Adult spinal deformity: effectiveness of interbody lordotic cages to restore disc angle and spino-pelvic parameters through completely mini-invasive trans-psoas and hybrid approach

PURPOSE

The aim of the study is to assess and quantify the effectiveness of interbody lordotic cages applied by trans-psoas approach to improve radiographic parameters, showing the differences between completely mini-invasive and hybrid approach.

METHODS

We collected data of 65 patients affected by degenerative lumbar deformity/diseases and underwent mini-invasive lateral interbody fusion followed by percutaneous (group A, completely mini-invasive) or open (group B, hybrid) posterior instrumentation. A subgroup underwent anterior column realignment (ACR). We assessed statistical differences in preoperative and postoperative (at least 6-month) coronal and sagittal parameters, and disc angle (DA) at each level of cage application.

RESULTS

107 lordotic cages were implanted. Group B had the most significant mean changes, especially in coronal Cobb angle, sagittal vertical axis, lumbar lordosis (LL), pelvic incidence-LL mismatch and DA. Concerning DA, at each level of lordotic cage application, in group A changed from -2.9° preop to -6.5° postop (p = 0.01); in group B, DA changed from -2.6° to -9.5° (p = 0.002) and from +1° to -13.2° in patients underwent ACR.

CONCLUSIONS

Minimally invasive lateral lumbar interbody fusion is an effective technique in improving sagittal parameters. When combined with posterior open approach and/or application of ACR procedure greater corrections are possible.

Nonsurgical treatment of Mason type II radial head fractures in athletes. A retrospective study

OBJECTIVE

The best treatment for moderately displaced radial head fractures (Mason type II) still remains controversial. In cases of isolated fractures, there is no evidence that a fragment displacement of ≥ 2 mm gives poor results in conservatively treated fractures.

PATIENTS AND METHODS

We retrospectively reviewed 52 patients (31M, 21F) affected by an isolated Mason type II fracture, treated with a long arm cast for two weeks between 2008 and 2013. All patients had practiced sports before being injured. They were all either bicyclists, or baseball, boxers, basketball, rugby, tennis or football players. The mean follow-up was 36 months. Elbow and forearm range of motion were measured. The Mayo Elbow Performance Score, the Broberg and Morrey rating system and the Disabilities of the Arm, Shoulder and Hand Score (DASH score) were analyzed. Follow-up radiographs were examined for evidence of consolidation, late displacement, early arthritis and non-unions.

RESULTS

Flexion was slightly impaired in the injured limb when compared to the uninjured limb (137°± 6° versus 139°±5°) as were extension (-3°±6° versus 1°±4°, p < 0.05), supination (86°±6° versus 88°±3°), pronation (87°±4° versus 88°±6°) and valgus deviation (10°±4° versus 8°±3°, p < 0.05). 40 patients had no elbow complaints; 9 patients experienced occasional pain, 2 a mild instability of the elbow, and 4 a mild loss of grip strength. The DASH score was excellent in 48 patients (92.31%). In only 6 cases (11.53%) degenerative changes were greater in formerly injured elbows than in uninjured elbows. All patients returned to their previous sports activities.

CONCLUSIONS

Isolated Mason type II fractures can have a good or excellent mid-term functional outcome even when treated conservatively.

Intraspinal extradural benign fibrous histiocytoma of the lumbar spine in a pediatric patient. Case report and literature review

INTRODUCTION

Benign fibrous histiocytoma (BFH) is a rare skeletal tumor. Spinal localizations have been previously described in 17 cases, and this is the first report of BFH occurring at the lumbar spine in a pediatric patient.

CASE REPORT

A 13-year-old male complained lower limb motor and sensory impairment with severe claudication and urination disorders. A huge intraspinal, extradural mass at L4-L5 level, clearly evident on a preoperative MRI, caused dislocation and severe compression of the cauda equina nerve roots. After a biopsy, confirming BFH, a tumor resection and L4-S1 vertebral arthrodesis was carried out. At 1 year follow-up, no recurrence was detached on postoperative MRI, with complete neurological recovery.

DISCUSSION AND CONCLUSION

Review of the literature is discussed. Histological examination is mandatory for a correct diagnosis and plan of treatment. None of the pediatric patients treated for BFH have ever shown local relapse.

Pharmacologic approaches to treatment resistant depression: Evidences and personal experience

AIM: To review evidence supporting pharmacological treatments for treatment-resistant depression (TRD) and to discuss them according to personal clinical experience.

METHODS: Original studies, clinical trials, systematic reviews, and meta-analyses addressing pharmacological treatment for TRD in adult patients published from 1990 to 2013 were identified by data base queries (PubMed, Google Scholar e Quertle Searches) using terms: “treatment resistant depression”, “treatment refractory depression”, “partial response depression”, “non responder depression”, “optimization strategy”, “switching strategy”, “combination strategy”, “augmentation strategy”, selective serotonin reuptake inhibitors antidepressants (SSRI), tricyclic antidepressants (TCA), serotonin norepinephrine reuptake inhibitors antidepressants, mirtazapine, mianserine, bupropione, monoamine oxidase inhibitor antidepressant (MAOI), lithium, thyroid hormones, second generation antipsychotics (SGA), dopamine agonists, lamotrigine, psychostimulants, dextromethorphan, dextrorphan, ketamine, omega-3 fatty acids, S-adenosil-L-metionine, methylfolat, pindolol, sex steroids, glucocorticoid agents. Other citations of interest were further identified from references reported in the accessed articles. Selected publications were grouped by treatment strategy: (1) switching from an ineffective antidepressant (AD) to a new AD from a similar or different class; (2) combining the current AD regimen with a second AD from a different class; and (3) augmenting the current AD regimen with a second agent not thought to be an antidepressant itself.

