Biomimetic vascularized adipose-derived mesenchymal stem cells bone-periosteum graft enhances angiogenesis and osteogenesis in a male rabbit spine fusion model

Aims

Several artificial bone grafts have been developed but fail to achieve anticipated osteogenesis due to their insufficient neovascularization capacity and periosteum support. This study aimed to develop a vascularized bone-periosteum construct (VBPC) to provide better angiogenesis and osteogenesis for bone regeneration.

Methods

A total of 24 male New Zealand white rabbits were divided into four groups according to the experimental materials. Allogenic adipose-derived mesenchymal stem cells (AMSCs) were cultured and seeded evenly in the collagen/chitosan sheet to form cell sheet as periosteum. Simultaneously, allogenic AMSCs were seeded onto alginate beads and were cultured to differentiate to endothelial-like cells to form vascularized bone construct (VBC). The cell sheet was wrapped onto VBC to create a vascularized bone-periosteum construct (VBPC). Four different experimental materials - acellular construct, VBC, non-vascularized bone-periosteum construct, and VBPC - were then implanted in bilateral L4-L5 intertransverse space. At 12 weeks post-surgery, the bone-forming capacities were determined by CT, biomechanical testing, histology, and immunohistochemistry staining analyses.

Results

At 12 weeks, the VBPC group significantly increased new bone formation volume compared with the other groups. Biomechanical testing demonstrated higher torque strength in the VBPC group. Notably, the haematoxylin and eosin, Masson's trichrome, and immunohistochemistry-stained histological results revealed that VBPC promoted neovascularization and new bone formation in the spine fusion areas.

Conclusion

The tissue-engineered VBPC showed great capability in promoting angiogenesis and osteogenesis in vivo. It may provide a novel approach to create a superior blood supply and nutritional environment to overcome the deficits of current artificial bone graft substitutes.

The associations of depression, anxiety, and insomnia at baseline with disability at a five-year follow-up point among outpatients with chronic low back pain: a prospective cohort study

BACKGROUND

No previous study has investigated the associations of depression, anxiety, and insomnia at baseline with disability at a five-year follow-up point among outpatients with chronic low back pain (CLBP). The study aimed to simultaneously compare the associations of depression, anxiety, and sleep quality at baseline with disability at a 5-year follow-up point among patients with CLBP.

METHODS

Two-hundred and twenty-five subjects with CLBP were enrolled at baseline, and 111 subjects participated at the five-year follow-up point. At follow-up, the Oswestry Disability Index (ODI) and total months of disability (TMOD) over the past five years were used as the indices of disability. The depression (HADS-D) and anxiety (HADS-A) subscales of the Hospital Anxiety and Depression Scale and the Insomnia Severity Index (ISI) were used to assess depression, anxiety, and insomnia at baseline and follow-up. Multiple linear regression was employed to test the associations.

RESULTS

The scores of the HADS-D, HADS-A, and ISI were correlated with the ODI at the same time points (both at baseline and follow-up). A greater severity on the HADS-D, an older age, and associated leg symptoms at baseline were independently associated with a greater ODI at follow-up. A greater severity on the HADS-A and fewer educational years at baseline were independently associated with a longer TMOD. The associations of the HADS-D and HADS-A at baseline with disability at follow-up were greater than that of the ISI at baseline, based on the regression models.

CONCLUSION

Greater severities of depression and anxiety at baseline were significantly associated with greater disability at the five-year follow-up point. The associations of depression and anxiety at baseline with disability at the long-term follow-up point might be greater than that of insomnia at baseline.

Fat Embolism Syndrome and in-Hospital Mortality Rates According to Patient Age: A Large Nationwide Retrospective Study

Introduction

Fat embolism syndrome (FES) is a rare life-threatening condition that can develop after traumatic orthopedic injuries. Controversy remains concerning the epidemiology in the elderly population. Therefore, this study aims to report FES related to in-hospital mortality stratified by age.

Methods

A retrospective trauma cohort study was conducted using data from the National Trauma Data Bank (NTDB) from 2007 to 2014. All FES cases were included in the study with the diagnosis of FES (ICD9 958.1). Death on arrival cases were excluded. Patients were stratified by age cohort: less than 40 (G1), 40–64 (G2), and greater than 65 (G3) years of age. The primary outcome evaluated was in-hospital mortality. Multivariable regression models were performed to adjust for potential confounders.

Results

Between 2007 and 2014, 451 people from a total of 5,836,499 trauma patients in the NTDB met the inclusion criteria. The incidence rate was 8 out of 100,000. The inpatient mortality rate was 11.8% for all subjects with the highest mortality rate of 17.6% in patients over 65. Multivariable analyses demonstrated that age greater than 65 years was an independent predictor of mortality (aOR 24.16, 95% CI 3.73, 156.59, p=0.001), despite higher incidence and injury severity of FES among patients less than 40. No significant association with length of hospital stay, length of intensive unit care, or length of ventilation use was found between the groups. Subgroup analysis of the elderly population also showed a higher mortality rate for FES in femoral neck fracture patients (18%) than other femoral fractures (14%).

