Search

Skipped multifocal pyogenic spondylodiscitis is a rare presentation of spinal infection. In our institution, we used the single posterior approach for circumferential debridement and anterior reconstruction with fibular allograft for treatment. This study aimed to ascertain the viability and reliability of this technique for these difficult cases.Nine patients with skipped pyogenic spondylodiscitis who received our treatment method from January 2012 to December 2019 were enrolled in this study. Visual analog scale scores, causative agents, laboratory data, comorbidities, and complications were recorded. The patients' clinical conditions were evaluated based on modified Brodsky's criteria, visual analogue scale, and Oswestry Disability Index.All the patients achieved infection eradication without repeat surgical treatment. The average visual analog scale score was 8.4 (range, 8-9) before operation, which decreased to 1.9 (range, 1-3) 1 year after the surgery. No patient experienced severe complications such as neurologic deterioration or fixation failure. All patients achieved a good or excellent outcome based on modified Brodsky's criteria. The Oswestry Disability Index improved from 80.4 (range, 70-86) preoperatively to 25.1 (range, 20-32) 1 year after the surgery.In our case series, good clinical outcomes and high successful rates could be achieved through the single-stage posterior-only approach. This could be considered an alternative method to manage patients with skipped pyogenic spondylodiscitis.

Benign prostatic hyperplasia is one of the most common diseases in the elderly male population. The urinary tract symptoms may increase the risk of falls and fractures. The results indicated that patients with benign prostatic hyperplasia could increase the risk of vertebral compression fractures in both the thoracic and lumbar spine and also hip fractures, but did not increase the risk of wrist fracture. The relationship between benign prostatic hyperplasia and the development of fall-related fractures, especially vertebral compression fractures, has been seldom mentioned in the literature. This study aimed to evaluate the risk of developing vertebral compression fracture, hip fracture, and wrist fracture in patients with benign prostatic hyperplasia. This study obtained claims data retrospectively from the National Health Insurance Research Database of Taiwan and identified 48,114 patients who were diagnosed as having benign prostatic hyperplasia. Subjects of the control cohort were individually matched at a ratio of 4:1 with those in the benign prostatic hyperplasia cohort according to age and the index day. Comorbidities were classified as those existing before the index day and included a previous fracture history, osteoporosis, myocardial infarction, congestive heart failure, diabetes mellitus, hypertension, cerebrovascular accident, etc. The end of the follow-up period of the analyses was the day when the patient developed new vertebral compression fractures, hip fractures, or wrist fractures, terminated enrollment from the National Health Insurance, or died or until the end of 2012. The study used the Cox proportion hazard model to determine the hazard ratio for developing new hip fractures. Patients with benign prostatic hyperplasia were significantly more likely than those in the control cohort to develop new vertebral compression fractures in the thoracic spine (0.43% vs. 0.40%, adjusted hazard ratio 3.03, confidence interval 2.12–4.31) and lumbar spine (1.26% vs. 1.23%, adjusted hazard ratio 4.12, confidence interval 3.39–5.01), and hip fracture (1.47% vs. 2.09%, adjusted hazard ratio 1.22, confidence interval 1.10–1.36), but does not increase the risk of wrist fracture (0.61% vs. 0.67%, adjusted hazard ratio 1.07, confidence interval 0.85–1.34). Patients with benign prostatic hyperplasia exhibited an increased risk of developing vertebral compression fractures in both the thoracic and lumbar spine and also hip fractures, but did not increase the risk of wrist fracture. However, more research is needed to confirm this trend in the clinical setting.

We present a 57-year-old female patient with iatrogenic lateral plantar nerve injury caused by endoscopic surgery for plantar fasciitis. Nerve grafting surgery was recommended, but the patient refused further surgical intervention because of personal reasons. After 1-year follow-up in outpatient clinics, she achieved only slight improvement in the lateral foot symptoms and still required oral analgesics for pain control. The purpose of this case report is to remind physicians of such a rare and serious complication that can occur after endoscopic surgery for plantar fasciitis. Good knowledge of anatomy and skilled surgical technique could decrease this type of complication.

Additional file 1.

Purpose To biomechanically compare the stability between open repair and arthroscopic transosseous repair technique for reattachment of the foveal triangular fibrocartilage complex (TFCC). We also evaluated the feasibility of a new aiming device for the creation of 2 bone tunnels simultaneously during the arthroscopic technique. Methods Six matched pairs of fresh-frozen forearm cadaver specimens were prepared for testing. Group I specimens were treated by open repair with suture anchor. Group II specimens were treated by arthroscopic transosseous suture with a new aiming device. Before and after disruption of the TFCC fovea and after its repair, dorsal and palmar translation of the ulna was measured in both groups in response to a load (3 kg) applied in the palmar and then in the dorsal direction. The total translation of the ulna was calculated as the sum of the mean dorsal and palmar translations. Results The mean total ulnar translation before and after TFCC disruption, and after TFCC repair was 5.94 ± 2.16 mm, 9.08 ± 2.64 mm, and 6.04 ± 2.18 mm, respectively. The specimens demonstrated a significant increase in the total translation of the ulna after disruption of the ulnar attachment of TFCC ( P = .003), whereas a significant decrease was observed after TFCC foveal repair ( P = .003). The median percentage of eliminated translation after TFCC repair was 64% and 172%, respectively, in groups I and II ( P = .043). Conclusions The athroscopic transosseous suture technique demonstrated superior repair efficacy to the open repair technique in terms of biomechanical strength. This cadaveric study also demonstrated the feasibility of a new aiming device. Clinical Relevance When making decisions about TFCC foveal repair, arthroscopic transosseous suture technique may provide better biomechanical strength than the open repair technique.