RESULTS: Switching from a TCA to another TCA provides only a modest advantage (response rate 9%-27%), while switching from a SSRI to another SSRI is more advantageous (response rate up to 75%). Evidence supports the usefulness of switching from SSRI to venlafaxine (5 positive trials out 6), TCA (2 positive trials out 3), and MAOI (2 positive trials out 2) but not from SSRI to bupropione, duloxetine and mirtazapine. Three reviews demonstrated that the benefits of intra- and cross-class switch do not significantly differ. Data on combination strategy are controversial regarding TCA-SSRI combination (positive results in old studies, negative in more recent study) and bupropion-SSRI combination (three open series studies but not three controlled trails support the useful of this combination) and positive regard mirtazapine (or its analogue mianserine) combination with ADs of different classes. As regards the augmentation strategy, available evidences supported the efficacy of TCA augmentation with lithium salts and thyroid hormone (T3), but are conflicting regard the SSRI augmentation with these two drugs (1 positive trial out of 4 for lithium and 3 out of 5 for thyroid hormone). Double-blind controlled studies showed the efficacy of AD augmentation with aripiprazole (5 positive trials out 5), quetiapine (3 positive trials out 3) and, at less extent, of fluoxetine augmentation with olanzapine (3 positive trials out 6), so these drugs received the FDA indication for the acute treatment of TRD. Results on AD augmentation with risperidone are conflicting (2 short term positive trials, 1 short-term and 1 long-term negative trials). Case series and open-label trials showed that AD augmentation with pramipexole or ropinirole, two dopamine agonists, could be an effective treatment for TRD (response rate to pramipexole 48%-74%, to ropinirole 40%-44%) although one recent double-blind placebo-controlled study does not support the superiority of pramipexole over placebo. Evidences do not justify the use of psychostimulants, omega-3 fatty acids, S-adenosil-L-metionine, methylfolate, pindolol, lamotrigine, and sex hormone as AD augmentation for TRD. Combining the available evidences with our experience we suggest treating non-responders to one SSRI bupropion or mirtazapine trial by switching to venlafaxine, and non-responders to one venlafaxine trial by switching to a TCA or, if TCA are not tolerated, combining mirtazapine with SSRI or venlafaxine. In non-responders to two or more ADs (including at least one TCA if tolerated) current AD regimen could be augmented with lithium salts (mainly in patients with bipolar depression or suicidality), SGAs (mostly aripiprazole) or DA-agonists (mostly pramipexole). In patients with severe TRD, i.e., non-responders to combination and augmentation strategies as well as to electroconvulsive therapy if workable, we suggest to try a combination plus augmentation strategy.

CONCLUSION: Our study identifies alternative effective treatment strategies for TRD. Further studies are needed to compare the efficacy of different strategies in more homogeneous subpopulations.

Degenerative facet joint changes in lumbar percutaneous pedicle screw fixation without fusion

BACKGROUND

Aim of the study was to evaluate degenerative lumbar facet-joints changes after percutaneous pedicle screw fixation (PPSF) in the treatment of lumbar fractures.

MATERIALS AND METHODS

Thirty patients underwent short PPSF without fusion. CT-scan was performed in the pre- and post-operative time at four, eight and 12 months. The six zygapophyseal joints adjacent the fracture's level were evaluated.

RESULTS

At four months patients showed no differences between pre- and post-operative joint radiographic aspect. At eight and 12 months, CT-scan demonstrated a progressive degeneration only in the middle joints respectively in 21.42% and in 76.92% of the cases. All 10 disrupted facet joints showed progressive degenerative changes at eight and 12 months.

CONCLUSION

Lumbar percutaneous fixation without fusion induces little degenerations essentially collocated in the middle joints close to fracture level at eight and 12 months. In the proximal and distal joints adjacent the screws degenerative changes can be seen only when associated to pedicle-screw encroachment.

Variation in response to short-term antidepressant treatment between patients with continuous and non-continuous cycling bipolar disorders

OBJECTIVES

The study aimed to compare effectiveness and safety of short-term antidepressant treatment between patients with continuous (CCC) and non-continuous (N-CCC) cycling bipolar disorders.

METHODS

The study sample included 101 patients with bipolar disorder, 22 (21.8%) CCC and 79 (78.2%) N-CCC. Response was defined as a HDRS21 total score <7 at 12 weeks of treatment and remission as a ≥50% reduction of baseline HDRS21 total score sustained for 8 weeks.

RESULTS

Compared with N-CCC patients, CCC patients achieved a significantly lower percentage of response (respectively 50% vs. 82.3%, χ²=9.6, p=0.002) and remission (respectively 40.9% vs. 69.6%, χ²=6.11, p=0.013). Adjusted logistic regression analysis indicated that CCC patients were 4.3 times more likely to be non-responders and 3.3 times more likely to be non-remitters than N-CCC patients.

CONCERNING

AD safety, 1 (5.0%) CCC patient committed a suicide attempt and AD-emerging switch was observed in 2 patients with N-CCC (2.5%) and in 1 with CCC (4.5%).

LIMITATIONS

The observational nature of the study, retrospective assessment of course, and unblinded outcomes assessment.

CONCLUSIONS

Our findings indicate that the presence or absence of a free interval identifies two different forms of bipolar disorders with different response not only to prophylactic treatment, as previously reported, but also to short-term ADs. We submit that clinicians should take into consideration their patients׳ pattern of cycling when prescribing short-term AD treatment. Moreover, subtypes of bipolar disorders might be used as moderators of treatment response in studies assessing the efficacy or the effectiveness of antidepressant treatment.

Short-term antidepressant treatment of bipolar depression: are ISBD recommendations useful in clinical practice?

OBJECTIVES

The study aimed to test the effectiveness of the ISBD Guidelines for short-term AD treatment of BP depression.

METHODS

The study sample included 255 patients with mood disorders (154 UP, 49 BP-I, 52 BP-II). Response was defined as a HDRS21 total score<7 at 12 weeks of treatment and remission as a ≥50% reduction of baseline HDRS21 total score sustained for 8 weeks.

RESULTS

Response was achieved by 64.9% of patients with UP disorder, 75.5% of patients with BP-I disorder and 75.0% with BP-II disorder without significant differences (χ²=3.0, p=0.219). The remission rate did not differ significantly among groups (χ²=3.8, p=0.151). The dropout rate was significantly higher for patients with UP (18.2%) than for patients with BP-I (2%) and BP-II (7.7%) disorder (χ²=10.1, p=0.006). Concerning AD safety, one patient with BP-I depression committed a suicide attempt and AD-emerging switch was observed in 2.9% of patients, 2 with BP-I and 1 with BP-II disorder.