Conclusion

In this retrospective cohort analysis, old age (≥ 65 years) was found to be an independent risk factor for in-hospital mortality among fat embolism syndrome patients. Elderly patients specifically with femoral neck fractures should be monitored for the development of FES.

Total hip arthroplasty has higher complication rates in stiff spine patients: a systematic review and network meta-analysis

Background

Ankylosing spondylitis (AS) and spinal fusion (SF) classified as stiff spines have been associated with the increased rate of complications following total hip arthroplasty (THA). However, the differences between the two cohorts have inconsistent evidence.

Methods

We searched for studies comparing complications among stiff spine patients, including SF and AS, who underwent THA in PubMed/MEDLINE, Embase, Cochrane CENTRAL, Web of Science, and Scopus until March 2021. Studies detailing rates of mechanical complications, aseptic loosening, dislocation, infection, and revisions were included. We performed network meta-analyses using frequentist random-effects models to compare differences between cohorts. We used P-score to rank the better exposure with the lowest complications.

Results

Fourteen studies were included in the final analysis. A total of 740,042 patients were included in the systematic review and network meta-analysis. Mechanical complications were highest among SF patients (OR 2.33, 95% CI 1.86, 2.92, p < 0.05), followed by AS patients (OR 1.18, 95% CI 0.87, 1.61, p = 0.82) compared to controls. Long Spinal Fusions had the highest aseptic loosening (OR 2.33, 95% CI 1.83, 2.95, p < 0.05), dislocations (OR 3.25, 95% CI 2.58, 4.10, p < 0.05), infections (OR 2.14, 95% CI 1.73, 2.65, p < 0.05), and revisions (OR 5.25, 95% CI 2.23, 12.32, p < 0.05) compared to AS and controls. Our results suggested that SF with longer constructs may be associated with higher complications in THA patients.

Conclusions

THAs following SFs have higher mechanical complications, aseptic loosening, dislocations, and infections, especially with longer constructs. AS patients may have fewer complications compared to this cohort.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-03237-8.

Cannabinoid Use for Pain Reduction in Spinal Cord Injuries: A Meta-Analysis of Randomized Controlled Trials

Background: Spinal cord injury (SCI) often involves multimodal pain control. This study aims to evaluate the efficacy and safety of cannabinoid use for the reduction of pain in SCI patients.

Methods and Findings: This study followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. We searched PubMed, EMBASE, Scopus, Cochrane, Web of Science, and ClinicalTrials.gov for relevant randomized controlled trials (RCTs) reporting the efficacy (e.g., pain relief) or safety (e.g., adverse events) of cannabinoids in patients with SCI, from inception to 25 December 2021. The study quality and the quality of evidence were evaluated by Cochrane ROB 2.0 and the Grading of Recommendations, Assessment, Development, and Evaluations system (GRADE), respectively. We used the random-effects model to perform the meta-analysis. From a total of 9,500 records, we included five RCTs with 417 SCI patients in the systematic review and meta-analysis. We judged all five of the included RCTs as being at high risk of bias. This meta-analysis indicated no significant difference in pain relief between the cannabinoids and placebo in SCI patients (mean difference of mean differences of pain scores: −5.68; 95% CI: −13.09, 1.73; p = 0.13; quality of evidence: very low), but higher odds of adverse events were found in SCI patients receiving cannabinoids (odds ratio: 3.76; 95% CI: 1.98, 7.13; p < 0.0001; quality of evidence: moderate).

Conclusion: The current best evidence suggests that cannabinoids may not be beneficial for pain relief in SCI patients, but they do increase the risks of adverse events, including dizziness, somnolence, and dysgeusia, compared to the placebo. Cannabinoids should not be regularly suggested for pain reduction in SCI patients. Updating the systematic reviews and meta-analyses by integrating future RCTs is necessary to confirm these findings.

Does Direct Surgical Repair Benefit Pars Interarticularis Fracture? A Systematic Review and Meta-analysis

BACKGROUND

Promising results have been shown in previous studies from direct pars interarticularis repair. These include Scott wiring, Buck repair, pedicle screw repair, and Morscher techniques. In addition, several minimally invasive techniques have been reported to show high union rates, low rates of implant failure and wound complications, shorter length of stay, a lower postoperative pain score with faster recovery, and minimal blood loss.

OBJECTIVES

To compare the evidence on techniques for direct pars interarticularis repair.

STUDY DESIGN

Systematic review and meta-analysis.

SETTING

Review article.

METHODS

We conducted a comprehensive search of databases to identify studies assessing outcomes of direct pars interarticularis defect repair. Two authors independently screened electronic search results, performed study selection, and extracted data for meta-analysis. Sensitivity and subgroup analyses were performed to assess risk of bias.

