small (< 1 fL) membranous structures stippled along the dendrite. The head of each spine is separated from its parent dendrite by a thin neck – a morphological feature that intuitively suggests it might function to limit the transmission of electrical and biochemical signals. Unfortunately, the extremely small size of spines has made direct measurements of their electrical properties difficult and, therefore, the functional implications of electrical compartmentalization have remained elusive. In this study, we use spatiotemporally controlled stimulation to generate calcium signals within the spine head and/or neighboring dendrite. By comparing these measurements we demonstrate that spines create specialized electrical signaling compartments, which has at least two functional consequences. First, synaptic stimulation, but not similar dendritic depolarization, can trigger the activation of voltage-gated calcium channels within the spine. Second, voltage changes in the spine head arising from compartmentalization shape the time course of synaptically evoked calcium influx such that it is biphasic. Thus, the electrical compartmentalization provided by spines allows for multiple modes of calcium signaling at excitatory synapses.
PMCID: PMC2734993  PMID: 19753104
11.  MIS Fusion of the SI Joint: Does Prior Lumbar Spinal Fusion Affect Patient Outcomes? 
Sacroiliac (SI) joint pain is a challenging condition to manage as it can mimic discogenic or radicular low back pain, and present as low back, hip, groin and/or buttock pain. Patients may present with a combination of lumbar spine and SI joint symptoms, further complicating the diagnosis and treatment algorithm [1-3]. SI joint pain after lumbar spinal fusion has been reported in the literature. Both clinical and biomechanical studies show the SI joint to be susceptible to increased motion and stress at the articular surface with up to 40-75% of patients developing significant SI joint degeneration after 5 years.
In a recent case series study of 50 patients who underwent minimally invasive SI joint arthrodesis, 50% had undergone previous lumbar spinal fusion and 18% had symptomatic lumbar spine pathology treated conservatively [4].
The purpose of this study is to determine if history of previous lumbar fusion or lumbar pathology affects patient outcomes after MIS SI joint fusion surgery.
We report on 40 patients with 24 month follow up treated with MIS SI joint fusion using a series of triangular porous plasma coated titanium implants (iFuse, SI-Bone, Inc. San Jose, CA). Outcomes using a numerical rating scale (NRS) for pain were obtained at 3-, 6-, 12- and 24 month follow up intervals. Additionally, patient satisfaction was collected at the latest follow up interval. Patients were separated into 3 cohorts: 1) underwent prior lumbar spine fusion (PF), 2) no history of previous lumbar spine fusion (NF), 3) no history of previous lumbar spine fusion with symptomatic lumbar spine pathology treated conservatively (LP). A repeated measures analysis of variance (rANOVA) was used to determine if the change in NRS pain scores differed across timepoints and subgroups. A decrease in NRS by 2 points was deemed clinically significant [5].
Mean age was 54 (±13) years and varied slightly but not statistically between groups. All subgroups experienced a clinically and statistically significant reduction in pain at all time points (mean change >2 points, p<0.001). There was a statistically significant effect of cohort (p=0.045), with the NF cohort (no prior lumbar spinal fusion) having a somewhat greater decrease in pain (by approximately 1 point) compared to the other 2 groups (PF and LP).Patient reported satisfaction by cohort was: 89% (NF), 92% (PF) and 63% (LP).Overall satisfaction rate was 87%.
Discussion and Conclusion:
Patients with SI joint pain, regardless of prior lumbar spine fusion history, show significant improvement in pain after minimally invasive SI joint fusion. The presence of symptomatic lumbar spine pathology potentially confounds the treatment affect, as patients may not be able to discriminate between symptoms arising from the SI joint and the lumbar spine. These patients expressed a lower satisfaction with surgery. Patients without other confounding lumbar spine pathology and who have not undergone previous spine surgery tend to be younger and experience a greater reduction in pain.
PMCID: PMC3664440  PMID: 23730380
Sacroiliac (SI) joint; lumbar fusion; minimally invasive surgery; MIS arthrodesis.
