Percutaneous vertebroplasty: Technique and results in 192 procedures

Percutaneous vertebroplasty with acrylic cement (usually polymethylmethacrylate) consists of injecting cement into vertebral bodies weakened by osseous lesions. The objective of this procedure is to obtain an analgesic effect by mechanical stabilization in destructive lesions of the spine. The three major indications are aggressive vertebral hemangiomas, severe or refractory pain related to osteoporotic vertebral fractures, and malignant vertebral tumors. Complications are infrequent, but occur essentially in patients with vertebral malignant tumors. We present our experience with 148 patients that underwent 192 percutaneous PMMA vertebroplasties for the treatment of painful osteoporotic compression fractures (76 patients, 105 vertebral levels), hemangiomas (31 patients, 43 vertebral levels) and neoplasms (31 patients, 43 vertebral levels). In a vast majority of appropriately selected cases and especially in osteoporotic cases, vertebroplasty constitutes a relatively simple procedure with a very high rate of success.

A universal pedicle screw and V-rod system for lumbar isthmic spondylolysis: a retrospective analysis of 21 cases

Objective

To investigate the surgical outcome of a universal pedicle screw-V rod system and isthmic bone grafting for isthmic spondylolysis.

Methods

Twenty-four patients with isthmic spondylolysis at L5 and grade 0–I spondylolisthesis (Meyerding classification) received isthmic bone graft and stabilization using the universal pedicle screw-V rod system. Back pain was evaluated using the visual analog scale (VAS) and time to bone healing, improvement in spondylolisthesis and intervertebral space height at L5/S1 and L4/L5 were assessed.

Results

Twenty-one patients were followed up for 24 months and included in the analysis. Back pain was markedly improved at 3 months postoperatively with a statistical difference in VAS scores compared with preoperative VAS scores (P<0.001). The VAS scores were 0 to 3 at 6 months postoperatively in all patients and no back pain was reported in all patients except 2 patients who complained of back pain after prolonged sitting. X-ray examination showed a bone graft healing time of 3 to 12 months. Grade I spondylolisthesis improved to grade 0 in 4 patients and no noticeable change was observed in the remaining 17 cases. The intervertebral space height at L5/S1 was statistically increased (P<0.05) while no statistically significant change was seen at L4/L5. There was no statistically significant difference in the ROM of the intervertebral disks of L5/S1 and L4/5 before and after surgery.

Conclusions

The universal pedicle screw-V rod system and isthmic bone grafting directly repairs isthmic spondylolysis and reduces back pain, prevents anterior displacement of the diseased segment and maintains intervertebral space height, thus offering a promising alternative to current approaches for isthmic spondylolysis.

[Imaging of inflammatory back pain]

We recommend magnetic resonance imaging of the sacroiliac joints as the first line imaging method in suspected inflammatory back disorder. Plain X-ray can be taken from those over 35 years of age. A nonconclusive finding in plain X-ray should be verified by MR imaging. For the present, diagnostic criteria for spondylarthritis do not take into account spinal changes. Typical spinal findings can, however, be helpful in making treatment decisions. In case the spinal region MR imaging should be utilized if possible, because radiography is particularly insensitive for thoracic spine. After a confirmed diagnosis, the inflammatory nature of the condition can usually be assessed clinically.

Infectious, inflammatory, and metabolic diseases affecting the athlete's spine

Sports and weight-bearing activities can have a positive effect on bone health in the growing, mature, or aging athlete. However, certain athletic activities and training regimens may place the athlete at increased risk for stress fractures in the spine. In addition, some athletes have an underlying susceptibility to fracture due to either systemic or focal abnormalities. It is important to identify and treat these athletes in order to prevent stress fractures and reduce the risk of osteoporosis in late adulthood. Therefore, the pre-participation physical examination offers a unique opportunity to screen athletes for metabolic bone disease through the history and physical examination. Positive findings warrant a thorough workup including a metabolic bone laboratory panel, and possibly a DEXA scan, which includes a lateral spine view.

The influence of preoperative MRI findings on lumbar fusion clinical outcomes

INTRODUCTION

Spinal fusion as a treatment for degenerative disc disease is controversial. Prior authors have identified various MRI findings as being pain generators, which might help guide patient selection for lumbar fusion procedures. These findings have included disc desiccation, disc contour, high-intensity zone annular disruption, the presence of Modic endplate changes, and disc space collapse. The purpose of this study is to investigate which MRI findings in patients with degenerative disc disease predict clinical improvement with lumbar fusion.