RESULTS

Forty studies were included in the final analysis. Union rate was higher in the pedicle screw repair group (effect size [ES] 95%; 95% CI, 86% to 100%), followed by the Buck repair group (ES 93%; 95% CI, 86% to 98%), Scott wiring (ES 85%; 95% CI, 63% to 99%), and Morscher method group (ES 63%; 95% CI, 2% to 100%). Positive functional outcome was higher for the Morscher method (ES 91%; 95% CI, 86% to 96%), followed by the Buck repair group (ES 85%; 95% CI, 68% to 97%), pedicle screw repair (ES 84%; 95% CI, 59% to 99%) and Scott repair group (ES 80%; 95% CI, 60% to 95%). Complication rates were highest among the Scott repair group (ES 12%; 95% CI, 4% to 22%) and Morscher method group (ES 12%; 95% CI, 0% to 34%).

LIMITATIONS

Heterogeneity of the included studies were noted. However, we performed sensitivity analyses from the available data to address this issue.

CONCLUSION

Our results indicate that pedicle screw repair and Buck repair may be associated with a higher union rate and lower complication rates compared to the Scott repair and Morscher method. Ultimately, the choice of technique should be based on the surgeon's preference and experience.

Does Surgical Repair Benefit Pipkin Type I Femoral Head Fractures?: A Systematic Review and Meta-Analysis

Background: Femoral head fractures are rare injuries with or without traumatic dislocations. The management of these fractures is crucial to prevent the development of severe complications and to achieve optimal functional outcomes. Wide treatment options for Pipkin 1 femoral head fractures range from fragment excision, fixation following open reduction with internal fixation, or conservative treatment such as close reduction alone after fracture dislocation. However, the best decision making remains controversial not only due to lack of large trials, but also inconsistent results reported. Therefore, we aim to compare the operative with nonoperative outcomes of Pipkin type 1 patients. Patients and Methods: We systemically searched MEDLINE, EMBASE, Cochrane library, In-Process & Other Non-Indexed Citations to identify studies assessing outcomes of Pipkin type 1 patients after conservative treatment, and open reduction with excision or fixation. Data on comparison of clinical outcomes of each management were extracted including arthritis, heterotopic ossification (HO), avascular necrosis (AVN), and functional scores (Thompson Epstein, Merle' d Augine and Postel Score). We performed a meta-analysis with the available data. Results: Eight studies (7 case series and 1 RCT) were included in this study. In a pooled analysis, the overall rate of arthritis was 37% (95% CI, 2-79%), HO was 20% (95% CI, 2-45%), and AVN was 3% (95% CI, 0-16%). In comparison of management types, the excision group reached the best functional outcomes including Thompson Epstein Score (poor to worse, 9%; 95% CI, 0-27%) and Merle d' Aubigne and Postel Score (poor to worse, 18%; 95% CI, 3-38%); ORIF group had the highest AVN rate (11%; 95% CI, 0-92%); conservative treatment had the highest arthritis rate (67%; 95% CI: 0-100%) and lowest HO rate (2%; 95% CI, 0-28%). Discussion: This meta-analysis demonstrates that different procedures lead to various clinical outcomes: fragment excision may achieve better function, conservative treatment may result in a higher arthritis rate, while ORIFs may have a higher AVN rate. These findings may assist surgeons in tailoring their decision-making to specific patient profiles. Future RCTs with multicenter efforts are needed to validate associations found in this study. Level of Evidence: II, systematic review and meta-analysis.

Impact of bisphosphonates and comorbidities on initial hip fracture prognosis

The aim of this study is to investigate the impact of bisphosphonate treatment on the prognosis of patients with initial hip fracture. Patients aged fifty years and older with initial hip fracture were identified from the Taiwan National Health Insurance Research Database between 2002 and 2011. A multi-state model was established to evaluate the transition between "first to second hip fracture", "first hip fracture to death", and "second hip fracture to death". Transition probability and cumulative hazards were used to compare the prognosis of initial hip fracture in a bisphosphonate treated cohort versus non-treated cohort. In addition, Deyo-Charlson comorbidities, both vertebral and non-vertebral fractures, and cataracts were also included for analysis. After 10-year follow-up, there is decreased cumulative transition probability for both second hip fracture and mortality after both first and second hip fracture in the bisphosphonate treated cohort. Multivariable, transition-specific time-dependent Cox model revealed that bisphosphonate treatment significantly reduced risk for second hip fracture in the first 5 years of the treatment (HR 0.88; 95% CI 0.79-0.99; P: 0.034), first hip fracture mortality (HR 0.88; 95% CI 0.83-0.93; P < 0.001), and second hip fracture mortality in the first 2 years of the treatment (HR 0.78; 95% CI 0.65-0.95; P = 0.011). Female sex, both vertebral and non-vertebral fractures, cataracts, dementia in the first 2 years, and DM with complication were all significantly associated with risk of a second hip fracture. Cerebrovascular disease and hemiplegia comorbidities had less risk of a second hip fracture. The risk of mortality after both first and second hip fracture was significantly associated with congestive heart failure, renal disease, myocardial infarction, and moderate to severe liver disease. Our study demonstrated that bisphosphonate treatment and strict management of comorbidities after the initial hip fracture significantly decrease the risk for a second hip fracture and mortality.