12.  A matched-pair cluster design study protocol to evaluate implementation of the Canadian C-spine rule in hospital emergency departments: Phase III 
Physicians in Canadian emergency departments (EDs) annually treat 185,000 alert and stable trauma victims who are at risk for cervical spine (C-spine) injury. However, only 0.9% of these patients have suffered a cervical spine fracture. Current use of radiography is not efficient. The Canadian C-Spine Rule is designed to allow physicians to be more selective and accurate in ordering C-spine radiography, and to rapidly clear the C-spine without the need for radiography in many patients. The goal of this phase III study is to evaluate the effectiveness of an active strategy to implement the Canadian C-Spine Rule into physician practice. Specific objectives are to: 1) determine clinical impact, 2) determine sustainability, 3) evaluate performance, and 4) conduct an economic evaluation.
We propose a matched-pair cluster design study that compares outcomes during three consecutive 12-months "before," "after," and "decay" periods at six pairs of "intervention" and "control" sites. These 12 hospital ED sites will be stratified as "teaching" or "community" hospitals, matched according to baseline C-spine radiography ordering rates, and then allocated within each pair to either intervention or control groups. During the "after" period at the intervention sites, simple and inexpensive strategies will be employed to actively implement the Canadian C-Spine Rule. The following outcomes will be assessed: 1) measures of clinical impact, 2) performance of the Canadian C-Spine Rule, and 3) economic measures. During the 12-month "decay" period, implementation strategies will continue, allowing us to evaluate the sustainability of the effect. We estimate a sample size of 4,800 patients in each period in order to have adequate power to evaluate the main outcomes.
Phase I successfully derived the Canadian C-Spine Rule and phase II confirmed the accuracy and safety of the rule, hence, the potential for physicians to improve care. What remains unknown is the actual change in clinical behaviors that can be affected by implementation of the Canadian C-Spine Rule, and whether implementation can be achieved with simple and inexpensive measures. We believe that the Canadian C-Spine Rule has the potential to significantly reduce health care costs and improve the efficiency of patient flow in busy Canadian EDs.
PMCID: PMC1802999  PMID: 17288613
13.  Upper gastrointestinal hemorrhage after nonresponsive thoracic spine pain: a case report 
This case study reports the findings of an upper gastrointestinal hemorrhage in a patient with thoracic spine pain reporting to a chiropractic clinic. The purpose of this article is to highlight the importance of identifying a patient's medication history as well as reviewing the signs and symptoms of gastrointestinal bleeding from a nonvariceal lesion.
Clinical Features
A 61-year–old woman presented with worsening middle thoracic spine pain of 3 months' duration along with recent abdominal pain. Medications, physical therapy, and spinal manipulation did not provide considerable improvement. The patient was taking ibuprofen daily to cope with her back pain.
Intervention and Outcome
The initial physical examination demonstrated mild increased tissue tension in the thoracic paraspinal muscles with mild restriction of thoracic spine range of motion secondary to the patient's pain. There was pain on palpation of the T4-5 and T7-8 spinal segments. The physical examination findings did not correlate to the patient's pain presentation, and she was referred back to her primary care physician. Two days after the initial examination, the patient experienced an upper gastrointestinal hemorrhage and underwent emergency surgery. It was determined postoperatively that she had a medication-induced duodenal ulcer that subsequently ruptured.
An upper gastrointestinal bleed should be considered in the differential diagnosis of a patient with a history of prolonged aspirin or nonsteroidal anti-inflammatory drug use with nonspecific abdominal symptoms.
PMCID: PMC2780958  PMID: 19646391
Upper gastrointestinal tract; Hemorrhage; Spinal injuries; Chiropractic
14.  Artificial Discs for Lumbar and Cervical Degenerative Disc Disease –Update 
Executive Summary
To assess the safety and efficacy of artificial disc replacement (ADR) technology for degenerative disc disease (DDD).
Clinical Need
Degenerative disc disease is the term used to describe the deterioration of 1 or more intervertebral discs of the spine. The prevalence of DDD is roughly described in proportion to age such that 40% of people aged 40 years have DDD, increasing to 80% among those aged 80 years or older. Low back pain is a common symptom of lumbar DDD; neck and arm pain are common symptoms of cervical DDD. Nonsurgical treatments can be used to relieve pain and minimize disability associated with DDD. However, it is estimated that about 10% to 20% of people with lumbar DDD and up to 30% with cervical DDD will be unresponsive to nonsurgical treatments. In these cases, surgical treatment is considered. Spinal fusion (arthrodesis) is the process of fusing or joining 2 bones and is considered the surgical gold standard for DDD.
