Spinal tuberculosis usually occurs in a single vertebral body or two to three adjacent vertebrae; it rarely occurs in multiple vertebral bodies. Surgery is indicated in cases that do not improve with conservative therapy, or when paralysis is evident. Two cases regarding patients with spinal tuberculosis in multiple vertebral bodies on whom surgery was performed are reported. Case 1, the patient was a 77-year-old woman with spinal tuberculosis in four vertebral bodies from the lower thoracic to the lumbar spine. As she had pronounced lower back pain, posterolateral fusion with a pedicle screw was performed. Case 2, the patient was a 29-year-old Indonesian man with spinal tuberculosis in 17 vertebral bodies of the spine who was unable to stand due to paralysis of both legs, thus posterolateral fusion with a pedicle screw was performed. Good results were obtained from tuberculostatic drug therapy and surgical instrumentation.
Spinal tuberculosis; Instrumentation; Antitubercular agents
Experimental study in animals.
Study the clinical behavior of animals after an induced leakage of cement during vertebroplasty in pigs. Study the distribution of polymethylmetacrilate inside the epidural space and prevertebral muscle. Study the histological findings of the spinal cord and muscles, which contact with cement.
Overview of Literature
Although vertebroplasty has a low rate of complication, leakage of cement is highly frequent. There is paucity, in how cement is distributed inside the spinal canal and what occurs when soft tissue comes into contact with polymethylmetacrilate.
We performed vertebroplasty on six pigs. We performed a leakage of cement into the epidural space and into prevertebral muscles. Two weeks later we performed an anatomic evaluation regarding the spreading of polymethylmetacrilate and a histological analysis of soft tissues that came into contact with it.
No clinical alterations were observed. We observed a laminar distribution of the cement surrounding dura mater, and creating a fusiform cavity inside muscles. Spinal cord was normal in all the animals. In dura mater, we observed: synovialmetaplasia, inflammatory reaction, crystal deposits, and giant-cell-reaction. In muscles, we observed: inflammatory reaction, crystal deposits, giant-cell-reaction, muscular atrophy, fibrosis, and synovial metaplasia.
The spinal cord was normal; it is likely that dura mater and cerebrospinal fluid are responsible to isolate neural structures from cement. Dura mater and muscle showed similar histological changes than other publications. Synovial metaplasia was observed in dura mater and muscles that came into contact with cement. The pulsatile rubbing between the tissue and cement could be responsible of this phenomenon.
Spinal cord; Psoas muscles; Histology; Vertebroplasty; Polymethylmethacrylate
Prospective cohort study.
There has been no research examining the use of intraoperative cell salvage during metastatic spinal surgery. The present work is a pilot study investigating the role of cell salvage during metastatic spine surgery.
Overview of Literature
There is no spinal literature about role of cell salvage and autologus transfusion in metastatic spinal cancer.
Sixteen spinal metastases patients who received red cell salvage using a leucocyte depletion filter were enrolled. Of these, ten patients who received salvaged blood transfusion were included in the final analysis. Data collection involved looking at the case notes, operating room records and the prospectively updated metastatic spinal cancer database maintained in the spinal department. Cell salvage data was recovered from the central cell salvage database maintained in the anesthetic department.
Amount of salvaged blood ranged from 120 to 600 mL (average, 318 mL). The average drop in hemoglobin was 1.65 units (range, 0.4-2.7 units). Three patients (30%) required postoperative allogenic blood transfusion. The average follow up was 9.5 months (range, 6-6 months). One patient developed new lung metastasis, at seven months. No patient developed new liver metastases. Preoperatively, six patients had diffuse skeletal metastases. Of this subgroup, three developed new skeletal metastases. No cases showed any wound related problems in the postoperative period.
In our study transfusion of intraoperatively salvaged blood did not result in disseminated metastatic cancer. We would suggest that red cell salvage might have a role during metastatic spine surgery.
Operative blood salvage; Spinal cord compression
We investigated normative temporal levels of white blood cell (WBC) and absolute neutrophil count (ANC) in uncomplicated anterior cervical discectomy and fusion (ACDF) using allograft and demineralized bone matrix (DBM).