Minimally Invasive Percutaneous Vertebroplasty for Thoracolumbar Instrumented Vertebral Fracture in Patients With Posterior Instrumentation

BACKGROUND

The traditional treatment for an instrumented vertebral fracture involves removing the loosened pedicle screws and extending the posterior instrumentation cephaladly or caudally. There has been a recent trend of performing minimally invasive fluoroscopy-guided percutaneous vertebroplasty as a salvage procedure.

OBJECTIVE

The aim of this study was to compare the outcomes of surgical interventions for instrumented vertebral fracture.

STUDY DESIGN

Retrospective assessment.

SETTING

All data came from Chang Gung Memorial Hospital, Taiwan.

METHODS

We retrospectively reviewed 35 patients with an instrumented vertebral fracture who underwent fluoroscopy-guided percutaneous vertebroplasty (Group I, n = 16) or extension of the posterior instrumentation (Group II, n = 19). Demographic data were recorded. The operating time, amount of intraoperative blood loss, time to postoperative ambulation, and duration of hospital stay were also evaluated. The visual analog scale (VAS) score, kyphotic angle on radiological images, Kirkaldy-Willis functional score, complications, and revision surgery were evaluated at one week and one, 3, 6, and 12 months postoperatively.

RESULTS

Group I had a shorter operating time (P < 0.001), less intraoperative blood loss (P < 0.001), earlier postoperative ambulation (P < 0.001), and a shorter hospital stay (P < 0.001). The mean VAS score improved significantly after surgery in both groups (P = 0.001). The postoperative kyphotic angle was better in Group II (P < 0.05). There was no significant between-group difference in the Kirkaldy-Willis functional score at the last follow-up (P = 0.91). There was no significant between-group difference in the need for revision surgery (Group I, n = 4; Group II, n = 5; P = 0.93).

LIMITATION

This study is a retrospective cohort.

CONCLUSIONS

Minimally invasive fluoroscopy-guided percutaneous vertebroplasty can be used as an alternative to extension of posterior instrumentation for instrumented vertebral fracture. It has several advantages, including a shorter operating time, earlier postoperative ambulation, less blood loss, and a shorter hospital stay. The clinical outcomes of these 2 treatment approaches were similar.

Distal femur fractures have a higher mortality rate compared to hip fractures among the elderly: Insights from the National Trauma Data Bank

INTRODUCTION

The comparison of mortality and morbidity between distal femur (DF) and hip fracture in the old age is rarely reported in the literature. We aim to analyze a nationwide database among the elderly to compare the outcomes between hip fractures and distal femur fractures in the United States.

MATERIALS AND METHODS

A retrospective analysis of the National Trauma Data Bank was queried between 2007-2014 to identify distal femur (DF) and hip fracture patients greater than 65 years of age. Outcomes analyzed included in-hospital mortality, total hospital length of stay(LOS), intensive care unit length of stay(ICU-LOS), length of ventilation use and hospital discharge disposition. Multivariable regression models were performed to adjust for potential confounders. Statistical significance was established at p < 0.001.

RESULTS

26,325 (10.1%) and 233,213 (89.9%) patients reported a diagnosis of DF and hip fracture, respectively. The inpatient mortality rate was significantly higher in the distal femur fracture group (8.3% vs. 6.7%), with significantly longer LOS (7.87 vs. 6.65), ICU-LOS (1.50 vs. 0.73), and required ventilation days (0.74 vs. 0.27). Multivariable analyses demonstrated that hip fracture patients had a lower mortality (adjusted odds ratio [aOR], 0.80; 95% CI [0.76, -0.85]; p < 0.001), shorter LOS ([aOR], -0.31; 95% CI [-0.39, -0.23]; P < 0.001), and more likely to be discharged home ([aOR], 0.88; 95% CI, 0.85, 0.91; P < 0.001, compared to DF fracture patients.

CONCLUSION

After adjusting for potential factors, DF fracture patients have a significantly higher mortality, longer LOS, and less likely to be discharged home compared to hip fractures among the elderly. These results may suggest clinicians and caregivers for closely monitoring of clinical conditions for these patients.

LEVEL OF EVIDENCE

III.

Early detection and intervention for acute perforated peptic ulcer after elective spine surgeries: a review of 13 cases from 24,026 patients

BACKGROUND

To determine how perforated peptic ulcers be diagnosed earlier after patients undergoing an elective spine surgery.

METHODS

Patients who underwent elective spine surgeries at our hospital between January 2000 and April 2018 and experienced an acute perforated peptic ulcer were included. An age-and gender-matched control group was comprised of 26 patients without a postoperative acute perforated peptic ulcer who received spine surgery during the same period. Medical records and imaging studies were thoroughly reviewed.

RESULTS

Thirteen patients were enrolled in the study group, including eight females and five males. Three patients, two females and one male, died of uncontrolled peritonitis during the hospital stay. All patients in the study group experienced the sudden onset of abdominal pain, which was continuous and progressively worsening. Patients with elevated serum amylase, a peptic ulcer history and increased intraoperative blood loss had a tendency to develop a postoperative perforated peptic ulcer.