LIMITATIONS

The observational nature of the study and unblinded outcomes assessment.

CONCLUSIONS

Our findings confirm the usefulness of ISBD Guidelines for short-term AD treatment of BP depression. These patients appear to have similar response and remission rate to those observed in UP depression and do not exhibit significant switch rates or risk of suicide. Our results are limited to patients with pure bipolar depression (excluding those with broadly defined mixed states), treated with ADs-mood stabilizers combination. We suggest to partially modify ISBD Recommendations 1 and 4, to include potential responders and to improve safety.

Paracetamol-codeine compared to ketorolac for pain control in the Emergency Department

OBJECTIVE

Paracetamol /codeine has shown a strong analgesic activity in several studies conducted among different kind of subjects, including those with trauma. Nevertheless, its efficacy in patients accessing the Emergency Department (ED) for different kind of pain has never been tested.

PATIENTS AND METHODS

This is a cross-sectional, observational, prospective, cohort study. Inclusion criteria were patients > 18 year old presenting to the ED for localized traumatic or inflammatory pain involving only extremities. Numeric scale (NRS) was recorded thirty minutes and two hours after the administration of the analgesic therapy, consisting of 15 mg of ketorolac or 1000 mg/60 mg of paracetamol/ codeine, both orally.

RESULTS

Two-hundred patients were consecutively enrolled; 87 were treated with paracetamol/codeine and 113 with ketorolac. The combination paracetamol/codeine resulted to be not inferior to ketorolac in non-traumatic pain group and trauma group (p = 0.635 and p = 0.482, respectively). Compared to ketorolac, the combination paracetamol/codeine exerted a significantly higher analgesic activity in patients with fractures and muscular pain (p = 0.044) and was more effective in acute pain (p = 0.002), with a significant effect two hours after the administration (p = 0.029).

CONCLUSIONS

Paracetamol/codeine is equivalent to ketorolac in non-traumatic pain and post-traumatic pain, but is superior in acute pain and in patients with fractures and muscular pain. Those results play in favor of the use of the combination paracetamol/codeine in patients accessing the ED for non-traumatic or traumatic pain of the extremities.

The impact of sagittal balance on low back pain in patients treated with zygoapophysial facet joint injection

INTRODUCTION

Aim of the study was to evaluate the effectiveness of facet joints injections in lumbar facet syndrome correlating clinical results to the sagittal contour of the spine.

METHODS

Facet joints degree degeneration was evaluated using MRI according to Fujiwara classification. Sagittal contour of the spine was evaluated according to Roussouly classification. The clinical results were evaluated with visual analog scale (VAS) at regular intervals.

RESULTS

Twenty-eight (70 %) of the 40 patients had clinical symptoms improvement, 12 (30 %) showed no benefit. There was a statistical significant correlation between postoperative VAS value improvement and Roussouly spine type 1 and 3 (p = 0.003). The benefit was more durable in patients with grade 2 or 3 degeneration.

CONCLUSIONS

Facet joints injections have a more effective diagnostic than therapeutic value. The procedure could, however, give a temporary pain relief in cases with an overload of the facet joints due to lumbar hyperlordosis.

Posterior percutaneous reduction and fixation of thoraco-lumbar burst fractures

BACKGROUND

Treatment of A3 thoraco-lumbar and lumbar spinal fractures nowadays remains a controversial issue. Percutaneous techniques are becoming very popular in the last few years to reduce the approach-related morbidity associated with conventional techniques.

HYPOTHESIS

Purpose of the study was to analyze the clinical and radiological outcome of patients who underwent percutaneous posterior fixation without fusion for the treatment of thoraco-lumbar and lumbar A3 fractures.

MATERIALS AND METHODS

Sixty-three patients, having sustained a single-level thoraco-lumbar fracture, underwent short segment percutaneous instrumentation and were retrospectively analyzed. sagittal index (SI) was calculated in all patients. Clinical and functional outcome were evaluated by Visual Analog Scale (VAS), Oswestry Disability Index (ODI) and Short Form General Health Status (SF-36).

RESULTS

Average operative blood loss was 82 mL (50-320). Mean pre-operative SI in the thoraco-lumbar segment was 13.3° decreased to 5.8° in the immediate postoperative with a mean deformity correction of 7.5. Mean pre-operative SI in the lumbar segment was 16.5° decreased to 11.3° in the immediate postoperative with a mean deformity correction of 5.2. Not statistically significant correction loss was registered at 1-year minimum follow-up. Constant clinical conditions improvement in the examined patients was observed.

CONCLUSION

Percutaneous pedicle screw fixation for A3 thoraco-lumbar and lumbar spinal fractures is a reliable and safe procedure.

LEVEL OF EVIDENCE

Level IV. Retrospective study.

Continuous circular cycling in bipolar disorder as a predictor of poor outcome

OBJECTIVE

This prospective study aims to determine if patients with bipolar disorder with a continuous circular course (CCC) are significantly different on clinical characteristics and response to long-term treatment from those with a non-continuous circular course (N-CCC). CCC was defined as the alternation of depression and (hypo)mania without a completely free interval, and N-CCC as the presence of free intervals after the sequence mania-depression or depression-mania.

METHOD

The study sample includes 140 consecutive patients with bipolar I or II disorder according to DSM-IV criteria, aged 18-65 years and receiving prophylactic treatment for. Treatment was based upon international guidelines and clinical experience at the time of patient's enrollment (from January 1998 to January 2006). Primary outcome was the absence of new episodes during the follow-up. Significance level was set at p<0.05.

RESULTS

Twenty-eight percent of the sample has CCC. Compared with N-CCC, CCC patients were older, had a later onset, a higher number of total, depressive and (hypo)manic episodes, and of switches, and spent a higher percentage of time ill in the year before entering the study. Polarity at onset and subsequent recurrences were more frequently mixed in N-CCC than in CCC patients. The proportion of patients in the CCC group who had no recurrences during the follow-up was significantly lower than in the N-CCC group.