Overview of Literature
No study has investigated the diagnostic usefulness of WBC and ANC for postoperative infection following ACDF using allograft and DBM.
Blood samples of 85 patients, who underwent one or two-level ACDF, were obtained and evaluated before surgery and on the first, third, fifth, seventh, fourteenth, thirtieth, and ninetieth postoperative days. No infection was found in all patients for at least one year follow-up period.
Mean WBC and ANC values increased significantly and reached peak levels on the first postoperative day. The peaked levels rapidly decreased but still remained elevated above the preoperative levels on the third postoperative day. The levels returned close to the preoperative levels on the fifth postoperative day. The mean WBC and ANC values did not get out of their normal reference ranges throughout the follow-up periods. One-level and two-level ACDF exhibited a similar course of postoperative changes in WBC and ANC values and no significant difference in mean levels of WBC and ANC throughout the follow-up periods.
Uncomplicated ACDF using allograft and DBM showed normal values of WBC and ANC during the early postoperative period. Therefore, significant abnormal values of WBC and ANC at an early postoperative period suggest the possibility of the development of acute postoperative infection after ACDF using allograft and DBM.
White blood cell; Absolute neutrophil count; Anterior cervical discectomy and fusion; Allograft; Demineralized bone matrix
A prospective study.
To evaluate the reliability and validity of the adapted Korean version of the Neck Pain and Disability Scale (NPDS).
Overview of Literature
The validity of Korean version of NPDS has not been completely demonstrated yet.
Translation/retranslation of the English version of NPDS was conducted, and all steps of the cross-cultural adaptation process were performed. The Korean version of the visual analog scale (VAS) measure of pain, NPDS and the previously validated Short Form-36 (SF-36) were mailed to 91 patients, who had been surgically treated for degenerative cervical disease. Eighty-one patients responded to the first mailing of questionnaires and 69 of the first time responder returned their second survey. Factor analysis and reliability assessment by kappa statistics of agreement for each item, the intraclass correlation coefficient and Cronbach's α were conducted. Concurrent and construct validity were also evaluated by comparing the responses of NPDS with the results of VAS and responses of SF-36.
Factor analysis extracted 3 factors. All items had a kappa statistics of agreement greater than 0.6. The NPDS showed excellent test/re-test reliability. Internal consistency of Cronbach's α was found to be very good. The NPDS was correlated with the VAS. The Korean version of NPDS showed good significant correlation with SF-36 total score and with single SF-36 domains scores.
The adapted Korean version of the NPDS was successfully translated and is considered suitable for outcome assessments in the Korean-speaking patients with neck pain.
Neck pain; Neck Pain and Disability Scale; Korean version
Cross sectional study.
To determine the accuracy of the screening magnetic resonance study of the lumbar spine in the diagnosis of nerve root compression in cases of low back pain as compared to the routine magnetic resonance imaging (MRI) study of the lumbar spine.
Overview of Literature
No local study has been conducted for this purpose. In an international study, the reported sensitivity and specificity of screening MRI lumbar spine protocol in the detection of nerve root compression are 54% and 100% respectively.
Patients of both genders older than 20 years of age with low back pain of any duration or any severity who were referred to the radiology department of Aga Khan University Hospital for MRI of their lumbar spine were evaluated. Two sets of MRI imaging were recruited for each patient: one labeled as 'screening' and the other labeled as 'routine'. The findings of screening MRI were compared with the findings of the routine MRI study.
A total of 109 patients fulfilling the inclusion criteria were included in this study. The diagnostic accuracy, specificity and sensitivity of the screening protocol in our study was 100%, 100% and 100%, respectively in comparison with the routine MRI lumbar spine study for the detection of nerve root compression.
Our data proved that the MRI screening study is a highly accurate tool, and its findings are comparable to the routine study for the detection of nerve root compression especially in cases of lumbar spondylosis.
Lumbar spine magnetic resonance imaging (MRI); Nerve root compression; Screening MRI; Radiculopathy; Disc herniation
The aim of this study was to describe translaminar microendoscopic herniotomy (TL-MEH) for cranially migrated lumbar disc herniations encroaching on the exiting nerve root in the preforaminal and foraminal zones and to report preliminary results of the procedure.