METHODS

A single-center surgical database of patients undergoing lumbar fusion was reviewed for patients whose indication for fusion surgery was primary disc pathology. We identified 51 patients (71 disc levels) who had completed 2-year prospectively collected outcomes questionnaires and had preoperative MRIs available for review. NRS (0-10) back and leg pain, Oswestry Disability Index (ODI) and SF-36 Physical Composite Summary scores were obtained preoperatively and at 1- and 2-year follow-up. MRIs were reviewed by three fellowship-trained spine surgeons who were asked to grade them for the following five characteristics: (a) disc desiccation, (b) disc contour, (c) presence of a high-intensity zone (HIZ) annular tear, (d) presence of Modic endplate changes and (e) disc height. Two-year outcome measures were compared to MRI findings to identify which findings correlated with improvement in outcome scores.

RESULTS

Statistically significant improvements were noted in back pain, leg pain, SF-36 PCS and ODI in the group overall. Disc desiccation, disc contour, presence of an HIZ lesion, and the presence of Modic endplate changes did not correlate with 2-year outcomes. Disc height was correlated with 2-year change in outcome measures. Discs with preoperative height less than 5 mm demonstrated a 23.4 point ODI improvement compared to 9.2 points for discs >7 mm. Similarly, SF-36 PCS improved 9.5 points in discs <5 mm compared to 0.7 in discs greater than 7 mm. Discs between 5 and 7 mm demonstrated intermediate levels of improvement.

CONCLUSIONS

Several commonly utilized MRI criteria proposed as indications for lumbar fusion do not seem to correlate with 2-year improvement in clinical outcomes. Discs which are narrowed and collapsed, preoperatively, demonstrate better improvement at 2 years postoperatively as compared to discs which have maintained disc height. Significant disc space collapse may represent a subset of "degenerative disc disease" which responds more favorably to treatment with fusion.

Low frequency of axial involvement in southern Italian Caucasian children with HLA-B27 positive juvenile onset undifferentiated spondyloarthritis

OBJECTIVES

To establish how many children with HLA B27-positive juvenile undifferentiated spondyloarthritis (JuSpA) living in southern Italy develop axial disease after 5 years of disease.

METHODS

All children with B27-positive enthesitis-related arthritis (ERA) consecutively seen in a 7-year period were entered in a special register and were followed prospectively. Each patient was examined at 6-month intervals, even if asymptomatic. In patients with inflammatory spinal pain and/or buttock pain, MRI of the sacroiliac joints and spine was performed. Five years after inclusion, sacroiliac joint plain radiographs were obtained and read blindly after being mixed with those of control subjects.

RESULTS

Thirteen children, 9 boys and 4 girls, with B27-positive ERA and one girl with B27-positive isolated SpA dactylitis were seen in the study period. Their median age at disease onset and at our first examination were 10 (range 2-16) and 12 years (range 3-16), respectively. During follow-up, only one patient had axial symptoms, i.e. alternate buttock pain. MRI revealed moderate bone oedema at both sacroiliac joints. After five years of disease, no patient showed reduced spinal movement. No sign of sacroiliitis was seen in any patient and control on plain films. A new MRI of the sacroiliac joints of the patient who showed bone oedema in the first years of disease was normal.

CONCLUSIONS

This study confirms that the onset of axial involvement in Italian Caucasian HLA-B27 positive children with ERA is rare in the first five years of disease.

[Dorsopathy in the elderly: pathobiology and multimodality therapy in clinical practice]

The lecture considers the most common causes of dorsopathy in elderly patients, by taking into account pathobiology, age markers, and aging processes. It discusses the general issues in the management of elderly patients, including advice on exercise and treatment; particular emphasis is placed on vitamin B group-containing xefocam and neurobion.