Artificial disc replacement is the replacement of the degenerated intervertebral disc with an artificial disc in people with DDD of the lumbar or cervical spine that has been unresponsive to nonsurgical treatments for at least 6 months. Unlike spinal fusion, ADR preserves movement of the spine, which is thought to reduce or prevent the development of adjacent segment degeneration. Additionally, a bone graft is not required for ADR, and this alleviates complications, including bone graft donor site pain and pseudoarthrosis. It is estimated that about 5% of patients who require surgery for DDD will be candidates for ADR.
Review Strategy
The Medical Advisory Secretariat conducted a computerized search of the literature published between 2003 and September 2005 to answer the following questions:
What is the effectiveness of ADR in people with DDD of the lumbar or cervical regions of the spine compared with spinal fusion surgery?
Does an artificial disc reduce the incidence of adjacent segment degeneration (ASD) compared with spinal fusion?
What is the rate of major complications (device failure, reoperation) with artificial discs compared with surgical spinal fusion?
One reviewer evaluated the internal validity of the primary studies using the criteria outlined in the Cochrane Musculoskeletal Injuries Group Quality Assessment Tool. The quality of concealment allocation was rated as: A, clearly yes; B, unclear; or C, clearly no. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to evaluate the overall quality of the body of evidence (defined as 1 or more studies) supporting the research questions explored in this systematic review. A random effects model meta-analysis was conducted when data were available from 2 or more randomized controlled trials (RCTs) and when there was no statistical and or clinical heterogeneity among studies. Bayesian analyses were undertaken to do the following:
Examine the influence of missing data on clinical success rates;
Compute the probability that artificial discs were superior to spinal fusion (on the basis of clinical success rates);
Examine whether the results were sensitive to the choice of noninferiority margin.
Summary of Findings
The literature search yielded 140 citations. Of these, 1 Cochrane systematic review, 1 RCT, and 10 case series were included in this review. Unpublished data from an RCT reported in the grey literature were obtained from the manufacturer of the device. The search also yielded 8 health technology assessments evaluating ADR that are also included in this review.
Six of the 8 health technology assessments concluded that there is insufficient evidence to support the use of either lumbar or cervical ADR. The results of the remaining 2 assessments (one each for lumbar and cervical ADR) led to a National Institute for Clinical Excellence guidance document supporting the safety and effectiveness of lumbar and cervical ADR with the proviso that an ongoing audit of all clinical outcomes be undertaken owing to a lack of long-term outcome data from clinical trials.
Regarding lumbar ADR, data were available from 2 noninferiority RCTs to complete a meta-analysis. The following clinical, health systems, and adverse event outcome measures were synthesized: primary outcome of clinical success, Oswestry Disability Index (ODI) scores, pain VAS scores, patient satisfaction, duration of surgery, amount of blood loss, length of hospital stay, rate of device failure, and rate of reoperation.
The meta-analysis of overall clinical success supported the noninferiority of lumbar ADR compared with spinal fusion at 24-month follow-up. Of the remaining clinical outcome measures (ODI, pain VAS scores, SF-36 scores [mental and physical components], patient satisfaction, and return to work status), only patient satisfaction and scores on the physical component scale of the SF-36 questionnaire were significantly improved in favour of lumbar ADR compared with spinal fusion at 24 months follow-up. Blood loss and surgical time showed statistical heterogeneity; therefore, meta-analysis results are not interpretable. Length of hospital stay was significantly shorter in patients receiving the ADR compared with controls. Neither the number of device failures nor the number of neurological complications at 24 months was statistically significantly different between the ADR and fusion treatment groups. However, there was a trend towards fewer neurological complications at 24 months in the ADR treatment group compared with the spinal fusion treatment group.
Results of the Bayesian analyses indicated that the influence of missing data on the outcome measure of clinical success was minimal. The Bayesian model indicated that the probability for ADR being better than spinal fusion was 79%. The probability of ADR being noninferior to spinal fusion using a -10% noninferiority bound was 92%, and using a -15% noninferiority bound was 94%. The probability of artificial discs being superior to spinal fusion in a future trial was 73%.
Six case series were reviewed, mainly to characterize the rate of major complications for lumbar ADR. The Medical Advisory Secretariat defined a major complication as any reoperation; device failure necessitating a revision, removal or reoperation; or life-threatening event. The rates of major complications ranged from 0% to 13% per device implanted. Only 1 study reported the rate of ASD, which was detected in 2 (2%) of the 100 people 11 years after surgery.