CONCLUSION

The presence or absence of a free intervals over the course of illness identifies two subtypes of bipolar disorder that differ in clinical presentation, outcome, and response to long-term treatment.

Percutaneous pedicle screw fixation in polytrauma patients

PURPOSE

The clinical outcome of polytrauma patients underwent spine fixation was analyzed and correlated both to surgical time (early versus delayed) and to fixation type (open versus percutaneous).

METHODS

Twenty-four polytrauma patients were retrospectively evaluated. Patients were evaluated according to age, accident dynamic, mechanical ventilation need, blood transfusion need, SAPS II score, type of vertebral injury, time of fixation (within or after 72 h) and type of fixation.

RESULTS

Nine patients underwent percutaneous pedicle screw fixation and 12 open fusion. An early fixation allows better clinical outcome considering ICU stay (13.7 versus 21.71 days), H-LOS (25.8 versus 69.5 days), mechanical ventilation need (7 versus 16.2), blood transfusion need (250 versus 592 cc).

CONCLUSIONS

In polytrauma patients an early spine fixation improves clinical outcome. Patients underwent percutaneous screw fixation showed a better outcome compared to open surgery group obtained despite worst clinical conditions.

Complications in lumbar spine surgery: A retrospective analysis

BACKGROUND

Surgical treatment of adult lumbar spinal disorders is associated with a substantial risk of intraoperative and perioperative complications. There is no clearly defined medical literature on complication in lumbar spine surgery. Purpose of the study is to retrospectively evaluate intraoperative and perioperative complications who underwent various lumbar surgical procedures and to study the possible predisposing role of advanced age in increasing this rate.

MATERIALS AND METHODS

From 2007 to 2011 the number and type of complications were recorded and both univariate, (considering the patients' age) and a multivariate statistical analysis was conducted in order to establish a possible predisposing role. 133 were lumbar disc hernia treated with microdiscetomy, 88 were lumbar stenosis, treated in 36 cases with only decompression, 52 with decompression and instrumentation with a maximum of 2 levels. 26 patients showed a lumbar fracture treated with percutaneous or open screw fixation. 12 showed a scoliotic or kyphotic deformity treated with decompression, fusion and osteotomies with a maximum of 7.3 levels of fusion (range 5-14). 70 were spondylolisthesis treated with 1 or more level of fusion. In 34 cases a fusion till S1 was performed.

RESULTS

Of the 338 patients who underwent surgery, 55 showed one or more complications. Type of surgical treatment (P = 0.004), open surgical approach (open P = 0.001) and operative time (P = 0.001) increased the relative risk (RR) of complication occurrence of 2.3, 3.8 and 5.1 respectively. Major complications are more often seen in complex surgical treatment for severe deformities, in revision surgery and in anterior approaches with an occurrence of 58.3%. Age greater than 65 years, despite an increased RR of perioperative complications (1.5), does not represent a predisposing risk factor to complications (P = 0.006).

CONCLUSION

Surgical decision-making and exclusion of patients is not justified only by due to age. A systematic preoperative evaluation should always be performed in order to stratify risks and to guide decision-making for obtaining the best possible clinical results at lower risk, even for elderly patients.

Cervical myelopathy due to ossification of the transverse atlantal ligament: a Caucasian case report operated on and literature analysis

One case of cervical myelopathy associated to ossification of transverse atlantal ligament (OTAL) and C1 posterior arch hypoplasia in a Caucasian adult female is reported. A 53-year-old female affected by cervical myelopathy was treated with C1 laminectomy and posterior arthrodesis. CT scan demonstrated that the distance between ossification of the ligament and anterior cortex of the posterior arch of atlas was 6,2mm leading to consistent space reduction for spinal cord at this level. Patient underwent spinal cord decompression and fixation with C1 poliaxial screws in lateral masses and two bilateral crossing C2 laminar screws with an improvement of neurological functions at 4-years follow-up. The association between OTAL and C1 hypoplasia was reported in very few cases. The treatment with C1 laminectomy without fusion is reported in medical literature with good clinical outcome. Our patient obtained a neurological improvement at midterm follow-up with spinal cord decompression and fusion.

[Pharmacotherapy plus psychotherapy in patients with mood disorder and Axis II codiagnosis. A review]

AIM

The main aim of this paper is to review data on the efficacy of combined therapy in patients with mood disorder and axis II codiagnosis. The secondary aim is to assess the impact of personality disorders, psychotherapies, and combination therapy approaches on the treatment outcome.

MATERIALS AND METHODS

We searched the Medline database using the following syntax: "major depressive disorder", "bipolar depression", "personality disorder", "comorbidity", "epidemiology", "combined therapy", "sequential therapy". The search included studies published up to february 2011. We divided the selected studies on the basis of the following pharmacotherapy and psychotherapy combination treatment approaches: concurrent treatment, sequential treatment and cross-over treatment.

RESULTS

We found six studies about this topic. They show that in patients with unipolar depression combined therapy does not increase significantly the remission rate of the acute phases. However, combined treatment has greater effects on social functioning, interpersonal sensitivity and aggressiveness than pharmacological treatment. The studies indicate also that in patients with either unipolar or bipolar disorder combined therapy is more effective than pharmacological therapy in reducing relapses.

DISCUSSION

The available limited data suggest that in patients with mood disorder and axis II codiagnosis pharmacological and psychological combined therapy is useful. In these patients the type of combination approach does not seem to influence the treatment outcome.

