Transforaminal lumbar interbody fusion with a tantalum cage: lumbar lordosis redistribution and sacral slope restoration with a modified posterior technique

BACKGROUND

Transforaminal lumbar interbody fusion (TLIF), a commonly used procedure in spine surgery, has the advantage of a lower incidence of nerve lesions compared to the posterior lumbar interbody fusion (PLIF) technique. The intersomatic arthrodesis has always been carried out with a single tantalum cage normally used for PLIF. Tantalum is a metal that is particularly used in orthopedic surgery. It has a modulus of elasticity similar to marrow and leads to high primary stability of the implant.

MATERIALS AND METHODS

Our study was a retrospective monocentric observational study evaluating clinical and radiological outcomes of tantalum cages in a modified TLIF technique with posterior instrumentation and autologous and/or homologous posterolateral bone grafting. The aim of the study was to evaluate clinical outcomes and the increase in or redistribution of lumbar lordosis. The intersomatic arthrodesis was always carried out with a single tantalum cage normally used for PLIF to reduce the neurological risk. We retrospectively studied 105 patients who were treated with a modified unilateral TLIF approach by two surgeons between 2013 and 2018. We evaluated the Oswestry Disability Index (ODI), Visual Analogue Scale (VAS) for back pain, global lumbar lordosis, lordosis of L4-sacrum, segmental lordosis of functional motion units that underwent arthrodesis, pelvic tilt, pelvic incidence, and the sacral slope in 77 patients. All patients were suffering from grade III or IV Pfirrmann, instability, or foraminal post-laminectomy stenosis and/or grade I-II degenerative spondylolisthesis or low-grade isthmic spondylolisthesis. They had no significant sagittal imbalance, with a sagittal vertical axis (SVA) of < 5 mm. The average follow-up duration was 30 months.

RESULTS

We achieved excellent clinical results, with only four cases of failure (5.2%). Moreover, we noticed a statistically significant redistribution of lumbar lordosis, with an average percentage increase in L4-S1 lordosis equal to 19.9% (P < 0.001), an average increase in the L4-S1/Lumbar lordosis (LL) ratio from 0.53 to 0.63 (P < 0.001), and a mean percentage increase in sacral slope equal to 7.6% (P < 0.001).

CONCLUSION

Thanks to the properties of tantalum, our modified single-portal TLIF technique is a valid surgical solution to obtain a solid arthrodesis and restore the correct lumbar lordosis distribution while reducing neurological complications and the number of failures.

LEVEL OF EVIDENCE

4 Trial registration statement: retrospective observational study, no trial registration.

What Is the Role of Traction Test Radiographs in the Preoperative Planning of Adolescent Idiopathic Scoliosis?

Lower instrumented vertebra (LIV) selection is critical to avoid complications like adding-on. This study aims to determine the usefulness of the traction test (TR) in selecting the LIV during surgery for adolescent idiopathic scoliosis (AIS). We analyzed 42 AIS patients with Lenke 1 curves who had preoperative, postoperative, and at least 12-month follow-up X-rays, as well as preoperative side bending (SB) and TR radiograms. Neutral vertebra (NV), stable vertebra (SV), lower instrumented vertebra (LIV), and Cobb angles were identified and compared on all radiographic images. In 23 cases, the TR resulted in SV proximalization compared to the preoperative X-rays, while in 8 cases, SV-TR was more distal. This distalization occurred in 50% of Lenke 1C curves, where a greater correction of the distal curve was found. NV-TR was proximal to NV-preop in 9 cases, while NV-SB was proximal in 22 cases. LIV was proximal to SV-TR in 8 cases, while it was proximal to SV-preop in 22. One patient with LIV proximal to SV-TR developed adding-on. In conclusion, the TR is crucial in AIS preoperative planning as it provides information distinct from that of standard X-rays and SB: (1) it better assesses gravitational stability than rotational stability; and (2) choosing LIV equal to or proximal to SV-TR may prevent adding-on, except in 'flexible' Lenke 1C curves where LIV should be equal or distal to SV-preop.

Paraparesis and congenital severe hyperkyphosis in Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome: A rare deformity management during the Sars-Cov-2 pandemic

Introduction

Mayer-Rokitansky-Küster-Hauser syndrome (MRKH) syndrome can be classified into two types: type I (isolated) without extragenital abnormalities; type II (associated) with the presence of extragenital dimorphisms. Skeletal abnormalities are the second most frequent extragenital manifestations.