There were no RCT data available for cervical ADR; therefore, data from 4 case series were reviewed for evidence of effectiveness and safety. Because data were sparse, the effectiveness of cervical ADR compared with spinal fusion cannot be determined at this time.
The rate of major complications was assessed up to 2 years after surgery. It was found to range from 0% to 8.1% per device implanted. The rate of ASD is not reported in the clinical trial literature.
The total cost of a lumbar ADR procedure is $15,371 (Cdn; including costs related to the device, physician, and procedure). The total cost of a lumbar fusion surgery procedure is $11,311 (Cdn; including physicians’ and procedural costs).
Lumbar Artificial Disc Replacement
Since the 2004 Medical Advisory Secretariat health technology policy assessment, data from 2 RCTs and 6 case series assessing the effectiveness and adverse events profile of lumbar ADR to treat DDD has become available. The GRADE quality of this evidence is moderate for effectiveness and for short-term (2-year follow-up) complications; it is very low for ASD.
The effectiveness of lumbar ADR is not inferior to that of spinal fusion for the treatment of lumbar DDD. The rates for device failure and neurological complications 2 years after surgery did not differ between ADR and fusion patients. Based on a Bayesian meta-analysis, lumbar ADR is 79% superior to lumbar spinal fusion.
The rate of major complications after lumbar ADR is between 0% and 13% per device implanted. The rate of ASD in 1 case series was 2% over an 11-year follow-up period.
Outcome data for lumbar ADR beyond a 2-year follow-up are not yet available.
Cervical Artificial Disc Replacement
Since the 2004 Medical Advisory Secretariat health technology policy assessment, 4 case series have been added to the body of evidence assessing the effectiveness and adverse events profile of cervical ADR to treat DDD. The GRADE quality of this evidence is very low for effectiveness as well as for the adverse events profile. Sparse outcome data are available.
Because data are sparse, the effectiveness of cervical ADR compared with spinal fusion cannot be determined at this time.
The rate of major complications was assessed up to 2 years after surgery; it ranged from 0% to 8.1% per device implanted. The rate of ASD is not reported in the clinical trial literature.
PMCID: PMC3379529  PMID: 23074480
15.  Percutaneous anterolateral balloon kyphoplasty for metastatic lytic lesions of the cervical spine 
European Spine Journal  2010;19(11):1948-1952.
The purpose of our report is to describe a new application of kyphoplasty, the percutaneous anterolateral balloon kyphoplasty that we performed in two cases of metastatic osteolytic lesions in cervical spine. The first patient, aged 48 years, with primary malignancy in lungs had two metastatic lesions in C2 and C6 vertebrae. Patient’s complaints were about pain and restriction of movements (due to the pain) in the cervical spine. The second patient, aged 70 years, with primary malignancy in stomach, had multiple metastatic lesions in thoracolumbar spine and C3, C4 and C5 vertebrae without neurological symptoms. The main symptoms were from cervical spine with severe pain even in bed rest and systematic use of opiate-base analgesis. The preoperative status was evaluated with X-rays, CT scan, MRI scan and with Karnofsky score and visual analogue pain (VAS) scale. Both patients underwent percutaneous anterolateral balloon kyphoplasty via the anterolateral approach in cervical spine under general anaesthesia. No clinical complications occurred during or after the procedure. Both patients experienced pain relief immediately after balloon kyphoplasty and during the following days. The stiffness also resolved rapidly and cervical collars were removed. VAS score significantly improved from 85 and 95 preoperatively to 30 in both patients. Karnofsky score showed also improvement from 40 and 30 preoperatively to 80 and 70, respectively, at the final follow-up (7 months after the procedure). Fluoroscopy-guided percutaneous anterolateral ballon kyphoplasty proved to be safe and effective minimally invasive procedure for metastatic osteolytic lesions of the cervical spine, reducing pain and avoiding vertebral collapse. Experience and attention are necessary in order to avoid complications.
PMCID: PMC2989267  PMID: 20499113
Cervical spine; Kyphoplasty; Osteolytic lesions; Metastatic lesions
16.  Applying psychological theories to evidence-based clinical practice: identifying factors predictive of lumbar spine x-ray for low back pain in UK primary care practice 
Psychological models predict behaviour in a wide range of settings. The aim of this study was to explore the usefulness of a range of psychological models to predict the health professional behaviour 'referral for lumbar spine x-ray in patients presenting with low back pain' by UK primary care physicians.