Bisphosphonate therapy in multiple myeloma in preventing vertebral collapses: preliminary report

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Transdiscal L5-S1 screws for the treatment of adult spondylolisthesis

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Critical analysis of lumbar interspinous devices failures: a retrospective study

Interspinous devices (IDs) were introduced in the 90s. Since then, they have rapidly become very popular for the minimally invasive treatment of lumbar pain disorders. They feature different shapes and biomechanical characteristics, and are used in the spine degenerative pathologies or as motion segment stabilizers (dynamic stabilization) or to obtain the decompression of neurological structures. The indications seem to be rather narrow and still to be verified in terms of their clinical efficacy. However, IDs are being extensively utilized beyond their classical indications with the inevitable risk of a clinical failure. The aim of the present work was to carry out a critical analysis of the causes of failure in a series of 19 patients. From January 2007 to March 2009, 19 patients with residual painful syndrome after the implantation of IDs were observed. The series includes 11 males and 8 females with a mean age of 53.6 years (range 38-84 years) who were operated on elsewhere and who underwent revision surgery at our hospital. The inclusion criteria were low back pain and/or radiculopathy after the device implantation without improvement of the painful symptomatology, radiculopathy with signs of sensory and motor deficit, intermittent neurogenic claudication, and infection. All patients were thoroughly re-assessed with new standard imaging examinations such as MRI and CT scans, considering the following image features: the position of the device with respect to the spinous processes (X-ray), the intervertebral disc disease of the level operated upon or of the adjacent levels (MRI), the segmental instability (dynamic X-rays), the severity of the canal stenosis (CT). The accurate evaluation of the clinical and imaging parameters revealed three main causes of failure: errors of indication, technical errors and the structural failure of the ID. The most frequent cause of failure was a wrong indication. The results of the study are presented and the causes of failure are discussed in detail.

[Obstructive Sleep Apnea Syndrome (OSAS): The role model of the Occupational Health Physician in specific clinical cases.]

Nowadays Sleeping disorders are a very interesting topic in Occupational medicine, they are involved in reduction of working performances and increased risk of work accidents (in work environment or while driving). Medical surveillance made from the Occupational Health Physician can be very helpful in early diagnosis of this kind of disease; during 2008 we fi nd out Obstructive Sleeping Apnea Disease (OSAS) in some Healthcare workers. We reported some clinical cases that show the role model of the occupational health physician in this kind of sickness. Our Experience shows the duty of Occupational health physician it's not limited to medical surveillance, but also to Health Promotion (as wrote in D.Lgs 81/08). This can be obtained by clinical and occupational solutions, like correct work shift planning and lifestyle changes; so the interest of the occupational physician have to be focused on introducing in medical surveillance also measures of health promotion regarding sleep disorders with the aim of preserving health condition in workers.

Biomimetic Mg-substituted hydroxyapatite: from synthesis to in vivo behaviour

The incorporation of magnesium ions (in the range 5-10 mol% in respect to Ca) into the hydroxyapatite structure, which is of great interest for the developing of artificial bone, was performed using magnesium chloride, calcium hydroxide and phosphoric acid, as reactants. Among the synthesized powders, the synthetic HA powder containing 5.7% Mg substituting for calcium was selected, due to its better chemico-physical features, and transformed into granules of 400-600 microm, for biocompatibility tests (genotoxicity, carcinogenicity, toxicity, in vitro cytotoxicity and in vivo skin irritation-sensitization tests). In vivo tests were carried out on New Zealand White rabbits using the granulate as filling for a femoral bone defect: osteoconductivity and resorption were found to be enhanced compared to commercial stoichiometric HA granulate, taken as control.

Peritoneal malignant mesothelioma: case report

Our study reports peritoneal diffuse malignant mesothelioma (DMM) in a 43 years old male patient, with no exposure to asbestos in his medical history; the partner of the patient was also not exposed to asbestos. The exposure to X-rays was also excluded. Different pathogenic mechanisms for the pathogenesis of a peritoneal diffuse malignant mesothelioma in this patient can be hypothesized, for example, SV40 infection and genetic susceptibility; a minimal domestic exposure to asbestos can be not excluded. Therefore, further studies in a larger number of subjects are necessary to determine whether one or all of these hypothetic pathogenic mechanisms are more significant for the development of malignant mesothelioma.

[Forensic implications and stress ina group of anaestheticians: a cross sectional study]

Aim of the study is the appraisal of stress in a group of the 500 anaestheticians and in a control group. Two anonymous self-administered questionnaires were utilized, one for the subjective appraisal of the perceived various risk related to job, and one for the subjective appraisal of stress: VRS questionnaire of Tarsitani and Biondi. The results of the study showed that all the anaestheticians identified the perception of the emotional aspects related to work as a risk factor. They put it mainly in relation with the forensic implications. The total score of scale VRS and the score for cluster depression, anxiety, aggressiveness are higher in the anesthetists than the control group.

Non-occupational malignant pleural mesothelioma due to asbestos and non-asbestos fibres

BACKGROUND AND AIM

The occurrence of malignant pleural mesothelioma (MPM) has been reported among population groups with no documented professional exposure to asbestos fibres living in different geographic areas. This paper reviews existing data related to non occupational MPM including its occurrence in the province of Catania (Sicily, Italy).

METHODS

An electronic search of literature related to non occupational MPM was performed including the year 2005.

RESULTS

Non occupational MPM in subjects living in areas contaminated by a variety of asbestos and non asbestos fibres has been well documented through a number of epidemiologic studies including cases series, case-control studies, and a cohort study. In addition, the observation of familial clustering of MPM, suggests that genetic factors may play a role in the pathogenesis of this malignancy. The epidemiological evidence also suggests that MPM may occur as a result of the interaction between environmental carcinogens, genetic factors, and virus infection.

CONCLUSION

It is likely that genetic predisposition and non-occupational exposure to low doses of asbestos and asbestos-like fibres may concur to the development of malignant mesothelioma. However, additional epidemiological and laboratory studies are needed to further understand the relationship between environmental exposure and individual susceptibility to this malignancy.