Research question

Association between MRKH and congenital scoliosis has been described; on the contrary, hyperkyphosis is very rare and sparsely described in the medical literature. Here we report our experience in the management of thoracolumbar hyperkyphosis in 16-year-old patient diagnosed with MRKH syndrome with an acute neurological impairment due to T11-T12 disc herniation.

Material and methods

Clinical and radiological images of the case were retrieved from the medical notes, operative records and imaging system.

Results

Posterior surgical correction was proposed to treat the severe spinal deformity; however, surgery was delayed because of SARS-CoV2 pandemic outbreak. During the pandemic, the patient had a major clinical and radiological deterioration with development of paraparesis. Complete clinical resolution of the paraparesis and restoration of balance was achieved with a two stage surgical approach, with a first anterior stage followed by a delayed posterior approach aimed at deformity correction.

Discussion

Congenital kyphosis are rare deformities that can progress rapidly leading to severe neurological deficits and worsening of the deformity. When patient has neurological deficit the surgical strategy to address the neurological problem first and plan the more complex and demanding corrective surgery remains a valid strategy that must be consider.

Conclusion

This is the first reported case of hyperkyphosis in Mayer-Rokitansky-Küster-Hauser syndrome (MRKH) syndrome surgically treated.

Automated Synthesis of 68Ga-DOTA-TOC with a Cationic Purification System: Evaluation of Methodological and Technical Aspects in Routine Preparations

BACKGROUND AND OBJECTIVE

Gallium-68 is a PET isotope available in each nuclear medicine departments, even those not equipped with a cyclotron, since it is easily obtained by eluting compact and transportable generator system. The preparation of Ga-68 DOTA-labeled compounds is performed by remotely controlled automated systems developed in order to ensure production efficiency, reproducibility of the results, fast reaction time, to facilitate the synthesis and minimize the radiation exposure. Many automatic synthesis systems are available on the radiopharmaceutical market, however, they requires some technical adaptations for routine use. We reported the [68Ga]Ga-DOTA-TOC production by automated cassette-based theranostic synthesizer system used in combination with a disposable GMP grade cassette system for cationic purification.

METHODS

The synthesizer is integrated with the 68Ge/68Ga generator systems and it allows to perform elution, eluate purification and radiolabeling in about 38 minutes. We have performed in 2 year (January 2016 - January 2018) over 100 [68Ga]Ga-DOTA-TOC preparations.

RESULTS

The average synthesis yield of radiopharmaceutical production was 54.4 ± 2.3 % and the radiochemical purity average was found 96.94 ± 0.74 %. Only three [68Ga]Ga-DOTA-TOC preparations have failed.

CONCLUSION

The methodology and the adopted technical solutions allowed to obtain a high quality radiopharmaceutical product as required by the European Pharmacopoeia.

Purification and characterization of ribosomal proteins L27 and L30 having antimicrobial activity produced by the Lactobacillus salivarius SGL 03

AIMS

The aim of this study was to investigate the antimicrobial potential of proteins secreted by a new strain of Lactobacillus salivarius.

METHODS AND RESULTS

The secretome of L. salivarius SGL 03 strain was analysed by gel-assisted fractionation and MS/MS to identify low-molecular-mass proteins. This strategy allowed us to identify 10 secreted proteins. Then, a combination of heterologous expression and agar well diffusion was used to characterize them as to their antimicrobial activity, mechanisms of action and stability. Our findings indicate that L27 and L30 proteins of the 50S ribosomal subunit have antimicrobial activity against Streptococcus pyogenes, Streptococcus uberis and Enterococcus faecium. In addition, both proteins are bactericidal against S. pyogenes and maintain their antimicrobial activity after different protease treatments, at acidic pH, after heat treatment, and if stored in a refrigerated ambient at least at 4°C.

CONCLUSIONS

The overall results demonstrated that the L27 and L30 ribosomal proteins are of interest as new antimicrobial molecules to prevent the growth of S. pyogenes, S. uberis and E. faecium.

SIGNIFICANCE AND IMPACT OF THE STUDY

Our results provide the first insight into the extra-ribosomal activity of L27 and L30 secreted proteins of L. salivarius. This study demonstrated the capacity of L. salivarius SGL 03 to produce antimicrobial molecules and suggested this strain as a promising probiotic candidate.