Psychological measures were collected by postal questionnaire survey from a random sample of primary care physicians in Scotland and north England. The outcome measures were clinical behaviour (referral rates for lumbar spine x-rays), behavioural simulation (lumbar spine x-ray referral decisions based upon scenarios), and behavioural intention (general intention to refer for lumbar spine x-rays in patients with low back pain). Explanatory variables were the constructs within the Theory of Planned Behaviour (TPB), Social Cognitive Theory (SCT), Common Sense Self-Regulation Model (CS-SRM), Operant Learning Theory (OLT), Implementation Intention (II), Weinstein's Stage Model termed the Precaution Adoption Process (PAP), and knowledge. For each of the outcome measures, a generalised linear model was used to examine the predictive value of each theory individually. Linear regression was used for the intention and simulation outcomes, and negative binomial regression was used for the behaviour outcome. Following this 'theory level' analysis, a 'cross-theoretical construct' analysis was conducted to investigate the combined predictive value of all individual constructs across theories.
Constructs from TPB, SCT, CS-SRM, and OLT predicted behaviour; however, the theoretical models did not fit the data well. When predicting behavioural simulation, the proportion of variance explained by individual theories was TPB 11.6%, SCT 12.1%, OLT 8.1%, and II 1.5% of the variance, and in the cross-theory analysis constructs from TPB, CS-SRM and II explained 16.5% of the variance in simulated behaviours. When predicting intention, the proportion of variance explained by individual theories was TPB 25.0%, SCT 21.5%, CS-SRM 11.3%, OLT 26.3%, PAP 2.6%, and knowledge 2.3%, and in the cross-theory analysis constructs from TPB, SCT, CS-SRM, and OLT explained 33.5% variance in intention. Together these results suggest that physicians' beliefs about consequences and beliefs about capabilities are likely determinants of lumbar spine x-ray referrals.
The study provides evidence that taking a theory-based approach enables the creation of a replicable methodology for identifying factors that predict clinical behaviour. However, a number of conceptual and methodological challenges remain.
PMCID: PMC3125229  PMID: 21619689
17.  Geriatric Trauma Patients With Cervical Spine Fractures due to Ground Level Fall: Five Years Experience in a Level One Trauma Center 
It has been found that significantly different clinical outcomes occur in trauma patients with different mechanisms of injury. Ground level falls (GLF) are usually considered “minor trauma” with less injury occurred in general. However, it is not uncommon that geriatric trauma patients sustain cervical spine (C-spine) fractures with other associated injuries due to GLF or less. The aim of this study is to determine the injury patterns and the roles of clinical risk factors in these geriatric trauma patients.
Data were reviewed from the institutional trauma registry of our local level 1 trauma center. All patients had sustained C-spine fracture(s). Basic clinical characteristics, the distribution of C-spine fracture(s), and mechanism of injury in geriatric patients (65 years or older) were compared with those less than 65 years old. Furthermore, different clinical variables including age, gender, Glasgow coma scale (GCS), blood alcohol level, and co-existing injuries were analyzed by multivariate logistic regression in geriatric trauma patients due to GLF and internally validated by random bootstrapping technique.
From 2006 - 2010, a total of 12,805 trauma patients were included in trauma registry, of which 726 (5.67%) had sustained C-spine fracture(s). Among all C-spine fracture patients, 19.15% (139/726) were geriatric patients. Of these geriatric patients 27.34% (38/139) and 53.96% (75/139) had C1 and C2 fractures compared with 13.63% (80/587) and 21.98% (129/587) in young trauma patients (P < 0.001). Of geriatric trauma patients 13.67% (19/139) and 18.71% (26/139) had C6 and C7 fractures compared with 32.03% (188/587) and 41.40% (243/587) in younger ones separately (P < 0.001). Furthermore, 53.96% (75/139) geriatric patients had sustained C-spine fractures due to GLF with more upper C-spine fractures (C1 and C2). Only 3.2% of those had positive blood alcohol levels compared with 52.9% of younger patients (P < 0.001). In addition, 6.34% of geriatric patients due to GLF had intracranial pathology (ICP) which was one of the most common co-injuries with C-spine fractures. Logistic regression analysis showed the adjusted odds ratios of 1.17 (age) and 91.57 (male) in geriatric GLF patients to predict this co-injury pattern of C-spine fracture and ICP.