CONCLUSION

Spine surgeons should be highly alert to these risk factors of postoperative perforated peptic ulcers inpatients who has history of peptic ulcer, large amount ofintraoperative blood loss and abnormal high serum amylase level after elective spine surgery. Early diagnosis and emergent surgical intervention promote better outcomes.

Trauma Center Outcomes After Transition From Level 2 to Level 1: A National Trauma Data Bank Analysis

BACKGROUND

Previous US-based studies have shown that a trauma center designation of level 1 is associated with improved patient outcomes. However, most studies are cross-sectional, focus on volume-related issues and are direct comparisons between levels. This study investigates the change in patient characteristics when individual trauma centers transition from level 2 to level 1 and whether the patients have similar outcomes during the initial period of the transition.

STUDY DESIGN

We performed a retrospective cohort study that analyzed hospital and patient records included in the National Trauma Data Bank from 2007 to 2016. Patient characteristics were compared before and after their hospitals transitioned their trauma level. Mortality; complications including acute kidney injury, acute respiratory distress syndrome, cardiac arrest with CPR, deep surgical site infection, deep vein thrombosis, extremity compartment syndrome, surgical site infection, osteomyelitis, pulmonary embolism, and so on; ICU admission; ventilation use; unplanned returns to the OR; unplanned ICU transfers; unplanned intubations; and lengths of stay were obtained following propensity score matching, comparing posttransition years with the last pretransition year.

RESULTS

Sixteen trauma centers transitioned from level 2 to level 1 between 2007 and 2016. One was excluded due to missing data. After transition, patient characteristics showed differences in the distribution of race, comorbidities, insurance status, injury severity scores, injury mechanisms, and injury type. After propensity score matching, patients treated in a trauma center after transition from level 2 to 1 required significantly fewer ICU admissions and had lower complication rates. However, significantly more unplanned intubations, unplanned returns to the OR, unplanned ICU transfers, ventilation use, surgical site infections, pneumonia, and urinary tract infections and higher mortality were reported after the transition.

CONCLUSIONS

Trauma centers that transitioned from level 2 to level 1 had lower overall complications, with fewer patients requiring ICU admission. However, higher mortality and more surgical site infections, pneumonia, urinary tract infections, unplanned intubations, and unplanned ICU transfers were reported after the transition. These findings may have significant implications in the planning of trauma systems for administrators and healthcare leaders.

Teriparatide and bisphosphonate use in osteoporotic spinal fusion patients: a systematic review and meta-analysis

PURPOSE

Osteoporosis is one of the most common conditions among adults worldwide. It also presents a challenge among patients undergoing spinal surgery. Use of Teriparatide and bisphosphonates in such patients has been shown to improve outcomes after fusion surgery, including successful fusion, decreased risk of instrumentation failure, and patient-reported outcomes. Herein, we performed a systematic review and indirect meta-analysis of available literature on outcomes of fusion surgery after use of bisphosphonates or Teriparatide.

METHODS

We conducted a comprehensive search of all databases (Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus) to identify studies assessing outcomes of spinal fusion among osteoporotic patients after use of Teriparatide or bisphosphonate. Four authors independently screened electronic search results, and all four authors independently performed study selection. Two authors performed independent data extraction and assessed the studies' risk of bias assessment using standardized forms of Revised Cochrane risk-of-bias tool for randomized trials (RoB 2) and Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I).

RESULTS

Nineteen studies were included in the final analysis. A total of 13 studies evaluated the difference in fusion rate between bisphosphonates and Teriparatide or control group. Fusion rate was higher for bisphosphonates (effect size (ES) 83%, 95% CI 77-89%) compared with Teriparatide (ES 71%, 95% CI 57-85%), with the p value for heterogeneity between groups without statistical significance (p = 0.123). Five studies assessed the impact of using bisphosphonate or Teriparatide on screw loosening. The rate of screw loosening was higher for bisphosphonates (ES 19%, 95% CI 13-25%) compared with Teriparatide (ES 13%, 95% CI 9-16%) without statistical significance (p = 0.52).

CONCLUSION

Our results indicate that while both agents may be associated with positive outcomes, bisphosphonates may be associated with a higher fusion rate, while Teriparatide may be associated with lower screw loosening. The decision to treat with either agent should be tailored individually for each patient keeping in consideration the adverse effect and pharmacokinetic profiles.

Association of age-related macular degeneration on fracture risks among osteoporosis population: a nationwide population-based cohort study

OBJECTIVES

Visual impairment is an important risk factor for fracture in the elderly population. Age-related macular degeneration (AMD) is the leading cause of irreversible visual impairment in elderly people. This study was conducted to explore the relationship between AMD and incident fractures in patients with osteoporosis (OS).

DESIGN

Retrospective analysis of Taiwan's National Health Insurance Research Database (NHIRD).

SETTING

A multicenter study conducted in Taiwan.

PARTICIPANTS AND CONTROLS

The current study used the NHIRD in Taiwan between 1996 and 2011. A total of 13 584 and 54 336 patients with OS were enrolled in the AMD group and the non-AMD group, respectively.

INTERVENTION

Patients with OS were included from the Taiwan's NHIRD after exclusion, and each patient with AMD was matched for age, sex and comorbidities to four patients with non-AMD OS, who served as the control group. A Cox proportional hazard model was used for the multivariable analysis.