[Fibers glass induced cytotoxicity and genotoxicity]

Man-made vitrous fibers, have been widely used as a substitute for asbestos, as an insulation material. However the fibrous morphology of MMVFs raises concern about potential health hazard. The aim of our study was to assess cytotoxic and genotoxic effects induced on a human alveolar cell line A549 by exposure to glass wool fibers (GW). Cells were exposed for 72 h to 5, 50, 100 microg/ml of glass wool, after incubation the cell viability was determined by a MTT reduction assay. The genotoxic effect was studies by Comet test. An undamaged cell appeared as a nucleoid and a cell with damaged DNA as a comet. Measurement of Comet parameters: % DNA in the tail, tail length and tail momente (the product of relative tail intensity and lenght, that provides a parameter of DNA damage) were obtained from the analysis. A MTT assay indicated that glass wool caused a decrease in cell viability and this decrease was concentration-dependent. The results of the Comet test for DNA damage detection indicated in cell exposed to glass wool fibers a significant increase of mean TM value. All these results provide that the glass wool fibers can induce cytotoxicity and genotoxicity

Electromagnetic interference to infusion pumps from GSM mobile phones

Electromagnetic interference (EMI) to critical care medical devices has been reported by various groups. Previuos studies have demonstrated that infusion and syringe pumps are susceptible of false alarm buzzing and block, when exposed to various EMI sources. Whether these events may have clinical relevance is still debated. The risk of EMI depends on several factors such as phone emitted power, distance and carrier frequency. We investigated the EMI on infusion and siringe pumps from GSM phones at various distances and emitted powers. Malfunctions were observed in 4/7 infusion pumps and 1/4 syringe pumps exposed to mobiles at their maximum output, for distances as long as 30 cm. The maximum power not inducing any malfunction even at 0 cm distance was also determined. The selection of a proper maximum power class reduces significantly the risk of EMI. Such a function is already built in the GSM standard and thus represents one of the feasible solutions to the EMI problem in hospitals.

Early trauma and increased risk for physical aggression during adulthood: the moderating role of MAOA genotype

Previous research has reported that a functional polymorphism in the monoamine oxidase A (MAOA) gene promoter can moderate the association between early life adversity and increased risk for violence and antisocial behavior. In this study of a combined population of psychiatric outpatients and healthy volunteers (N = 235), we tested the hypothesis that MAOA genotype moderates the association between early traumatic life events (ETLE) experienced during the first 15 years of life and the display of physical aggression during adulthood, as assessed by the Aggression Questionnaire. An ANOVA model including gender, exposure to early trauma, and MAOA genotype as between-subjects factors showed significant MAOA×ETLE (F_1,227 = 8.20, P = 0.005) and gender×MAOA×ETLE (F_1,227 = 7.04, P = 0.009) interaction effects. Physical aggression scores were higher in men who had experienced early traumatic life events and who carried the low MAOA activity allele (MAOA-L). We repeated the analysis in the subgroup of healthy volunteers (N = 145) to exclude that the observed G×E interactions were due to the inclusion of psychiatric patients in our sample and were not generalizable to the population at large. The results for the subgroup of healthy volunteers were identical to those for the entire sample. The cumulative variance in the physical aggression score explained by the ANOVA effects involving the MAOA polymorphism was 6.6% in the entire sample and 12.1% in the sub-sample of healthy volunteers. Our results support the hypothesis that, when combined with exposure to early traumatic life events, low MAOA activity is a significant risk factor for aggressive behavior during adulthood and suggest that the use of dimensional measures focusing on behavioral aspects of aggression may increase the likelihood of detecting significant gene-by-environment interactions in studies of MAOA-related aggression.

Externalizing and oppositional behaviors and karate-do: the way of crime prevention. A pilot study

Childhood disruptive behaviors can be precursors to later deviance. To verify the efficacy of karate, a complex psychomotor activity that enhances self-regulation and executive skills, as an intervention for externalizing behaviors, 16 children, ranging in age from 8 to 10 years, and meeting diagnostic criteria for oppositional defiant disorder were studied. Eight were randomly assigned to a 10-month Wa Do Ryu karate program, whereas 8 children received no intervention. The children were assigned to a larger karate class, composed of typically developing youngsters. Three domains of temperament--intensity, adaptability, and mood regulation--were measured at the beginning and the end of the training period in all 16 participants. A significant improvement in temperament scale scores was measured in the karate group for all tested items compared to controls. Karate, when properly taught, can be a useful adjunct in multimodal programs aimed at externalizing behavior reduction.

[Airborne contact dermatitis]

A comprehensive bibliographical retrieval of case reports on "airborne contact dermatitis" (ACD) was performed. The present review deals with the first cases published in 1986, 1991, 2001 by Huygens as well as by Dooms-Goossens, and continues with the other pertaining clinical presentations until to day. Solid particles, rather than gases or droplets, are the most frequently reported causes of ACD.

[Smoking habits in health care workers: experience in two general hospitals of Eastern Sicily]

PURPOSE

The aim of our study was to assess the smoking habits in health care workers.

MATERIALS AND METHODS

In concomitance with a medical examination for Health Care Surveillance requested by the Italian Laws (D. Lgs. 626/94), our operative units interviewed 2,000 persons (47.9% males, 52.1% females, mean age = 45 yrs (SD+/-9.41 yrs) working in two General Hospitals of Eastern Sicily.

RESULTS

The prevalence of smokers was found to be higher in men (34.5%) than in women (33.6%), in Health Care Operators (36.4%) and professional nurses (36.2%) than in medical doctors (27.7%), in night-time workers (34,5%) then in day-time-workers (28,7%). The compliance with smoking restriction was found to be poor; in fact, 60% out of smokers declared to smoke during the working hours.

CONCLUSIONS

This investigation has revealed the significant prevalence of tobacco smoking among the health care workers in general. We think that the inclusion of an anonymous questionnaire on smoking habits within the Services of Sanitary Surveillance may help in the national campaign against cigarette smoking.

[Airbone contact dermatitis caused by latex exposure: a clinical case]

We describe the case of a nurse who showed eczematous lesions wide-spread over the neck and face. She worked as a attendant to a surgical chamber and wore vinyl gloves because of previous episodes of contact dermatitis caused by rubber gloves. The allergologic examination demonstrated that total IgE was 69.8 kU/1, both the Skin prick tests and the patch test for latex were positive. Persisting her dermatological symptomatology, in the suspicion of a airborne contact dermatitis, the nurse was removed and addressed to administrative functions for detecting the clinical follow-up. Fortunately, the eczematous manifestations spontaneously disappeared immediately after her transfer. In this case the presence of eczema mainly on air-exposed areas was interpreted as a sign of airborne contact dermatitis to latex. The case is reported in that the clinical picture is not very common.