Geriatric patients tend to sustain more upper C-spine fractures than non-geriatric patients regardless of the mechanisms. GLF or less not only can cause isolated C-spines fracture(s) but also lead to other significant injuries with ICP as the most common one in geriatric patients. Advanced age and male are two risk factors that can predict this co-injury pattern. In addition, it seems that alcohol plays no role in the cause of GLF in geriatric trauma patients.
PMCID: PMC3601504  PMID: 23519239
Geriatric; Trauma; Ground level fall; Cervical spine fracture; Alcohol
18.  An overview of the role of cancer stem cells in spine tumors with a special focus on chordoma 
World Journal of Stem Cells  2014;6(1):53-64.
Primary malignant tumors of the spine are relatively rare, less than 5% of all spinal column tumors. However, these lesions are often among the most difficult to treat and encompass challenging pathologies such as chordoma and a variety of invasive sarcomas. The mechanisms of tumor recurrence after surgical intervention, as well as resistance to radiation and chemotherapy, remain a pervasive and costly problem. Recent evidence has emerged supporting the hypothesis that solid tumors contain a sub-population of cancer cells that possess characteristics normally associated with stem cells. Particularly, the potential for long-term proliferation appears to be restricted to subpopulations of cancer stem cells (CSCs) functionally defined by their capacity to self-renew and give rise to differentiated cells that phenotypically recapitulate the original tumor, thereby causing relapse and patient death. These cancer stem cells present a unique opportunity to better understand the biology of solid tumors in general, as well as targets for future therapeutics. The general objective of the current study is to discuss the fundamental concepts for understanding the role of CSCs with respect to chemoresistance, radioresistance, special cell surface markers, cancer recurrence and metastasis in tumors of the osseous spine. This discussion is followed by a specific review of what is known about the role of CSCs in chordoma, the most common primary malignant osseous tumor of the spine.
PMCID: PMC3927014  PMID: 24567788
Spine tumor; Chordoma; Cancer stem cell; Stem cell marker; Chemoresistance
19.  Isolated septic facet joint arthritis as a rare cause of acute and chronic low back pain – a case report and literature review 
Polish Journal of Radiology  2012;77(4):72-76.
The most common cause of low back pain is degenerative disease of the intervertebral disc and other structures of the lumbar spine. However, in some cases other less frequent causes of such pain can be seen, for example septic facet joint arthritis. Until now, only 40 cases of such inflammatory changes within the spine have been reported in the literature. The disease is probably underestimated due to improper diagnostic pathway.
Case Report:
The authors describe a case of a 53-year-old woman who was repeatedly hospitalized during a five-month period because of an acute, severe low back pain, with sphincter dysfunction, partially resembling sciatic symptoms. Physical examinations revealed also focal tenderness in the area of the lumbar spine. Inflammatory markers (ESR – erythrocyte sedimentation rate, CRP – C-reactive protein) were elevated. Conservative analgetic treatment brought only partial and temporary relief of the pain and symptoms. The final accurate diagnosis of isolated septic facet joint arthritis at the level of L5/S1 was established after several months from the onset of the first symptoms, after performing various imaging examinations, including bone scintigraphy as well as CT and MRI of the lumbosacral spine. The patient fully recovered after antibiotic therapy and surgery, which was proven in several follow-up examinations showing no relevant pathology of the lumbar spine. The authors broadly describe the etiology and clinical symptoms of the septic facet joint arthritis as well as the significant role of imaging methods, especially MRI, in diagnostic process. The authors also discuss currently available treatment options, both conservative and surgical.
The diagnostic procedure of septic facet joint arthritis requires several steps to be taken. Establishing a correct diagnosis may be difficult, that is why it is important to remember about rare causes of low back pain and to perform detailed physical examination, laboratory tests and choose appropriate imaging techniques.
PMCID: PMC3529718  PMID: 23269942
low back pain; diagnostics; facet joint arthritis
20.  En bloc spondylectomy in malignant tumors of the spine 
European Spine Journal  2008;17(4):600-609.