PRIMARY OUTCOME MEASURES

Transitions for OS to spine fracture, OS to hip fracture, OS to humero-radio-ulnar fracture and OS to death.

RESULTS

The risks of spine and hip fractures were significantly higher in the AMD group (HR=1.09, 95% CI=1.04 to 1.15, p<0.001; HR=1.18; 95% CI=1.08 to 1.30, p=0.001, respectively) than in the non-AMD group. The incidence of humero-radio-ulnar fracture between AMD and non-AMD individuals was similar (HR=0.98; 95% CI=0.90 to 1.06; p=0.599). However, the risk of death was higher in patients with OS with older age, male sex and all types of comorbidity (p<0.05), except for hyperthyroidism (p=0.200).

CONCLUSION

Patients with OS with AMD had a greater risk of spine and hip fractures than did patients without AMD.

Cement Augmentation for Single-Level Osteoporotic Vertebral Compression Fracture: Comparison of Vertebroplasty With High-Viscosity Cement and Kyphoplasty

BACKGROUND

Although the majority of available evidence suggests that vertebroplasty and kyphoplasty (KP) can relieve pain associated with vertebral compression fractures (VCFs) and improve function, evidence of clinical and radiographic outcome in highly viscous cement vertebroplasty (HVC) or KP for the treatment of VCFs is limited. The purpose of this study was to compare the clinical effects between HVC and KP in the treatment of single-level osteoporotic VCFs including radiographic and clinical outcomes.

METHODS

From January 2017 to October 2018, 96 patients with single-level osteoporotic vertebral compression fracture who had undergone either KP or HVC surgery at our hospital were reviewed retrospectively, with at least 1 year follow-up. All patients were divided into the HVC group (n = 50) or the KP group (n = 46). Clinical data including clinical and radiologic evaluation results were performed pre- and postoperatively.

RESULTS

The operation time of the HVC group (32.24 ± 10.08 minutes) was less than that of the KP group (40.76 ± 9.49 minutes), with significant differences. Compared with preoperative data, the visual analog scale scores, Oswestry disability index scores, vertebral body height, and local kyphotic angle were improved after surgery. There were no significant differences between the 2 groups in local kyphotic angle, vertebral body height, leakage rate of bone cement, and incidence of adjacent-level vertebra fracture.

CONCLUSIONS

Restoring the vertebral height and local kyphotic angle corrections of HVC are similar with those of KP. Additionally, KP is not superior in the leakage rate of bone cement and incidence of adjacent-level vertebra fracture compared to HVC.

Surgical Outcomes for Upper Lumbar Disc Herniation: Decompression Alone versus Fusion Surgery

Upper lumbar herniated intervertebral disc (HIVD), defined as L1-2 and L2-3 levels, presents with a lower incidence and more unfavorable surgical outcomes than lower lumbar levels. There are very few reports onthe appropriate surgical interventions for treating upper lumbar HIVD. This study aimed to evaluate the surgical outcome of decompression alone, when compared with spinal fusion surgery. A retrospective study involving a total of 7592 patients who underwent surgery due to HIVD in our institution was conducted. A total of 49 patients were included in this study: 33 patients who underwent decompression-only surgery and 16 patients who underwent fusion surgery. Demographic data, perioperative information, and functional outcomes were recorded. The visual analog scale (VAS) scores showed improvement in both groups postoperatively. The three-month postoperative Oswestry Disability Index score was significantly better in the fusion group. Additionally, 10 patients (76.9%) in the decompression group and 5 patients (83.3%) in the fusion group reported improvement in preoperative motor weakness. The final “satisfactory” rate was 66.7% in the decompression group and 93.8% in the fusion group (p = 0.034). The overall surgical outcomes of patients with upper lumbar HIVD were satisfactory in this study without any major complications. More reliable satisfactory rates and better functional scores at the three-month postoperative follow-up were reported in the fusion group.

Comparison of Percutaneous Endoscopic Surgery and Traditional Anterior Open Surgery for Treating Lumbar Infectious Spondylitis

Minimally invasive surgery is becoming popular for treating spinal disorders. The advantages of percutaneous endoscopic debridement and drainage (PEDD) for infectious spondylitis include direct observation of the lesion, direct pus drainage, and earlier pain relief. We retrospectively reviewed 37 patients who underwent PEDD and 31 who underwent traditional anterior open debridement and interbody fusion with bone grafting from 2004 to 2012. The causative organisms were isolated from 30 patients (81.1%) following PEDD, and from 25 patients (80.6%) following open surgery (p = 0.48). Staphylococcus aureus was the most common pathogen (38.2%). In the PEDD group, blood loss (<50 mL versus 585 ± 428 mL, p < 0.001) was significantly lesser and the duration of hospitalization (24.4 ± 12.5 days versus 31.5 ± 14.6 days, p = 0.03) was shorter than that in the open surgery group. Serologically, there were significantly faster C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) normalization rates in the PEDD group (p < 0.001, p = 0.009, respectively). In the two-year follow-up radiographs, 26 out of 30 (86.7%) open surgery patients showed bony fusions of the infected segments. On the contrary, sclerotic change of the destructive endplates was observed and the motion of infected spinal segments was still preserved in the PEDD group. There was no significant difference in the change of sagittal profile, including primary correction gain, correction loss, and actual correction gain/loss. PEDD is an effective alternative option and should be considered prior to traditional extensive spinal surgery—particularly for patients with early-stage spinal infection or serious complicated medical conditions.