The purpose of this study was to investigate pullout strength of three types of pedicle screws with and without cement augmentation in osteoporotic bone using finite element analysis.Twelve 3D finite element models were created to investigate the effect of pullout strength when comparing between pedicle screw types and bone cement clouds. The bottom side of bone block model was constrained and U-shape head was applied 1 mm in direction of longitudinal axis of pedicle screw to perform pullout resistance. The material properties of the FEA was set as linear elastic, homogenous, isotropic condition. The element sensitivity of convergence testing has been performed and variation of the sequential analytical results was less than 3%.The results showed that the maximum total reaction force (133.8 N) was detected in the model of cannulated pedicle screw combined with a central pin with 4 ml cement augmentation, but, in contrast, the minimum total reaction force (106.8 N) was discovered in the model of cannulated pedicle screw without cement. A strong relationship (r = 0.9626) is found in comparison with the biomechanical results between pullout strength of sawbone testing and reaction forces of the FEA.The study concludes that the cannulated pedicle screw can not only provide an inner guider for cement flow and increase bending resistance (deflection effect) when a central pin is selected, but also can improve the pullout strength in the osteoporotic bone to add cement augmentation. The design of the cannulated pedicle screw is suggested for poor bone quality to change pullout failure.

Epidural fibrosis is an inevitable aspect of the postoperative healing process which is one of the causes of failed back surgery syndrome following spinal surgery. The aim of the present study was to examine the inhibitory effect of 1,4-butanediol diglycidyl ether-crosslinked hyaluronan (cHA) on spinal epidural fibrosis in a swine model. Epidural fibrosis was induced through conduction of hemi-laminotomy (L2 and L3) or laminectomy (L4 and L5), while L1 was assigned as the control group in six pigs. The cHA was applied to L3 and L5 surgical sites. MRI evaluation, histologic examination, expressions of matrix metalloproteinases (MMPs), and cytokines in scar tissue were assessed four months after surgery. cHA treatment significantly decreased the scar formation in both hemi-laminotomy and laminectomy sites. cHA also significantly increased MMP-3 and MMP-9 expression in scar tissue. Further, the epithelial-mesenchymal transition -related factors (transforming growth factor-β and vimentin) were suppressed and the anti-inflammatory cytokines (CD44 and interleukin-6) were increasingly expressed in cHA-treated sites. The current study demonstrated that cHA may attenuate spinal epidural fibrosis formation after laminectomy surgery by enhancing the expression of MMPs and anti-inflammatory pathways.

This study examined the relationships between the factors that influence residents&rsquo, attitudes toward supporting for sustainable tourism in an island context. A quantification approach was employed to obtain the residents&rsquo, perspectives. This study collected 384 valid questionnaires from the residents and analyzed the collected data using structural equation modeling to test the model. The findings revealed that the Maximizing Community Participation dimension demonstrated a positive direct effect on residents&rsquo, support for sustainable tourism, and this dimension explained most of the variance in the model. The Perceived Economic Benefits dimension exhibited a positive direct effect on the residents&rsquo, support for sustainable tourism. Perceived Economic Benefits mediated the effect of Environmental Sustainability on support for sustainable tourism. The findings provide practical implications for policy makers on the promotion of sustainable tourism.

Tibiotalocalcaneal (TTC) arthrodesis with retrograde nail is a widely used treatment option for severe ankle arthropathy. With inherent biomechanical benefits in axial loading and strong bending stiffness, high union rate and good clinical outcomes have been reported in the literature. However, some undesired complications, such as osteomyelitis or implant failure, can develop after this procedure. Herein, we report the case of an 86-year-old man with right ankle osteomyelitis after TTC arthrodesis with retrograde nail. After removing the previous implants and extensive debridement, we used an antibiotic cement nail with multiple screws fixation as a salvage procedure in the same operation. The patient fully recovered without further surgical treatment.