En bloc spondylectomy is a technique that enables wide or marginal resection of malignant lesions of the spine. Both all posterior techniques as well as combined approaches are reported. Aim of the present study was to analyse the results of 21 patients with malignant lesions of the spine, all treated with en bloc excision in a combined posteroanterior (n = 19) or all posterior approach (n = 2). Twenty-one consecutive patients, operated between 1997 and 2005, were included into this retrospective study. Thirteen patients had primary malignant lesions, eight patients had solitary metastases, all located in the thoracolumbar spine. There were 16 single level, three two-level, one three-level and one four-level spondylectomy. The patients were followed clinically and radiographically (including CT studies) with an average follow-up of 4 years. Out of 11 patients with primary Ewing or osteosarcoma seven patients are alive without any evidence of disease. One patient died after 5 years from other causes and three are alive with evidence of disease. Latter had either a poor histologic response to the preoperative chemotherapy (n = 2) or an intralesional resection (n = 1). All three patients with solitary spinal metastases of Ewing or osteosarcoma died of the disease. Five patients with solitary metastases of mainly hypernephroma are alive. In total, six resections were intralesional, mainly due to large intraspinal tumor masses, with two patients having had previous surgery. In the remaining cases, wide (n = 10) or marginal (n = 5) resection was accomplished. There were one pseudarthrosis requiring extension of the fusion and two cases with local recurrences and repeated excisional surgery. At follow-up CT studies, all cages were fused. Health related quality of life analysis (SF-36) revealed only slightly decreased physical component and normal mental component scores compared to normals in those patients with no evidence of disease. En bloc spondylectomy enables wide or marginal resection of malignant lesions of the spine in most cases with acceptable morbidity. Intralesional resection, poor histologic response, and solitary spinal metastases of Ewing and osteosarcoma are associated with a poor prognosis.
PMCID: PMC2295282  PMID: 18214553
Spondylectomy; Vertebrectomy; En bloc resection; Malignant tumors; Metastases; Spine
21.  Seventh cervical vertebral body solitary osteochondroma. Report of a case and review of the literature 
European Spine Journal  2005;14(8):795-798.
Solitary osteochondroma of the cervical spine is a rare manifestation of a common bony tumour. It can create symptoms, depending on the adjacent compressed structures. In this report, a patient suffering solitary osteochondroma on the anterolateral aspect of the C7 vertebral body is presented and the literature is reviewed. A 46-year-old female presented with dysphagia and pain at the anterolateral surface of her neck during cervical movements or application of local pressure. The clinical and imaging assessment ascertained that the above complaints were due to a local tumour in the neck firmly attached to the spine at the anterolateral aspect of the C7 and which resembled an osteochondroma. Surgical treatment was chosen due to the persistence of the symptoms. The lump was resected using an anterolateral cervical approach and it was sent to the pathology department for confirmation of the lesion’s histological character. The patient was completely relieved of her symptoms. Resection of the osteochondroma seems to be the only reliable solution for definitive relief from the clinical complaints. This surgical treatment, as it is reported, has no major complications and gives good functional results. One to four per cent of the osteochondromas are located at the spine. At the cervical spine, they can cause neurological symptoms and more rarely, dysphagia. Reviewing the literature, no case of solitary osteochondroma located in the anterior aspect of the C7 body was found. Two cases suffering from dysphagia were reported due to external compression by anterior hyperostosis of the cervical spine, but not due to osteochondroma.
PMCID: PMC3489254  PMID: 15912348
Benign tumour; Solitary osteochondroma; Cervical spine; C7; Dysphagia
22.  AB 52. Metastatic formation of scalp as a first symptom in a patient with squamous cell lung cancer 
Journal of Thoracic Disease  2012;4(Suppl 1):AB52.
The incidence of cutaneous metastases from cancer regardless of primary tumor varies from 0.7% to 10% with frequent localization in the head, neck and trunk. Frequent primary tumor is considered for male patients lung cancer - ranking in descending order of adenoCa, squamous, SCLC and Ca undetermined type - and incidence rate of 2.8% to 7.5%, and for women breast cancer.
Patients and methods
Male, 58 years old, smoker of 60 p/y referred by surgeon because of a two months worsening of dyspnea, without any other symptoms of the respiratory system (baseline because of gradually increasing size of the formations of scalp and neck, which underwent head and neck CT scan). The XR and the subsequent CT chest scan revealed a large mass of the right hilum with attendant node of the left lower lobe and enlargement of the mediastinal lymph nodes.
The endoscopic image showed an exophytic necrotizing formation fully occluding the left stem bronchus. Obtained biopsies revealed squamous cell lung cancer, poorly differentiated, and respectively the FNAC\biopsy of formation of the scalp. The staging of the patient reveals osteolytic lesions in skull and spine, and secondary focus in left adrenal gland. The patient is subjected to a combination of chemotherapy and radiotherapy.