Overview of Literature
Conventional interlaminar approaches for preforaminal and foraminal lumbar disc herniations result in extensive removal of the lamina and facet joint to remove disc fragments safely. More destructive approaches increase the risk of postoperative segmental instability.
TL-MEH is a minimally invasive procedure for herniotomy via the translaminar approach using a microendoscopic technique. TL-MEH was performed in seven patients with a cranially migrated lumbar disc herniation encroaching on the exiting nerve root. The disc fragments were located in the preforaminal zone in four patients, and in the preforaminal and foraminal zones in three.
All patients experienced immediate relief from symptoms after surgery and satisfactory results at the final follow-up. Surgical complications, such as a dural tear, nerve injury, and surgical site infection, were not investigated.
TL-MEH seemed to be an effective and safe alternative minimally invasive surgical option for patients with a cranially migrated lumbar disc herniation encroaching the exiting nerve root in the preforaminal and foraminal zones.
Lumbar disc herniation; Endoscopic surgery; Translaminar approach; Tubular surgery
Prospective randomized study of antibiotic prophylaxis in elective spine surgery.
The aim of this study was to compare the rate of postoperative surgical site infection for a single dose of two different generations of cephalosporin with different dosage and timing of the antibiotics.
Overview of Literature
Current recommendation for prophylaxis in elective spine surgery is up to 60 minutes prior to incision. No study has investigated between different generation of cephalosporin for prophylaxis in elective spine surgery with respect to choice, dosage and timing.
This study was a prospective randomized study of 90 patients, assessed for the occurrence of surgical site infection (defined by the Centers for Disease Control and Prevention criteria) and other infections for up to 6 months after surgery. Demographic, surgical and further data were collected on subsequent operations, including hardware removal.
Mean age in our group was 47 years (range, 19-71 years). The male to female ratio was 49:41 and the average timing of administration of antibiotics was 77 minutes (range, 30-120 minutes). The average blood loss was 626 mL (range, 150-3,000 mL) with a mean duration of surgery for 3.2 hours (range, 1.5-6 hours). One case of superficial infection and one case of deep infection met the exclusion criteria.
Our results support the use of a single preoperative dose of antibiotics in instrumented and non-instrumented elective spine surgery up to one hour prior to incision. There was no difference in terms of occurrence of surgical site infection with respect to dosage, choice and timing of antibiotics.
Antibiotic prophylaxis; Spine; Surgical site infection
A prospective analysis of an adaptive change of the spinopelvic alignment after total knee arthroplasty.
To evaluate the effect of correction of the contractured knee in flexion on the spinopelvic alignment by total knee arthroplasty.
Overview of Literature
Flexion contracture of the knee joint may affect the body posture and precipitate the symptoms in the lumbar spine, which is known as the 'knee-spine syndrome'.
Fifteen patients who could be followed at least over 12 months were used in this study. Neutral whole spine lateral standing radiograms taken at certain intervals were analyzed. The subjects were divided into two groups (group A, the patients who obtained over 10° correction; group B, the others). The sacral slope, the pelvic tilt and the pelvic incidence were measured preoperatively and at 12 months and thereafter postoperatively in all the patients. Also, the thoracic kyphosis, lumbar lordosis, and lumbosacral angle were measured, including the spinal sagittal balance, S1 overhang and spino-sacral angle.
The average correction of the contractured knee in flexion were 13.8° in group A and 2.7° in group B. The median of changes of the sacral slope were 4.2° in group A and -0.4° in group B. These results revealed that there was a significant increase of the sacral slope for group A (p=0.001). However, there were no significant differences between the other parameters.
The sacral slope appears to be affected by the change of the flexion contracture after total knee arthroplasty.
Sagittal; Alignment; Spine; Pelvis; Total knee arthroplasty
Prospective study of changes in intervertebral disc degeneration after injection of bupivacaine.
To examine whether injection of bupivacaine into human intervertebral discs accelerates their degeneration.
Overview of Literature
Bupivacaine is commonly used for therapy and diagnosis of discogenic low back pain. However, several in vitro studies have reported toxic effects of bupivacaine to disc cells. We sought to evaluate whether this finding is clinically relevant.