The conventional screw is unable to provide enough screw-bone interface strength for osteoporotic cencellous bone, and complications resulting from loosening or failure of the implants remain a significant clinical problem. Hence, the purpose of this study is to investigate pullout strength and energy in three types of the pedicle screws, including conventional solid pedicle screw, cannulated pedicle screw, and cannulated pedicle screw with a central pin, using osteoporotic sawbone test block with different bone cement volumes through pullout force testing.The control group (n = 15) of the osteoporotic sawbone test block includes groups A, B, and C to reflect three types of the pedicle screws without bone cement augmentation. The cemented group (n = 45) of the osteoporotic sawbone test block includes groups D1, D2, D3, E1, E2, E3, F1, F2, and F3 to reflect three types of the pedicle screws with PMMA bone cement of 2, 3, and 4 mL augmentation.The results showed that the pullout strength and energy in the cemented group were significantly larger than that in the control group. Moreover, the best performances of the pullout strength and energy in the cemented group were evidenced obviously in the case of cannulated pedicle screw with a central pin with 4 mL bone cement augmentation.This study concludes that cement argumentation in the cannulated pedicle screw with a central pin can increase a pullout strength of pedicle screw for severe osteoporotic patients while bone cement of injective volume is limited.

The aryl hydrocarbon receptor (AhR) is a ligand-dependent transcription factor whose activity is modulated by xenobiotics and physiological ligands. Activation of the AhR by environmental xenobiotics may induce a conformational change in AhR and has been implicated in a variety of cellular processes, including inflammation and tumorigenesis. It is unknown whether the activation of AhR serves a role in modulating the progression of osteosarcoma. The osteosarcoma cell line MG-63, was treated with AhR ligand, 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD). TCDD treatment degrades AhR expression through activation of the AhR signaling pathway, however there were no survival differences observed in MG-63 cells. There were concomitant elevations of cyclooxygenase-2 and receptor activator of nuclear factor-κB ligand secretion from MG-63 cells upon TCDD treatment on a protein and mRNA level at 24 and 72 h. In addition, TCDD treatment also increases the production of prostaglandin E2 on MG-63 cells, and induces the expression of chemokine receptor CXCR4. However, CXCL12 production was not altered in MG-63 cells when stimulated with TCDD. The AhR antagonist CH-223191, blocks the effects on TCDD-induced RANKL, COX-2, PGE2 and CXCR4 changes. In conclusion, these findings suggest that AhR signal therapy should be further explored as a therapeutic option for the treatment of osteosarcoma.

The dysfunction of voltage-gated ion channels contributes to the pathology of ischemic stroke. In this study, we developed rat models of transient ischemic attack (TIA) and reversible ischemic neurological deficit (RIND) that was induced via the injection of artificial embolic particles during full consciousness, that allow us to monitor the neurologic deficit and positron emission tomography (PET) scans in real-time. We then evaluated the infarction volume of brain tissue was confirmed by 2,3,5-triphenyl tetrazolium chloride (TTC) staining, and gene expressions were evaluated by quantitative real-time PCR (qPCR). We found that rats with TIA or RIND exhibited neurological deficits as determined by negative TTC and PET findings. However, the expression of voltage-gated sodium channels in the hippocampus was significantly up-regulated in the qPCR array study. Furthermore, an altered expression of sodium channel β-subunits and potassium channels, were observed in RIND compared to TIA groups. In conclusion, to our knowledge, this is the first report of the successful evaluation of voltage-gated ion channel gene expression in TIA and RIND animal models. This model will aid future studies in investigating pathophysiological mechanisms, and in developing new therapeutic compounds for the treatment of TIA and RIND.

Background and objective During bone drilling, the heat generated by friction depends directly on bone quality and surgical parameters. Excessive bone temperatures may cause thermal necrosis around the pilot hole, weaken the purchase of inserted screws, and in turn reduce the stability of screw fixation. A few studies have addressed the key parameters of drilling, such as the rotation speed of the drill-bit, feed force (axial force), feed rate, tool type, and tip geometry of drill-bits. Nevertheless, in the literature, information on the relationship between bone quality and thermally affected regions is still lacking. This study employed a three-dimensional dynamic elastoplastic finite element model to evaluate the influence of surgical parameters on the bone temperature elevation and assess the risk region of thermal necrosis for different bone qualities as a function of drilling parameters. Methods To ascertain the heat generation rate and the high-risk region of thermal necrosis, the effects of bone quality, feed rate, feed force, and drill-bit diameter on the bone temperature elevation were explained using a three-dimensional dynamic elastoplastic finite element model, which was validated through experimental measurements. Results The bone temperature was affected by the drilling parameters; the maximum temperature was attained at the junction of cancellous and cortical bones. The bone temperature increased with cortical bone thickness, bone density, and drill-bit diameter, and it decreased with the drilling speed and feed force. Conclusions The present model could assess the risk region of thermal necrosis by accurately analyzing the bone temperature elevation for various bone qualities, feed forces, and feed rates. The bone temperature increased with the bone mineral density and cortical bone thickness. The highest bone temperature and maximum necrosis region were found near the junction of cortical and cancellous bones. Increasing the drilling speed or feed force can minimize the bone temperature elevation and the risk range of thermal necrosis.