Skin metastases from lung cancer is a relatively rare event in the natural course of the disease, of the order of 2.8% to 7.5%, in particular to adenoCa and rarely in squamous histological type. The chest and the abdominal wall is the most common location (due to surface and proximity to the initial primary lesion). The prognosis for metastatic foci of skin is poor, responds poorly to chemotherapy, while the cutaneous lesions do not respond adequately, due to reduced blood supply of the skin.
In conclusion, cutaneous metastases are rarely the first manifestation of lung cancer and any appearance of cutaneous lesions in a particularly male smoker should raise the suspicion of investigation of potential malignancy of the lung.
PMCID: PMC3537429
23.  Odontoid metastasis: a potential lethal complication 
Nearly one third of cervical spine metastasis has a primary breast malignancy. Patients with cervical metastasis have higher mortality due to advanced stage of the malignancy. Treatment is palliative to relieve pain, prevent pathological fracture, improve mobility and function, and prolong survival. We describe a 40-year-old woman with a history of breast cancer who presented with neck and shoulder pain of 1 week duration with no neurological deficit. Following clinical examination, radiographs taken of the cervical spine was normal. Radiographs repeated 3 weeks later revealed a large lytic lesion of the odontoid occupying 70–80% of the peg. Further investigation including magnetic resonance imaging and bone scan showed no further spinal lesions. She underwent cyclical radiotherapy with complete resolution of the odontoid peg lesion and clinically was asymptomatic at 2 years. Metastatic lesions of the odontoid are atypical, and this case reinforces the necessity of early detection to evade disastrous consequences.
PMCID: PMC2784062  PMID: 19921483
Odontoid; Metastases; Spine; Secondaries; Complication
24.  Odontoid metastasis: a potential lethal complication 
Nearly one third of cervical spine metastasis has a primary breast malignancy. Patients with cervical metastasis have higher mortality due to advanced stage of the malignancy. Treatment is palliative to relieve pain, prevent pathological fracture, improve mobility and function, and prolong survival. We describe a 40-year-old woman with a history of breast cancer who presented with neck and shoulder pain of 1 week duration with no neurological deficit. Following clinical examination, radiographs taken of the cervical spine was normal. Radiographs repeated 3 weeks later revealed a large lytic lesion of the odontoid occupying 70–80% of the peg. Further investigation including magnetic resonance imaging and bone scan showed no further spinal lesions. She underwent cyclical radiotherapy with complete resolution of the odontoid peg lesion and clinically was asymptomatic at 2 years. Metastatic lesions of the odontoid are atypical, and this case reinforces the necessity of early detection to evade disastrous consequences.
PMCID: PMC2784062  PMID: 19921483
Odontoid; Metastases; Spine; Secondaries; Complication
25.  Primary bone tumours of the spine: a 42-year survey from the Leeds Regional Bone Tumour Registry 
European Spine Journal  2006;16(3):405-409.
We conducted a review of the Leeds Regional Bone Tumour Registry for primary bone tumours of the spine since establishment in 1958 until year 2000. To analyse the incidence of primary tumours of the spine and to record the site of occurrence, sex distribution, survival and pathology of these tumours. Primary tumours of the spine are particularly rare, accounting for between 4 and 13% of published series of primary bone tumours. The Leeds Bone Tumour Registry was reviewed and a total of 2,750 cases of bone tumours and tumour-like cases were analysed. Consultants in orthopaedic surgery, neurosurgery, oncology and pathology in North and West Yorkshire and Humberside contribute to the Registry. Primary bone tumours of the osseous spine constitute only 126 of the 2,750 cases (4.6%). Chordoma was the most frequent tumour in the cervical and sacral regions, while the most common diagnosis overall was multiple myeloma and plasmacytoma. Osteosarcoma ranked third. The mean age of presentation was 42 years and pain was the most common presenting symptom, occurring in 95% of malignant and 76% of benign tumours. Neurological involvement occurred in 52% of malignant tumours and usually meant a poor prognosis. The establishment of Bone Tumour Registries is the only way that sufficient data on large numbers of these rare tumours can be accumulated to provide a valuable and otherwise unavailable source of information for research, education and clinical follow-up.
PMCID: PMC2200710  PMID: 16865376
Tumour; Spine; Registry

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