Minimally Invasive Transforaminal Lumbar Interbody Debridement and Fusion with Percutaneous Pedicle Screw Instrumentation for Spondylodiscitis

BACKGROUND

Minimally invasive transforaminal lumbar interbody debridement and fusion (MiTLIDF) with percutaneous pedicle screw instrumentation (PSI) is a less invasive treatment for lumbar spondylodiscitis.

METHODS

Patients with single-level lumbar spondylodiscitis were surgically treated by interbody debridement and fusion through an anterior or transforaminal approach combined with open or percutaneous PSI (group A: anterior debridement and interbody fusion with open posterior PSI; group B: transforaminal lumbar interbody debridement and fusion [TLIDF] with open posterior PSI; group C: anterior debridement and interbody fusion with percutaneous PSI; group D: MiTLIDF with percutaneous PSI). Perioperative data, fusion status, infection-free survival, and clinical outcome measurements were compared among the 4 surgical groups.

RESULTS

A total of 82 patients were included in this study. TLIDF was associated with shorter operative time when compared with the anterior approach (group A: 302.8 ± 59.9 minutes; group B: 209.2 ± 31.0 minutes; group C: 260.6 ± 62.5 minutes; group D: 207.1 ± 33.6 minutes; P < 0.001). Percutaneous PSI resulted in less intraoperative blood loss (group A: 907.5 ± 253.7 mL; group B: 859.4 ± 201.2 mL; group C: 532.9 ± 193.7 mL; group D: 399.1 ± 84.3 mL) and reduced immediate postoperative pain (group A: 5.5 ± 0.9; group B: 4.9 ± 0.9; group C: 3.9 ± 0.7; group D: 3.2 ± 0.7) than open PSI (P < 0.001). There were no significant differences in terms of overall infection-free survival (P = 0.936).

CONCLUSIONS

This study demonstrated MiTLIDF with percutaneous PSI is a safe and effective treatment for lumbar spondylodiscitis while incurring no adverse effects in terms of fusion rate, functional recovery, and infection eradication.

Management of Infected Transforaminal Lumbar Interbody Fusion Cage in Posterior Degenerative Lumbar Spine Surgery

BACKGROUND

The postoperative infection rates for transforaminal lumbar interbody fusion (TLIF) have ranged from <2% to 4%. However, no consensus has been reached on the treatment strategies. TLIF cage preservation or revision surgery for lumbar spine reconstruction are 2 possible treatments. We aimed to determine the most effective method for organ/space infection control.

METHODS

The data from 4923 patients who had undergone TLIF with cage and posterior pedicle-screw instrumentation for spondylolysis or degenerative spondylolisthesis from January 2008 to December 2015 were retrospectively analyzed. Of the 4923 patients, 32 (0.65%) had developed organ/space infection of the interbody cage and were divided into 2 groups: those whose interbody cage was removed for revision (group 1) and those who interbody cage was retained (group 2). We compared the initial management of both groups in terms of age, sex, elapsed time to diagnosis, changes in spinal lordotic angle, visual analog scale score, fusion status, and Kirkaldy-Willis functional outcomes.

RESULTS

The 32 patients with organ/space infection had a mean age of 66.3 years and a follow-up period of 23.8 months. Significant differences were observed in the mean elapsed time to diagnosis (P = 0.004), lordotic angle correction at the disease level (P = 0.03), and Kirkaldy-Wallis functional outcomes (P = 0.01). Of the 17 patients undergoing debridement for implant retention, 9 (52.9%) exhibited poor results.

CONCLUSIONS

The most important factor contributing to TLIF cage retention failure was epidural fibrosis of the previous transforaminal route and biofilm adhesion on interbody devices affecting infection clearance. Thus, we would recommend a combined anterior and posterior approach or the transforaminal route for radical debridement with cage removal and fusion to achieve better clinical outcomes.

Reliability and validity of the Depression and Somatic Symptoms Scale among patients with chronic low back pain

BACKGROUND

The Depression and Somatic Symptoms Scale (DSSS), which is a free scale that includes a depression subscale (DS) and a somatic subscale (SS), was developed to evaluate depression and somatic symptoms simultaneously. This study aimed to examine the reliability and validity of the DSSS among patients with chronic low back pain (CLBP).

METHODS

Two-hundred and twenty-five patients with CLBP were enrolled. Psychiatric diagnoses were made based on the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-IV-Text Revision. The DSSS, Oswestry Disability Index, Hospital Anxiety and Depression Scale (HADS), and Short Form 36 (SF-36) were administered. Cronbach's alpha was used to test internal consistency. Receiver operating characteristic (ROC) analysis was used to identify cutoff scores for a major depressive episode (MDE).