Brain morphological signatures for chronic pain

Chronic pain can be understood not only as an altered functional state, but also as a consequence of neuronal plasticity. Here we use in vivo structural MRI to compare global, local, and architectural changes in gray matter properties in patients suffering from chronic back pain (CBP), complex regional pain syndrome (CRPS) and knee osteoarthritis (OA), relative to healthy controls. We find that different chronic pain types exhibit unique anatomical ‘brain signatures’. Only the CBP group showed altered whole-brain gray matter volume, while regional gray matter density was distinct for each group. Voxel-wise comparison of gray matter density showed that the impact on the extent of chronicity of pain was localized to a common set of regions across all conditions. When gray matter density was examined for large regions approximating Brodmann areas, it exhibited unique large-scale distributed networks for each group. We derived a barcode, summarized by a single index of within-subject co-variation of gray matter density, which enabled classification of individual brains to their conditions with high accuracy. This index also enabled calculating time constants and asymptotic amplitudes for an exponential increase in brain re-organization with pain chronicity, and showed that brain reorganization with pain chronicity was 6 times slower and twice as large in CBP in comparison to CRPS. The results show an exuberance of brain anatomical reorganization peculiar to each condition and as such reflecting the unique maladaptive physiology of different types of chronic pain.

[Analgesic effects of cannabinoids on central pain syndrome]

It was shown that cannabinoids anandamide, HU210 and WIN 55,212-2 inhibit both spontaneous episodes of pain and mechanical allodynia in rats with central pain syndrome caused by disturbance of inhibitory processes in the dorsal horns of lumbar spinal cord. The analgesic effect is most pronounced in the intrathecal route of administration. The intensity of analgesic actions of cannabinoids on the central pain syndrome in rats, depending on the drug is as follows: HU210 > WIN 55,212-2 > anandamide.

Guidance of magnetic resonance imaging and placement of skin-marker localization devices

AIM

A variety of magnetic resonance imaging (MRI)-compatible skin-marker localization devices are available on the market. MRI protocols call for the liberal use of the skin markers over the specific site of symptoms or over any palpable mass. This study investigates the usefulness of patient-assisted placement of 1 000-mg fish oil capsules as skin markers over the area of maximum localized pain, signs, or symptoms and correlates this placement with any potential underlying neuropathology or potential pain generator.

METHODS

One-hundred symptomatic patients undergoing MRI were assessed for focal or localized signs or symptoms. Under the direction of a physician and with guidance from the patient, the MRI technician placed a 1 000-mg fish-oil capsule over the area of maximum pain or signs and symptoms. Patients with poorly localized, diffuse symptoms or an area of maximal signs and symptoms outside the field of view of the MRI were not included in this study. All MRI exams were reviewed by clinical physicians and radiologists or neuroimaging physicians.

RESULTS

In all 100 cases, the images show clearly visible MRI-compatible skin-surface markers that correlate with potential underlying neuropathology.

CONCLUSION

Our results show that 1 000-mg fish-oil capsules can be used as MRI localization devices as a cost-effective alternative to more expensive commercially available devices.

Prevalence and profile of back pain in Nigerian adolescents

OBJECTIVE

This study aimed to investigate prevalence, characteristics, perceived predisposing factors and mode of treatment sought for back pain among school-aged adolescents in Nigeria.

SUBJECTS AND METHODS

A self-administered questionnaire employed in this cross-sectional study was distributed to 4,400 students [mean age 15.0 ± 1.7 years (range 10-19)] from 44 randomly selected schools.

RESULTS

Of the 4,400 questionnaires, 3,185 were completed (1,455 boys and 1,730 girls), thereby yielding a response rate of 72.4%. The lifetime and point prevalence of back pain were 59 and 17%, respectively. Low back pain was the most prevalent type, reported by 25%. The prevalence of back pain was 59.7% among boys and 57.5% among girls. Back pain was significantly associated with age, religion and involvement in commercial activity (p < 0.05). Among those with back pain, most cases were mild (56%), but chronic in 21%, and 27% used self-medication. Prolonged sitting posture (17%) was the most implicated predisposing factor to back pain.

CONCLUSION

Back pain is common among Nigerian adolescent students, but it is mostly mild. The prevalence of back pain increased with advancing age in both genders. More research is needed to find necessary risk factors and interventions including appropriate back education to reduce back pain.