We selected 46 patients with low back pain who showed disc degeneration at only one level (L4-L5 or L5-S1) on magnetic resonance imaging (MRI) (discography group, n=18), discoblock group (injection of bupivacaine, n=18), and a control group, n=10). There were no significant differences in baseline characteristics across the 3 groups. The two experimental groups underwent either discography or anesthetic discoblock, respectively. All three groups were followed up 5 years after the examination.
At 5 years follow-up, there was no significant difference in the rate of disc degeneration among the 3 groups (p>0.1). Moreover, X-ray images showed that there was no significant difference in disc height, range of motion, or translation between flex and extension position (p>0.1).
In conclusion, radiologic and MRI findings did not show acceleration of intervertebral disc degeneration at 5 years after a single injection of bupivacaine into human discs.
Lumbar vertebrae; Intervertebral disc degeneration; Bupivacaine
We describe four cases of delayed union in female patients with severe osteoporotic vertebral fractures, which were treated in a similar but less costly method to kyphoplasty. Due to domestic regulations, inflatable tamps for kyphoplasty are not available to every clinical orthopedists in Japan. In our clinical experience of four cases of delayed lumbar spine union between 2009 and 2010, we performed vertebroplasty using a reduction and spreading prod (Oyamada prod) for fracture reduction and a pediatric uromatic balloon (Medicon Co. Ltd.) to enlarge the pre-existing cavity. Our clinical results were comparable to those of kyphoplasty procedures performed in the USA. Our procedure could be used to overcome the shortage of medical supplies in developing countries or in countries such as Japan, which often prioritize financial concerns over providing optimal health care. Our method could serve as a useful compromise for moribund patients considering its cost efficiency.
Osteoporotic vertebral fracture; Kyphoplasty; Pediatric uromatic balloon; Cost-efficiency
Here, we report on a rare case of a giant invasive sacral schwannoma. The patient was a 58-year-old woman who had a 6-year history of non-specific buttock pain. Histological investigation confirmed the diagnosis of cellular schwannoma. The following numerical aberration was detected using the GTG-banding method for karyotypes: 47,XX,-14,+18,+22. Cytogenetic studies of schwannomas have indicated a complete or partial loss of chromosome 22 as the most common abnormality, but this case is cytogenetically rare because of the recurrence of trisomy 22.
Sacrum; Neurilemmoma; Cytogenetics
Symptomatic Tarlov (perineural cysts) are uncommon. In the following hemodialysis case, cauda equina syndrome was not detected after combined spinal-epidural anesthesia untilthe patient reported a lack of sensation in the perianal area 14 days postoperatively. She had normal motor function of her extremities. A laminectomy and cyst irrigation was performed. After the operation, her sphincter disturbance subsided gradually and her symptoms had disappeared.
Cauda eqina syndrome; Perineural cyst; Hemodialysis
We describe a rare case of lumbar spinal stenosis due to a large calcified mass in the ligamentum flavum. This patient presented with a 12-month history of severe right leg pain and intermittent claudication. A computed tomography scan was performed, revealing a large calcified mass on the ligamentum flavum at the right-hand side of the lumbar spinal canal. We performed a laminotomy at the L4/5 level with resection of the calcified mass from the ligamentum flavum. The findings of various analyses suggested that the calcified mass consisted mostly of Ca3(PO4)2 and calcium phosphate intermixed with protein and water. The calcified mass in the ligamentum flavum was causing lumbar spinal stenosis. Surgical decompression by resection of the mass was effective in this patient. The calcified material was composed mainly of elements derived from calcium phosphate. Degenerative changes in the ligamentum flavum of the lumbar spine may have been involved in the production of this calcified mass.
Spinal stenosis; Calcification; Ligamentum flavum; Calcium phosphate
Gorham's disease is a rare disorder characterized by clinical and radiological disappearance of bone by proliferation of non-neoplastic vascular tissue. The disease was first reported by Jackson in 1838 in a boneless arm. The disease was then described in detail in 1955 by Gorham and Stout. Since then, about 200 cases have been reported in the literature, with only about 28 cases involving the spine. We report 2 cases of Gorham's disease involving the spine and review related literature to gain more understanding about this rare disease.