Objective: Confirmation of nasogastric tube (NGT) placement is sometimes difficult in clinical practice. Hence, the purpose of this study is to validate the accuracy of manometry for intragastric NGT placement confirmation in intubated, mechanically ventilated patients. Methods: A total of 100 adult patients who underwent elective open abdominal surgery and required gastric decompression were enrolled in this prospective descriptive study at a university-affiliated teaching hospital. The position of NGTs was verified by two blinded investigators, of whom the first investigator used the manometric technique and the second investigator used a fiberscope for verification. The manometric technique involved using a cuff pressure manometer to verify NGT placement. The primary measurements, sensitivity and specificity of the manometric technique in verifying NGT placement were calculated according to the standard findings of fiberoptic inspection. Results: In 81 of 100 NGT placements, intragastric placement was interpreted by the manometric technique. All of these 81 placements were confirmed by fiberoptic inspection. The manometric technique was therefore 100% sensitive. The 19 placements interpreted as extragastric placement by the manometric technique were confirmed by fiberscopy as being in the oral cavity, trachea, or esophagus, indicating 100% specificity. These results revealed 100% accuracy of the manometric technique in verifying intragastric placement of NGTs in intubated, mechanically ventilated patients. Conclusions: The manometric technique is a convenient, inexpensive, and highly accurate method for verifying NGT placement. This technique may be used to verify correct NGT placement for the purpose of gastric decompression and in those environments where a roentgenogram is not available.

NaY–SiO2 extrudate was prepared by blending NaY powder with silica gel, followed with kneading, extruding, and calcination. The impact of silica binder on the structure and surface properties of NaY–SiO2 extrudate was investigated. The nitrogen adsorption/desorption isotherm suggests the formation of cylindrical mesopores for NaY–SiO2. X-ray powder diffraction, transmission electron microscopy, and Fourier transform infrared suggest that in kneading, dealumination and cleavage of the intracrystalline Si–O–Al bond via acid hydrolysis occur. This acid hydrolysis causes shrinkage of the zeolite lattice along the zeolite channel due to dislodgement of Al3+ cations. The dealumination increases the silica/alumina ratio of NaY concomitantly with the removal of Na+, leading to an increase in the hydrophobicity of NaY, while reaction of the silica binder with NaY debris and/or aluminum residue forms new Bronsted acid sites. Moreover, backfilling the vacancies created in the dealumination by mobile Si(OH)4 makes th...

Vanadia redox catalysts, V2O5/SiO2, V2O5/TiO2, and V2O5/TiO2–SiO2 having different structures were prepared by incorporating vanadium oxytripropoxide on granular SiO2, TiO2 nano-particles, and TiO2-grafted-SiO2 pellets, respectively. In order to accelerate the catalyst deactivation, the catalysts were tested for oxidation of 1,2-dichlorobenzene (o-DCB) with temperature elevated from 200 to 550 °C. Using EXAFS and XRPD, the structural changes in the accelerated aging tests were characterized to assess the catalyst stability and the role of the grafted TiO2 in catalysis. The correlation of catalyst structures with catalytic reaction results indicated that: (1) the grafted TiO2 helps anchoring and dispersing vanadia in the catalyst preparation; (2) monomeric vanadia species with umbrella geometry, polymeric VO4, and TiVO4 coexisting with V2O5 clusters were formed on TiO2–SiO2 pellet, granular SiO2, and TiO2 nano-particles, respectively; (3) oxidative destruction of o-DCB induces the aggregation of vanadia species on the supports leading to a decrease of catalytic activity; (4) lower total oxidation selectivity for V2O5/TiO2 as opposed to the other two catalyst samples could be due to the presence of higher Bronsted-to-Lewis acid sites ratio; (5) a decrease of vanadium-atoms valence charge induced by TiO2–V2O5 interactions alleviates strong adsorption of oxygen-containing intermediates on vanadia sites, thereby increasing the reaction rate; and (6) hydration of vanadia in reaction could lead to aggregation of the vanadia species and catalyst deactivation.

During L3–5 instrumented spinal surgery for degenerative spondylolisthesis in a 75-year-old woman, the right L-3 pedicle screw was accidentally pushed into the retroperitoneum and then migrated to the inferior vena cava (IVC). The patient was transferred to the surgical intensive care unit, and after careful discussion with cardiology specialists, a minimally invasive endovascular technique was used to remove the migrating pedicle screw within the IVC and thus salvage this critical case.Pedicle screw instrumentation is an effective procedure, but not risk free. Every detail should be scrutinized during surgery, even instrument construction. A minimally invasive endovascular technique should be considered in this patient population.