Analysis of hepatitis C virus infection among health-care workers: an observational study

AIM

Hepatitis C virus (HCV) is one of the most common blood-borne pathogens transmitted from patients to health care workers (HCWs). The Centers for Disease Control and Prevention (CDC) have developed a set of universal precautions to help prevent transmission of blood-borne pathogens between patients and HCWs in health care settings. HCV infection status among HCWs and proportion of HCWs experiencing occupational blood exposure accidents were monitored to assess the risk of HCV infection among HCWs at a hospital in Catania, Italy.

METHODS

The number of HCWs reporting occupational blood exposure accidents during 1999 and 2004 were compared to examine whether there was any change in the incidence of these accidents among 900 HCWs. HCV infection status of these HCWs was also analyzed in 1999 and 2004 to determine how many were infected with HCV during this time period.

RESULTS

HCV infection was detected in 21 out of 900 subjects in 1999. The remaining 879 HCWs remained HCV-negative until they were last tested in 2004. There was a statistically significant decrease in the number of HCWs that experienced occupational blood exposure accidents from 306 in 1999 to 240 in 2004 (P = 0.001).

CONCLUSIONS

The finding that all 871 HCV-negative HCWs remained HCV-negative from 1999 until 2004 supports the view that the set of universal precautions recommended by the CDC are helpful for preventing HCV transmission from patients to HCWs. HCWs must continue following these precautions to prevent transmission of HCV and other blood-borne pathogens between patients and HCWs in the future.

[In vitro exposure of U937 cells to potassium dichromate: study of apoptosis]

The aim of our study is to evaluate the genotoxic damage of cells treated with different concentrations of potassium dichromate. For this reason we have utilised U937 cells, a cellular line derived from acute promyelocytic leukaemia. Our results show that the minimum concentration of potassium dichromate induces apoptosis in the U937 cells and is of 600 microM, already after 12 hours, the cells treated with potassium dichromate with a concentration of 500 microM presented an apoptosis of 27% while the respective control showed a base apoptosis of 9.5%. Our experimental data indicate that the model adopted by us, may be a valid instrument to study the cytotoxic effects of compounds containing Chromium. In particular we have evidenced a clear genotoxic effect of these compounds demonstrated by a significant increase of the apoptosis percentage which is time and dose dependent.

[Occupational hand injuries in an area of high prevalence of farming and craft work]

Hand injuries exceed 20% of all occupational injuries. This article reviews the history of 237 hand injuries mostly occurred in craftsmen and farmers. The results allow us to make some considerations on the role of occupational physician in their prevention.

Osseointegration in hip prostheses: experimental study in sheep

Sixteen 2- to 3-year-old sheep were submitted to a hemiarthroplasty of the hip joint with a specially designed femoral component. The proximal two thirds of the stem had a circumferential, plasma-sprayed, porous coating with hydroxyapatite. The animals where killed a 15, 30, 60, 90, 120, 180, 200, 270, 360, and 540 days after surgery. Femurs were submitted to plain radiographs, computerised tomography (CT) scan, and dual energy X-ray absorptiometry (DEXA). Cross-sections were obtained at four different levels and studied using scanning electron microscopy. In the coated portion of the stem, apposition of woven immature bone was evident at 15-30 days and mature lamellar bone by 30 days. With time, the gap between the endosteum and the coated surface was filled by bridges of lamellar bone with a marked trabecular orientation. In the distal uncoated portion of the stem, the implant was initially surrounded by fibrous tissue that, with time, transformed into lamellar bone.

[Prevalence of HCV in health care workers in Southern Italy]

PURPOSE

To assess the prevalence of hepatitis C virus (HCV) in the population exposed to biological risk of two hospitals in southern Italy.

PATIENTS AND METHODS

All health care workers of two main hospitals of Sicily, potentially exposed to biological risk underwent health surveillance. Health care personnel were arranged into seven occupational group, and five age bands (< 30, 31-40 years, 25-30 years, 41-50, 51-60 years, > 60 years). We estimated the prevalence of hepatitis C infection in 1800 healthcare workers by means of nucleic acid amplification and genotype by means of sequencing, the workers were also tested for liver function.

RESULTS

The overall prevalence of anti-HCV was 2.1%, corresponding to 39 persons. The prevalence in health workers was higher in nurses than in surgeon, group perceived to be at greatest risk of occupational exposure, and higher in elderly workers (> 45 years) than in younger ones.

CONCLUSION

Prevalence of anti-HCV in our study was higher than in blood donors, and lower than in general population in southern of Italy. The 45% of HCV infected healthcare workers were unaware of their condition and their potential to infect patients. Testing for HCV infection should be routinely performed for health care workers to detect the infection, which frequently results in a chronic asymptomatic carrier state for many years before the development of symptomatic liver disease, and perform precocious therapy with interferon.

[Environmental monitoring of occupational exposure to glutaraldehyde at a hospital]

BACKGROUND

To evaluate the air pollution in operating theatres of a Sicily Hospital produced by 2% alkaline solutions of glutaraldehyde, which is used to disinfect flexible endoscopy units, filling tanks and cleaning surfaces. Personnel reported subjective symptoms as: headache, dizziness, anxiety, drowsiness on the job, loss of attention, irritation of the skin and respiratory tract.

METHODS

Environmental valuation of glutaraldehyde was made by infrared photoacustic spectroscopy.

RESULTS

The final results is not very comforting infact we found value of glutaraldehyde which exceeded the upper limit value (0.05 ppm) due to behavioral rules, to not well ventilated workplaces and to not automated washing units.

Histologic and ultrastructural analysis in a case of massive failure of Zirconia ball head

The in vivo histological and ultrastructural analysis of periprosthetic tissue collected at time of revision surgery for failure of a 28 mm yttria-tetragonal zirconium oxide polycrystal (YTZP) ball head, 2 years after implantation is reported. Histologic analysis showed Zirconia particles, rounded to polygonal ranging from 2m to more than 10m intra or extra cellular in a stroma without vessels with few giant cells. Scanning electron microscopy (SEM) and energy dispersive X-ray analysis (EDAX) showed the different shape from rounded to polygonal of Zirconia. SEM analysis of the internal part of Zirconia ball head showed the presence of different fracture lines especially in the internal surface (Hip International 2002; 4: 388-93).