Gorham's disease; Spine
For about 20 years, vertebroplasty has been used to achieve relief from pain and improve function in eligible patients affected by vertebral fractures. The procedure is also performed in patients with tumours of the vertebral body. The aim of this study was to investigate, by means of a literature review, correlations between vertebroplasty and the need for rehabilitation after patients with tumour-related vertebral fractures were operated on. This review was based on literature from the US National Library of Medicine, National Institutes of Health (PubMed), using the following Medical Subject Headings (MeSH) terms: "vertebroplasty," "surgical procedures minimally invasive," "bone neoplasm," "spine," "postoperative care," "rehabilitation," and "exercise." In total, 14 citations were retrieved: potentially relevant studies were identified by searching titles and abstracts, and then the full text of the selected articles was reviewed. From this review, the postoperative course of vertebroplasty today does not strictly indicate the need for rehabilitation.
Spine; Bone neoplasm; Surgical procedures, minimally invasive; Vertebroplasty; Postoperative care
This was designed as a retrospective study.
We investigated the relationship between bone mineral density (BMD) and chronic lower back pain (LBP).
Overview of Literature
In spite of a large number of epidemiological surveys on the prevalence of LBP and BMD measurements completed separately in the general population, the relationship between the two has not been well documented.
The study included 171 patients with chronic LBP who underwent the BMD study. The control group was selected from our database regarding BMD without LBP.
A total of 678 subjects, aged 18 to 100 years (mean, 49.9±12.9 years) were included in the study, 25% (n=171) of the subjects had LBP. Compared to those patients without LBP, patients exhibiting LBP had statistically significant lower mean weight, hip and spine BMD and T-score. Lower BMD and T-scores were significant regardless of the age group, gender, menopausal status, and obesity classification.
Chronic LBP has a negative correlation with hip and spine bone mineral density.
Lumbar vertebrae; Hip; Bone density; Absorptiometry, Photon
When anterior reduction fail in the surgical treatment of cervical bilateral facet fracture-dislocation with concomitant disc extrusion, it is necessary to perform a reduction using a posterior approach and then a third anterior procedure is often necessary to accomplish the anterior reconstruction. This presents difficulties for both patients and surgeons because of the need for frequent position changes (supine-prone-supine). The purpose of this study is to illustrate a modified surgical technique, which is anterior reduction and fixation with a prefixed polyetheretherketone (PEEK) cage to a buttress plate for the treatment of irreducible bilateral cervical facet fracture-dislocation with a prolapsed disc is an enhancing technique for the stability of the interbody graft than a buttress plate alone because the PEEK cage has more fixation power and reduces both the number of position changes and the length of the operation.
Fracture dislocation; Cage; Anterior reduction
We report a pediatric baseball player having both a fracture of the posterior ring apophysis and spondylolysis. He was presented to a primary care physician complaining of back pain and leg pain. Despite conservative treatment for 3 months, the pain did not subside. He was referred to our clinic, and surgical intervention was carried out. First, a bony fragment of the caudal L5 apophyseal ring was removed following fenestration at the L5-S interlaminal space, bilaterally: and decompression of the bilateral S1 nerve roots was confirmed. Next, pseudoarthrosis of the L5 pars was refreshed and pedicle screws were inserted bilaterally. A v-shaped rod was inserted beneath the L5 spinous process, which stabilized the pars defects. After the surgery, back pain and leg pain completely disappeared. In conclusion, the v-rod technique is appropriate for the spondylolysis direct repair surgery, especially, in case the loose lamina would have a partial laminotomy.
Spondylolysis; V-rod technique; Apophyseal ring fracture
This report is composed of two patients with anteriorly located cervical intradural arachnoid cyst and review of 24 cases in Englishlanguage literature. Both of our patients were in the first two decades of life with neck pain and motor weakness. With suspicious diagnosis of anterior arachnoid cyst surgery was carried out in both cases, though laminectomy in one and laminoplasty in the other. The cyst wall was widely fenestrated with subsequent subtotal excision of the cyst. Both cases had good long-term outcome. The review disclosed male predominance. 73% of the patients were diagnosed within the first two decades of life. Neck pain and motor weakness were the dominant signs and symptoms of this pathology. Magnetic resonance imaging showing a cerebrospinal fluid (CSF) containing cyst was the best mode of diagnosis. Wide cyst fenestration with waying CSF into subarachnoid cyst was the most appropriate and applied surgery with optimal outcome.