To investigate bimetallic interactions, Pt-Ru/C catalysts were prepared by coimpregnation (Pt-Ruco/C) and successive impregnation (Ru-Ptse/C), while Pt/C, Ru/C, and reduced Pt-Rublackwere used as reference. Those samples were characterized by XAS and TPR. When Pt(absorber)-Ru(backscatter)phase-and-amplitude correction is applied to Fourier transformed (FT) EXAFS of Pt-Rublackat Pt edge, the characteristic peak of Pt-Ru interactions appears at 2.70 Å´, whereas, when Pt-Pt correction is applied, the peak appears at about 2.5 Å´. Detailed EXAFS analysis for Pt-Ruco/C and Pt-Ruse/C confirms the nature of the characteristic peak and further indicates that the interactions can semiquantitatively be determined by the relative intensity between Pt-Ru and Pt-Pt characteristic peaks. This simple method in determining bimetallic interaction can be extended to characterize Pt-Pd/γ-Al2O3. However, for Pt-Re/γ-Al2O3, Pt-Re interactions cannot be determined by the method because of the overlap of Pt-Pt and Pt-Re characteristic peaks due to similar phase functions.

Rationale: Stellate Ganglion Block (SGB) provides a blockade of sympathetic signals from the sympathetic chain and appears to be a promising method of controlling refractory ventricular arrhythmias, but there are scanty data in the literature. Patient concerns: Herein, we describe a 59-year-old male patient with a history of non-ischemic cardiomyopathy and suffering from frequent VT episodes, who received ICD implantation and regular amiodarone medication control. Diagnoses: Monomorphic VT refractory to standard medication control and focal extensive catheter ablation. Interventions: Left Stellate Ganglion Block (LSGB) was performed under ultrasound-assisted injection at the C6 level using a 10 ml solution of 0.4% lidocaine and 0.5% bupivacaine. Outcomes: In our case, refractory VT subsided and sinus rhythm was retained immediately after LSGB. There were no VT episodes for at least 3 hours during the inter-hospital transfer, which did not involve any specific complications. Lessons: LSGB may provide effective VT control and play an important role in rescue and bridge therapy before catheter ablation.

Purpose: The purpose of this study is to evaluate the efficacy of percutaneous endoscopic debridement and drainage (PEDD) in patients with surgical site infection (SSI) following instrumented lumbar fusion. Methods: We retrospectively reviewed the medical records of 20 patients (6 women and 14 men; average age, 60.1 years) who underwent PEDD at our institute to treat SSI following instrumented lumbar fusion from January 2010 to December 2015. The terminal event, or failure of PEDD treatment, was defined as a shift in treatment methods to open surgery. Risk factors were analyzed to determine their effect on the therapeutic results of PEDD. Clinical outcomes were assessed by careful physical examination, regular serologic testing, and imaging studies to determine whether continued conservative treatment or open surgery was necessary. Results: Causative bacteria was identified in 17 (85%) of the 20 biopsy specimens. Successful infection control through PEDD was identified in 13 patients (65%). Both the visual analog scale and Oswestry disability index significantly improved in these patients. Detection of the causative pathogens was the only risk factor influencing the terminal event in the remaining seven patients (35%). Conclusion: In this study, PEDD was an effective treatment approach for obtaining a bacteriological diagnosis, relieving the patient’s symptoms, and assisting in eradication of SSI following instrumented lumbar fusion. The use of species-specific antibiotics for the offending pathogens appears to be the most important factor to determine the success rate. The indications of this procedure could be extended to treat patients with SSI after instrumented lumbar fusion.

STUDY DESIGN A retrospective study. OBJECTIVE To evaluate the efficacy and safety of percutaneous vertebroplasty (PV) for treating patients with symptomatic osteoporotic vertebral compression fractures (VCFs) adjacent to lumbar instrumented circumferential fusion. SUMMARY OF BACKGROUND DATA Few studies have investigated adjacent VCFs and their management after spinal fusion surgery for degenerative lumbar disease. PATIENTS AND METHODS From January 2005 to July 2011, a total of 23 patients with lumbar instrumented circumferential fusion suffered from adjacent symptomatic osteoporotic VCFs. All of these patients received PV using polymethylmethacrylate bone cement augmentation in our institute. Radiography and magnetic resonance imaging were used for imaging studies. The visual analog scale and modified Brodsky criteria were used to compare clinical outcomes before and after surgery. The minimum follow-up period was 18 months (range, 18-45 mo). RESULTS One level PV was performed in 18 patients and 2 levels were performed in 5 patients. The patients' visual analog scale scores improved by an average of 54.3 points after the procedure. Twenty patients returned to their preinjury activities of daily living. Lumbar lordosis was increased from 28.9 degrees before PV to 36.2 degrees after PV. The average restoration of the fractured vertebral body height was 14.0%. No surgery-related complications occurred except asymptomatic cement leakage in 4 patients. CONCLUSIONS PV is a minimally invasive and effective procedure to treat patients with symptomatic osteoporotic VCFs adjacent to lumbar instrumented circumferential fusion.