[Occupational exposure to formaldehyde at a service of pathologic anatomy]

OBJECTIVE

Aim of the present study is to evaluate the air pollution produced by formaldehyde in pathological anatomy.

METHODS

This study was made with instrumental approach based on environmental evaluation of 10% formaldehyde used in pathological anatomy, by an infrared gas analyser (Brüel & Kjaer), and clinical approach of pathological anatomy personnel.

RESULTS

The final result is not very comforting because we found values of formaldehyde during specific activities which exeeded the current limits proposed by industrial hygienist, infact we found in a different settings 1.81 ppm, 3.78 ppm, 8.3.05 ppm. The personnel exposed reported subjective symptoms as reactive airway symptoms, headache, skin problems.

CONCLUSIONS

To reduce air pollution we have indicated technical precautions as forced ventilation which is a major engineering control for reducing risk from chemical agents, use of personal protective equipment (PPE) as last resort for protection, behavioral rules and health surveillance.

[Suspected glutaraldehyde poisoning: a case report]

AIMS

To report a case of anxiety, possibly due to glutaraldehyde poisoning in a female anaesthesiologist working in an operating room and exposed to 2% solution of glutaraldehyde, the only chemical used for disinfection of flexible endoscopic instruments.

METHODS

A clinical evaluation was made and neurobehavioural functions were explored by sensitive neuropsychological testing: testing included a simple and complex reaction time and examination of the autonomic nervous system. The atmospheric concentration of glutaraldehyde was measured by means of a Brüel & Kjaer Multigas Monitor type 1302 analyzer.

RESULTS

Adverse neurobehavioural effects, including headache, loss of attention, dizziness, anxiety, drowsiness on the job, alteration of homeostatic reflexes, were observed, and sensitive neuropsychological testing confirmed neurobehavioural impairment. No blood alterations related to exposure were found. Very high levels of glutaraldehyde were detected in the operating theatre. After ten days away from exposure to glutaraldehyde no symptoms and no behavioral effects on the central and autonomic nervous systems were detectable.

CONCLUSIONS

Although conclusions cannot be drawn from a single case, exposure to a high level of glutaraldehyde, subjective symptoms, alteration of neurobehavioural performance, no consumption of CNS medication, no neurological or psychiatric disorders, no coffee consumption and alcohol intake, no exposure to other neurotoxic agents, complete recovery after removal from exposure to glutaraldehyde, are indicative of glutaraldehyde poisoning.

Quality handbook in radiotherapy: personal experience

The Quality Handbook includes the description of the activities carried out in Radiotherapy and the methodology used to ensure the Quality Assurance according to the principles indicated in national and international documents of reference and the recommendations of accreditation agencies. The structure of the Quality Handbook, the main aspects of single chapters, the selected quality indicators undergoing inspections are analysed and procedures to be followed for changes and updating of the Quality Handbook are described. The Quality Assurance program is illustrated in another article of this issue.

Quality handbook in radiotherapy. Brachytherapy: personal experience

Brachytherapy is a conventional method of radiation therapy characterized by peculiar technical, clinical, operational and radioprotection problems. Therefore, the management of a service or department of brachytherapy requires a specific organization aimed at Quality Assurance. In this report, the personal experience with the drawing up of a Quality Handbook of brachytherapy with reference to the method used and the structure of the document, is described.

Quality assurance in radiotherapy: personal experience

The approach to the implementation of a Quality Assurance Program applied from 1 October 2000 at the Radiotherapy Service of the "Università Cattolica del S. Cuore, Policlinico "A. Gemelli" of Rome, is described. Some major aspects of this program are analyzed.

[Low flow anesthesia and environmental pollution]

AIM OF THE STUDY

The aim of the present study is to evaluate operating room pollution and isoflurane and N2O consumption in open system and low flow anesthesia.

MATERIALS AND METHODS

Environmental concentration of N2O and isoflurane were measured in an operating room of 150 m3 with 10 air changes by an infrared gas analyser (Brüel & Kjaer) in open system and in low flow anesthesia. Accurate measurement of ihalatory anaesthetic and N2O consumption was made.

RESULTS

Concentrations of N2O and isoflurane in operating room were 4.83 ppm and 0.4 ppm respectively, lower compared with open systems: 301 ppm and 11.1 ppm respectively. Isoforane consumption was 25 cc in five hours during low flow anaesthesia, lower compared with open system: 125 ppm, N2O consumption was 4 l/m in open system, 1 l/m in low flow anaesthesia.

Surface analysis of a femoral stem after failed total hip replacement

We analysed the surface of a Ti alloy femoral stem in a cementless total hip replacement with early failure. A specific protocol consisting of non destructive and destructive tests was used in the evaluation of the retrieved stem. The tests confirmed that implant fretting due to bone abrasion constitutes an early phase of loosening.

[Environmental monitoring and health monitoring for personnel exposed to inhalation anesthetics]

OBJECTIVES

The aim of this study is to verify the results of medical surveillance for personnel exposed to inhaled anaesthetics in operating rooms (300 exposed), and estimate the level of pollution in operating theatres of a university hospital.

METHOD

Determination of the baseline and final value of the environmental anaesthetics by infrared photoacoustic spectroscopy; medical check-up and blood tests.

RESULTS

During our observation we found in all rooms (new rooms and older rooms) values of nitrous oxide and isoflurane acceptable, all the anaesthetic's concentration are below the limits proposed by C.M. number 5 of the 14/03/89. Personnel reported subjective symptoms especially anxiety, but no blood alteration related to exposure were found.

CONCLUSIONS

Technical precautions as use of low flow system, replacement of nitrous oxide with air, careful check of anaesthetic machine, and behavioral rules have decreased the emission of anaesthetics in the environment. Blood tests are found are not a valid index of possible damage caused by exposure. A large percentage of anaesthesiologists are found to have anxiety.