Cervical; Arachnoid cyst; Intradural; Review of the literature; Spinal
Hyperextension injury in the thoracic spine is uncommon with only a few cases documented in the literature. The mechanism of these injuries is hyperextension combined with axial or shearing force. These types of injuries are associated with a high risk of dural tears and paraplegia. A 91-year-old female presented with acute back pain from a hyperextension injury in thoracic spine with no neurological deficit. Lumbar magnetic resonance imaging showed a intervertebral disc rupture. On day 20 of hospitalization, the herniated intervertebral disc compressed the spinal cord with incomplete paraplegia. Hyperextension injuries involving the three columns are very unstable and we recommend surgical treatment as soon as possible, not only because of the initial trauma, but a ruptured disc herniation can damage the spinal cord.
Thoracic Vertebrae; Paraplegia; Disc herniation
Schmorl nodes represent displacement of intervertebral disc tissue into the vertebral body and have been considered as an asymptomatic incidental radiological finding on plain radiographs, computed tomography and magnetic resonance imaging (MRI). Although uncommon, acute symptomatic Schmorl nodes causing severe back pain do occur. We report here an unusual case of acute painful Schmorl node in a young healthy woman, with no previous trauma, presenting with a sudden significant localized back pain within hours accompanied by characteristic findings on a MRI scan. We reviewed all reports of symptomatic Schmorl nodes known in the literature, focusing mainly on MRI findings, and recent treatment options.
Magnetic resonance imaging; Acute painful Schmorl node; Intravertebral disc herniation
Lumbar epidural varices are rare and usually mimick lumbar disc herniations. Back pain and radiculopathy are the main symptoms of lumbar epidural varices. Perineural cysts are radiologically different lesions and should not be confused with epidural varix. A 36-year-old male patient presented to us with right leg pain. The magnetic resonance imaging revealed a cystic lesion at S1 level that was compressing the right root, and was interpreted as a perineural cyst. The patient underwent surgery via right L5 and S1 hemilaminectomy, and the lesion was coagulated and removed. The histopathological diagnosis was epidural varix. The patient was clinically improved and the follow-up magnetic resonance imaging showed the absence of the lesion. Lumbar epidural varix should be kept in mind in the differential diagnosis of the cystic lesions which compress the spinal roots.
Epidural; Varix; Perineural cyst; Surgery
Intradural extramedullary spinal ependymomas are extremely rare. Herein, we describe a lesion-type spinal ependymoma that followed a malignant course, and discuss its clinical presentation, etiopathogenesis, and treatment. We present a patient who was diagnosed with an intradural extramedullary spinal tumor at T4-T6. The patient underwent gross total resection of the tumor without damage to the spinal cord. Histological examination, classified the lesion as a World Health Organization (WHO)-grade 2 ependymoma. One and a half years later, magnetic resonance imaging detected a recurring tumor at T4-T5. The tumor was removed and classified as a WHO-grade 3 anaplastic ependymoma. The patient was started on a course of regional spinal cord radiotherapy. The patient achieved tumoral control and clinical stabilization after the recurrence. We must consider the differential diagnosis of intradural extramedullary spinal tumors. The best treatment for this lesion is gross total resection and adjunctive radiotherapy is necessary in cases of malignant-change.
Ependymoma; Intradural extramedullary spinal cord neoplasms; Spinal cord tumor
We report herein the case of an 18-year-old man who underwent endoscopic resection for an osteoid osteoma in the seventh cervical facet joint. The patient had experienced right neck pain for approximately one year, but no neurological abnormalities were noted. Cervical magnetic resonance imaging suggested an osteoid osteoma in the superior articular process of the seventh cervical vertebra. The tumor was resected microendoscopically. Operative time was 1 hour 29 minutes, and blood loss was 5 mL. During the two years since surgery, the patient has remained pain free with no cervical spine instability. We thus propose microendoscopic surgery for osteoid osteoma developing in a posterior element of the cervical spine is a potentially effective operative procedure.
Endoscopic surgery; Osteoid osteoma; Cervical spine