Background Pyogenic spondylodiscitis is a form of spinal infection that can result in severe back pain and even death. However, information is lacking on the relative effectiveness of various therapies. A retrospective chart review was conducted to investigate whether early surgical treatment of pyogenic spondylodiscitis coupled with intravenous antibiotics results in better patient prognoses than intravenous antibiotics therapy alone. Methods All patients treated for pyogenic spondylodiscitis at a single medical center from July 2006 to July 2011 were retrospectively reviewed. The inclusion criteria consisted of diagnosis of an early stage infection without neurological deficit, and patients without severe sepsis who were suitable candidates for early surgery as determined by a Pittsburgh bacteremia score

STUDY DESIGN A case report. OBJECTIVE To inform the spine surgeons another cause of late complications after instrumented spinal fusion surgery. SUMMARY OF BACKGROUND DATA Posterior lumbar instrumented fusion has been widely applied as an effective procedure for treating patients with degenerative lumbar spine disease. The development of pathology at the mobile segment adjacent to the lumbar spinal fusion has been termed as adjacent segment disease. METHODS Most patients with adjacent segment disease present with recurrent back pain, sciatica, intermittent claudication, or even muscle weakness. Herein, we report the case of a 58-year-old man with posterior lumbar instrumented fusion at L4-L5 who complained of recurrent neurological symptoms mimicking adjacent instability and stenosis. In addition to severe adjacent stenosis at L3-L4, preoperative magnetic resonance imaging showed an intraspinal extradural tumor-like mass with compression of the neurological elements. RESULTS The well-capsulated tumor mass was gently dissected and meticulously excised without injury to the adhesive dura or nerve roots. The tumor specimen was fixed in formalin, and then decalcified and tinted using several special stains, which conformed metallic wear debris, resulting in foreign body reaction. CONCLUSIONS The metallic wear particulates may initiate a cascade of immune and inflammatory responses. Therefore, attention should be paid to patients who are found to have loosening of the implants at the metal-metal or metal-bone interface.

The Dynesys system is a nonfusion pedicle-screw stabilization system, an implant device designed to preserve intersegmental kinematics and reduce loading at facet joints. Several biomechanical in vitro experiments and clinical studies have proven the efficacy of the Dynesys. The most common complication associated with the use of this system is loosening of the pedicle screw. We present here a case of a patient who developed the rare complication of pedicle screw breakage following Dynesys instrumentation. Seven months after surgery, the patient experienced progressive, intractable back pain radiating to both the buttocks. Radiography revealed breakage of the left L5 pedicle screw in addition to a halo sign around the right pedicle screw. Revision surgery with a new Dynesys instrumentation and autologous bone graft was used to treat this complication.

Objective In response to the major concerns of cement leakage and associated neurological injuries with regards to percutaneous vertebroplasty, balloon kyphoplasty (BK) was devised and introduced in 1998. This study retrospectively evaluated the clinical outcomes and radiological findings of the first 100 patients receiving BKs because of osteoporotic vertebral compression fractures (VCFs) at our institute. Materials and Methods A total of 100 patients (85 female and 15 male) with 130 osteoporotic VCFs undergoing BKs from January 2007 to July 2009 were enrolled. BK using VCFX (Central Medical Technologies, Taiwan) and associated polymethylmethacrylate augmentation was performed on these patients with symptomatic VCFs that responded poorly to conservative therapy. All patients received preoperative magnetic resonance imaging to determine which level needed BK. Radiographies were used for preoperative and postoperative imaging studies. A Huskisson’s visual analog scale was used to compare the clinical result of pain relief before and after surgery. Results The rupture of 20 (15.4%) balloons was noted during the operations. Nineteen (14.6%) cement leakages were found postoperatively, 7 cement leakages with balloon rupture and 12 with balloon integrity. No neurological complications occurred for either balloon rupture or integrity postoperatively. The visual analog scale scores improved from 87 preoperatively to 32 at final follow-up visit. Eighty-six patients returned to their preinjury activities of daily living and achieved better quality of life than their preoperative status. The average restoration of the fractured vertebral body height was 36.5%. The average correction of the sagittal alignment was 7.2°. Conclusions BK is an effective and low-risk method to treat painful osteoporotic VCFs. However, balloon rupture with Telebrex contrast medium extravasation is troublesome and can obscure the visual field of intraoperative fluoroscopy influencing the following injection of bone cement.

Purpose: Sacral insufficiency fractures (SIFs) can cause severe lower back pain and immobility, which have limited therapeutic options. No previous studies have compared clinical outcomes and radiographic findings of sacroplasty with or without balloon assistance for the treatment of SIFs. Methods: Forty-five patients with SIFs were divided into two groups. One group had 18 patients treated using sacroplasty with balloon assistance, and the other had 27 patients treated without balloon assistance. The operation time and cement injection volume were compared between these two groups. Clinical outcomes were evaluated using visual analog scale (VAS), Oswestry Disability Index (ODI), and Odom’s criteria. Cement leakage rate was examined by postoperative radiography and computed tomography. Results: Sacroplasty with balloon assistance was associated with significantly longer operative time ( p = 0.003) and larger cement injection volume ( p = 0.038). Cement leakages were found in 4 of 18 patients (22.2%) with balloon assistance and 15 of 27 patients (55.6%) without balloon assistance, which showed significant difference ( p = 0.027). No significant differences were observed between sacroplasty with and without balloon assistance with regard to clinical outcomes including improvement in VAS, ODI, and Odom’s criteria. Conclusions: Sacroplasty with balloon assistance was shown to achieve greater cement injection with longer operation time and can decrease the risk of cement leakage. Both sacroplasty with and without balloon assistance showed good-to-excellent clinical outcomes for the treatment of SIFs.