A planning study for palliative spine treatment using StatRT and megavoltage CT simulation

Megavoltage CT (MVCT) simulation on the TomoTherapy Hi·Art system is an alternative to conventional CT for treatment planning in the presence of severe metal artifact. StatRT is a new feature that was implemented on the TomoTherapy operator station for performing online MVCT scanning, treatment planning and treatment delivery in one session. The clinical feasibility of using the StatRT technique and MVCT simulation to palliative treatment for a patient with substantial spinal metallic hardware is described. A patient with metastatic non-small-cell lung cancer involving the thoracic spine underwent conventional kilovoltage CT simulation. The metal artifact due to stainless steel spine-stabilizing rods was too severe for treatment planning, despite attempts to correct using density override. The patient was then re-scanned using MVCT on a tomotherapy unit. Plans were generated using both StatRT and conventional tomotherapy planning (Tomo plan) with different settings for comparison. StatRT planning ran a total of five iterations in a short planning window (10-15 min). Two Tomo plans were generated using: (1) five iterations in the "full scatter" mode, and (2) 300 iterations in the "beamlet" mode. It was noted that the DVH of the StatRT plan was almost identical to the Tomo plan optimized by the "full scatter" mode and the same number of iterations. Dose distribution analysis reveals that these three planning methods yielded comparable doses to heart, lungs and targets. This work also demonstrated that undermodulation can result in a high degree of thread effects. The overall time for the treatment process (including 7 minutes for simulation, 15 minutes for contouring, 10 minutes for planning and 5 minutes for delivery) decreases from hours to around 40 minutes using the StatRT procedure. StatRT is a feasible treatment-planning tool for physicians to scan, contour and treat patients within one hour. This can be particularly beneficial in urgent palliative treatments.

Percutaneous therapy for symptomatic synovial cysts

Synovial cysts have long been known to create radicular pain in the spine, with the clinical effect mimicking a disk herniation. These cysts have traditionally been treated with open surgical therapy. Now a minimally invasive, image-guided approach to treatment is available to relieve this problem, using a simple percutaneous needle stick and injection. This article describes the technical aspects and precautions needed for this intervention.

Spinal cord compression complicating aseptic spondylodiscitis in ankylosing spondylitis

Aseptic spondylodiscitis is a well recognized complication of ankylosing spondylitis. Neurological complications of such discovertebral lesions are uncommon. We report a new case with a diagnosis of T12-L1 spondylodiscitis which developed ten years after a spinal cord compression. Such neurological complications of aseptic spondylodiscitis may be explained by proliferative epidural tissue without predominant inflammatory infiltrates and also the development of new bone reaction, suggesting the contribution of mechanical factors.

Primary spinal hydatid disease

Primary spinal hydatid disease is rare. Spinal hydatid disease should be considered in the differential diagnosis of spinal cord compression syndrome in endemic countries and evaluated with imaging and serology. Our case was a 34- year-old man. The patient presented with progressive back pain for 8 months and lower extremity weakness for 3 months. Neurological examination was suggestive of upper motor neuron type of paraperesis. Magnetic resonance images of the thoracal region showed an intradural multicystic lesion. The mass was explored with T 10-11 laminectomy. It had displaced the cord to the right side. The fluid was clear and did not contain pus. The lesion was easily dissected from the cord and was resected totally. The pathological diagnosis was hydatid disease.

Acute pyogenic diskitis (spondylodiskitis) in adults

Most cases of back pain are the result of degenerative changes in the spine or are related to musculoskeletal elements. Pyogenic infections of the back can be subcategorized into cases involving the paraspinal epidural space, vertebral bodies, or the intervertebral disk spaces. Any region of the spine may be the site of diskitis, although the process most commonly involves the lumbar spine. Most cases of diskitis are managed with conservative therapy, including antibiotics and spinal immobilization using braces or corsets. Surgical therapy is generally reserved for patients with neurological complications, spinal instability, or progressive spinal deformity or those who fail to respond clinically to antibiotic therapy alone.

Appropriate selection of patients with lumbar spinal stenosis for interspinous process decompression with the X STOP device

With the aging of the population, the number of patients suffering from progressive lumbar spinal stenosis with symptomatic neurogenic intermittent claudication is projected to increase. Unfortunately, these patients are limited to a choice between nonsurgical conservative care and more invasive decompressive surgical procedures such as laminectomy with or without fusion. The X STOP interspinous process decompression system is a commercially available device that provides a minimally invasive alternative treatment, an intermediate option within the continuum of care for these patients. The X STOP is appropriate for patients with moderately severe functional impairment whose symptoms are exacerbated in extension and relieved in flexion. Implanted between the spinous processes without disrupting the normal anatomical structures, the X STOP limits narrowing of the spinal canal and neural foramina by reducing extension at the symptomatic level(s). In this report the author details the approved indications for use of the X STOP and discusses several illustrative cases.