Mid-term results of an uncemented femoral stem with modular neck options

We prospectively assessed the results of 239 primary total hip replacements performed using a conical stem combined with modular necks of different lengths and inclinations (Modulus System, Lima Corporate San Daniele Del Friuli, Udine, Italia) in 222 patients (50 men, 172 women), undergoing surgery between October 2001 and December 2006 and presenting with anatomical deformities of the proximal femur and/or acetabulum, including developmental dysplasia (DDH), ankylosis, and sequelae of osteotomies or fractures. Such conditions can make hip replacement problematic. The mean age at the time of surgery was 57.6 years (22 ÷ 83). No patients were lost to follow-up. 3 femoral components underwent revision. At a mean of 5 years follow-up the Harris Hip Score showed a significant improvement, increasing from 35 preoperatively to a mean of 96.6. Using Kaplan-Meier analysis the survival rate at 5 years was 98.28%. The Modulus stem showed good mid-term results in terms of survival, as well as clinical and radiographic outcome.

Molecular epidemiological investigation of an outbreak of Pseudomonas aeruginosa infection in an SCT unit

From May to October 2006, six severe Pseudomonas aeruginosa infections were diagnosed in patients undergoing SCT in the SCT unit of the Careggi hospital (Florence, Italy). Four of the infected patients were treated consecutively in the same room (room N). On the hypothesis of a possible environmental source of infection, samples were collected from different sites that had potential for cross-contamination throughout the SCT unit, including the electrolytic chloroxidant disinfectant used for hand washing (Irgasan) and the disinfectant used for facilities cleaning. Four of the environmental samples were positive for P. aeruginosa: three Irgansan soap samples and a tap swab sample from the staff cleaning and dressing room. The AFLP (amplified fragment length polymorphism) typing method employed to evaluate strain clonality showed that the isolates from the patients who had shared the same room and an isolate from Irgasan soap had a significant molecular similarity (dice index higher than 0.93). After adequate control measures, no subsequent environmental sample proved positive for P. aeruginosa. These data strongly support the hypothesis of the clonal origin of the infective strains and suggest an environmental source of infection. The AFLP method was fast enough to allow a 'real-time' monitoring of the outbreak, permitting additional preventive measures.

Chest pain unit and decentralized testing of cardiac markers

Chest pain is one of the most important reasons of Emergency Department arrivals (5% of total). As it is not possible to rule-in all patients claiming chest pain, it has been proposed to create new departments to monitor these patients during some hours, in order to exclude or confirm an acute coronary syndrome. These departments are named Chest Pain Units (CPUs). The Chest Pain Unit has been created since June 1998 in Alessandria Hospital "SS. Antonio e Biagio e C. Arrigo". Chest Pain Unit patients presenting in Emergency Department with an unclear defined chest pain are submitted to a continuous ECG monitoring of S-T trend for 24 h. Moreover, cardiac markers such as myoglobin, mass CK-MB and Troponin-I are tested at arrival and Troponin-I is tested again serially 3, 6, 9, 18 h after the first sampling. It is really important to be able to measure these markers of myocardial damage with robust and quick methods. A point-of-care analyzer is available in our chest pain unit and enables our department to obtain results in a very short time at low cost and with quality similar to that of clinical chemistry laboratories' instruments. This easy-to-use analyzer can be run by nurses without interfering in their normal activities. The presentation of our experience will be completed by describing all patients admitted in our Chest Pain Units from January to June 1998.

The high prevalence of "soft" bipolar (II) features in atypical depression

Seventy-two percent of 86 major depressive patients with atypical features as defined by the DSM-IV and evaluated systematically were found to meet our criteria for bipolar II and related "soft" bipolar disorders; nearly 60% had antecedent cyclothymic or hyperthymic temperaments. The family history for bipolar disorder validated these clinical findings. Even if we limit the diagnosis of bipolar II to the official DSM-IV threshold of 4 days of hypomania, 32.6% of atypical depressives in our sample would meet this conservative threshold, a rate that is three times higher than the estimates of bipolarity among atypical depressives in the literature. By definition, mood reactivity was present in all patients, while interpersonal sensitivity occurred in 94%. Lifetime comorbidity rates were as follows: social phobia 30%, body dysmorphic disorder 42%, obsessive-compulsive disorder 20%, and panic disorder (agoraphobia) 64%. Both cluster A (anxious personality) and cluster B (e.g., borderline and histrionic) personality disorders were highly prevalent. These data suggest that the "atypicality" of depression is favored by affective temperamental dysregulation and anxiety comorbidity, clinically manifesting in a mood disorder subtype that is preponderantly in the realm of bipolar II. In the present sample, only 28% were strictly unipolar and characterized by avoidant and social phobic features, without histrionic traits.