Identifying offending pathogens is crucial for appropriate antibiotic administration for infectious spondylitis. Although computed tomography (CT)-guided biopsy for bacteriologic diagnosis is a standard procedure, it has a variable success rate. Some reports claim percutaneous endoscopic discectomy and drainage offer a sufficient amount of tissue for microbiologic examination and easy application. We therefore compared the diagnostic value of CT guidance with that of endoscope guidance in 52 patients with suspected infectious spondylitis. Twenty patients underwent percutaneous endoscopic discectomy and drainage by an orthopaedic surgeon and the other 32 patients underwent CT-guided biopsies by a radiologist. Patients were followed a minimum of 12 months after treatment. Culture results of the biopsy specimens were recorded. Causative bacteria were identified more frequently with percutaneous endoscopy than in CT-guided biopsy (18 of 20 [90%] versus 15 of 32 [47%]). We observed no biopsy-related complications or side effects in either group. The data suggest percutaneous endoscopic discectomy and drainage yield higher bacterial recovery rates than CT-guided spinal biopsy. Level of Evidence: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Percutaneous vertebroplasty is widely discussed in the management of osteoporotic spinal compression fracture, but few reports are available concerning salvage procedures after failure of this technique. We studied 22 percutaneous vertebroplasty patients who required revision surgery upon presentation of new symptoms postoperatively. The indications for revision surgery included recurrent intractable back pain with no response to medical treatment, infectious spondylitis, cement leakage with neurologic deficit, and cement dislodgement and/or fragmentation. Five patients underwent repeated percutaneous vertebroplasty of the initially cemented vertebrae. Seventeen patients underwent anterior, posterior, or combined anterior and posterior surgery. Four patients required a third surgical procedure because of poor augmentation with cement, subsidence of the anterior bone graft, or pullout of the instrumentation. Finally, four (18%) patients underwent repeat vertebroplasty, two (9%) patients underwent anterior surgery only, one (5%) patient underwent posterior surgery only, and 15 (68%) patients underwent combined anterior and posterior surgery; all but one regained ambulatory status equivalent to that prior to surgery. In conclusion, percutaneous vertebroplasty is a simple and effective, but not risk- or complication-free procedure for the treatment of osteoporotic spinal compression fracture. The spine surgeon should be familiar with varied approaches and techniques for revision surgery. Combined anterior and posterior surgery seems to be the most secure salvage method to treat severely osteoporotic patients in whom percutaneous vertebroplasty initially failed.

In the classic Hirabayashi procedure, the lamina door is tethered open by sutures between the spinous process and facet capsule or para-vertebral muscle. Our early experiences showed, however, that the loosened sutures result in dislodgement and reclosure of the lifted lamina. We present a modified method to ensure secure fixation and prevent restenosis due to hinge closure.12 patients with cervical spondylotic myelopathy underwent unilateral open-door laminoplasty using suture anchor fixation between 2000 and 2004. The sutures were tied and fixed onto the holed lateral mass screws, instead of using the conventional suture technique. We used radiography, MRI, and CT for imaging studies. The Nurick score was used to assess severity of myelopathy, and the Japanese Orthopedic Association (JOA) score was used to evaluate clinical outcomes before surgery and at the last follow-up visit.All patients experienced functional improvement of at least 1 Nurick score after surgery. The JOA score for the 12 patients increased significantly from 6.9 (SD 3.0) before surgery to 13 (SD 1.6) at final follow-up. Postoperative radiography and CT showed increased sagittal diameter and canal expansion. Average preoperative and postoperative ranges of motion for the cervical spine were 48 (SD 4.6) and 36 (SD 2.7), respectively. No neurological deterioration due to hinge reclosure and no major surgery-related complications were observed during the follow-up period.Open-door laminoplasty using suture anchor fixation effectively maintains expansion of the spinal canal and resists closure while preserving alignment and flexibility. This modified technique is easy to use, has a low complication rate, and provides marked functional improvement for patients with cervical spondylolytic myelopathy.

Outstanding results have been achieved using vertebroplasty for the treatment of osteoporotic spinal compression fractures. However, few reports are available in the management of multiple-level compression fractures due to severe osteoporosis. This study prospectively evaluated the clinical and surgical outcomes of patients receiving vertebroplasty due to multiple-level osteoporotic spinal compression fractures. Eighteen patients underwent more than four levels of vertebroplasty due to multiple-level osteoporotic spinal compression fracture. All patients received a preoperative magnetic resonance imaging (MRI) check-up to determine which level needed vertebroplasty. Detailed evaluations were made in accordance with the patients’ clinical tracking, pre- and postoperative daily activities, Denis pain scale, and Roland–Morris score. After an average follow-up period of 36 months, the group receiving multiple-level vertebroplasty showed significant improvement, as registered on the Denis pain scale, Roland-Morris score, and in the activity of daily living. No major complications occurred during operation or postoperation, except one patient who expired due to suffocation at the rehabilitation center 3 weeks after vertebroplasty. The use of vertebroplasty with cement to treat multiple-level osteoporotic spinal compression fractures in the elderly does have value, and brings good results to patients which were previously unimaginable. Preoperative MRI to evaluate the non-union levels and determine which levels needed vertebroplasty is very important.

We evaluated the impact of lumbar instrumented circumferential fusion on the development of adjacent level vertebral compression fractures (VCFs). Instrumented posterior lumbar interbody fusion (PLIF) has become a popular procedure for degenerative lumbar spine disease. The immediate rigidity produced by PLIF may cause more stress and lead to greater risk of adjacent VCFs. However, few studies have investigated the relationship between PLIF and the development of subsequent adjacent level VCFs. Between January 2005 and December 2009, a total of 1936 patients were enrolled. Of these 224 patients had a new VCF and the incidence was statistically analysed with other covariants. In total 150 (11.1%) of 1348 patients developed new VCFs with PLIF, with 108 (72%) cases at adjacent segment. Of 588 patients, 74 (12.5%) developed new subsequent VCFs with conventional posterolateral fusion (PLF), with 37 (50%) patients at an adjacent level. Short-segment fusion, female and age older than 65 years also increased the development of new adjacent VCFs in patients undergoing PLIF. In the osteoporotic patient, more rigid fusion and a higher stress gradient after PLIF will cause a higher adjacent VCF rate. Cite this article: Bone Joint J 2015;97-B:1411–16.

Common management approaches for spinal infections include conservative administration of antibiotics and aggressive surgical debridement. Minimally invasive endoscopic treatment has been reported and is gaining widespread attention because of its simplicity and effectiveness. This study retrospectively evaluated the clinical outcomes of bilateral portal percutaneous endoscopic debridement and lavage with dilute povidone-iodine solution in the treatment of patients with lumbar pyogenic spondylitis. From January 2007 to December 2011, a total of 22 patients diagnosed with single-level lumbar pyogenic spondylitis underwent bilateral portal percutaneous endoscopic debridement and lavage with dilute povidone-iodine solution at the authors’ institution. Clinical outcomes were assessed by careful physical examination, visual analog scale pain score, modified MacNab criteria functional score, regular serologic testing, and imaging studies to determine whether percutaneous endoscopic debridement and lavage treatment was successful or if surgical intervention was required. Causative bacteria were identified in 19 (86.4%) of 22 biopsy specimens. Eighteen patients had satisfactory relief of back pain and uneventful recovery after this treatment. The success rate was 81.8% (18 of 22). Both visual analog scale and modified MacNab criteria scores improved significantly in successfully treated patients. No major surgical complications were noted, except for 3 patients who had residual or subsequent paresthesia in the affected lumbar segment. Percutaneous endoscopic debridement and lavage is a minimally invasive procedure that can yield a higher bacterial diagnosis, relieve back pain, and help to eradicate lumbar pyogenic spondylitis. It is an effective alternative treatment for patients with spinal infection before extensive open surgery. [ Orthopedics. 2015; 38(10):e856–e863.]

Background The goal of surgical management of metastatic spinal tumours is to remove the tumour mass, restore spinal stability and alignment, and provide a better quality of life. A single posterior transpedicular approach, with circumferential decompression, for anterior reconstruction has been advocated to reduce the risk of complication and morbidity associated with a combined anterior-posterior approach. The purpose of our study was to evaluate the clinical outcomes of patients who underwent a single posterior approach for anterior reconstruction at our institution to determine the feasibility and effectiveness of the approach, including the use of a cervical trabecular metal (TM) mesh cage as a vertebral body replacer. As a secondary aim, we evaluated the effect of accumulated experience with the surgical approach on clinical outcomes. Methods Twenty consecutive cases of single posterior approach were identified from a retrospective review of spinal surgeries performed at our institution between January 2009 and December 2012. Information on the following clinical outcomes was retrieved from the medical charts for analysis: visual analogue pain score (VAS); neurological status, classified on the Frankel scale; vertebral body reconstruction; spinal alignment, using Cobb’s angle; operative time; volume of blood loss; complications; and the modified Brodsky criteria score, which was used to classify functional recovery as excellent, good, fair, or poor. Results Pre- to post-surgical evaluation of outcomes demonstrated a significant decrease in pain (p