RESULTS

Subjects with an MDE (N=21) had greater severities of depression, anxiety, somatic symptoms, and disability as compared with those without an MDE. The Cronbach's alpha values of the DS and SS were 0.90 and 0.83, respectively. The DS and SS were significantly correlated with the Oswestry Disability Index, the HADS, and the SF-36 subscales. The DS had the greatest area under the receiver operating characteristic curve (0.96) as compared with the SS and the HADS subscales. The cutoff score for an MDE was a DS score ≥15 (sensitivity and specificity: 100% and 88.7%, respectively).

CONCLUSION

The DSSS subscales were of acceptable reliability and validity. The DS can be used as a tool for evaluating the severity of depression and detecting an MDE in patients with CLBP.

Factors related to post surgical neurologic improvement for cervical spine infection

BACKGROUND

Cervical spine infections are uncommon but potentially dangerous, having the highest rate of neurological compromise and resulting disability. However, the factors related to surgical success is multiple yet unclear.

METHODS

We retrospectively reviewed the medical records of 27 patients (16 men and 11 women) with cervical spine infection who underwent surgical treatment at Chang Gung Memorial Hospital, Linkou branch, between 2001 and 2014. The neurological status, by Frankel classification, was recorded preoperatively and at discharge. Group X had neurologic improvement of at least 1 grade, group Y had unchanged neurologic status, and group Z showed deterioration. We recorded the patient demographic data, presenting symptoms and signs, interval from admission to surgery, surgical procedure, laboratory data, perioperative antibiotic course, pathogens identified, coexisting medical disease, concomitant nonspinal infection, and clinical outcomes. We intended to evaluate the different characteristics of patients who improved neurologically after treatment.

RESULTS

The mean age of our cohort was 56.6 years. Anterior cervical discectomy and fusion was the most commonly performed surgical procedure (74.1%). The Frankel neurological status improved in 70.4% (group X, n = 19) and unchanged in 29.6% (group Y, n = 8). No patients worsened. Motor weakness was most common (96.3%) neurological deficit, followed by sensory abnormalities (37.0%), and bowel/urine incontinence (33.3%). The main difference in presentation between group X and group Y was neck pain (100% vs. 75.0%; p = .02), not fever. Group X had a shorter preoperative antibiotic course (p = .004), interval from admission to operation (p = .02), and hospital stay (p = .01).

CONCLUSION

Clinicians should be more suspicious in patients who present with neck pain and any neurological involvement even in those without fever while establishing early diagnosis. Earlier operative treatment in group X result in better neurologic recovery and shorter hospital stay due to disease improvement.

Appropriate duration of post-surgical intravenous antibiotic therapy for pyogenic spondylodiscitis

Background

Most guidelines recommend 6 to 12 weeks of parenteral antibiotic treatment for pyogenic spondylodiscitis. When surgical debridement is adequately performed, further intravenous antibiotic treatment duration can be reduced than that of conservative treatment alone theoretically. However, the appropriate duration of post-surgical parenteral antibiotic treatment is still unknown. This study aimed to identify the risk factors of recurrence and evaluate the appropriate duration after surgical intervention.

Methods

This 3-year retrospective review included 102 consecutive patients who were diagnosed with pyogenic spondylodiscitis and underwent surgical intervention. Recurrence was defined as recurrent signs and symptoms and the need for another unplanned parenteral antibiotic treatment or operation within one year. This study included two major portions. First, independent risk factors for recurrence were identified by multivariable analysis, using the database of demographic information, pre-operative clinical signs and symptoms, underlying illness, radiographic findings, laboratory tests, intraoperative culture results, and treatment. Patients with any one of the risk factors were considered high-risk; those with no risk factors were considered low-risk. Recurrence rates after short-term (≤3 weeks) and long-term (> 3 weeks) parenteral antibiotic treatment were compared between the groups.

Results

Positive blood culture and paraspinal abscesses were identified as independent risk factors of recurrence. Accordingly, 59 (57.8%) patients were classified as low-risk and 43 (42.2%) as high-risk. Among the high-risk patients, a significantly higher recurrence rate occurred with short-term than with long-term antibiotic therapy (56.2% vs. 22.2%, p = 0.027). For the low-risk patients, there was no significant difference between short-term and long-term antibiotic therapy (16.0% vs. 20.6%, p = 0.461).

Conclusions

The appropriate duration of parenteral antibiotic treatment in patients with pyogenic spondylodiscitis after surgical intervention could be guided by the risk factors. The duration of postoperative intravenous antibiotic therapy could be reduced to 3 weeks for patients without positive blood culture or abscess formation.

Risk factors and quality of life for the occurrence of hip fracture in postmenopausal women

Background

To identify the risk factors and changes of quality of life in the first occurrence of hip fracture in Taiwanese postmenopausal women.

Methods

In this case-control study, we enrolled 100 postmenopausal women with accidental first-incident hip fracture and 100 women without hip fracture. The control group was matched to the study group according to age. Evaluation consisted of a questionnaire, an interview to both assess quality of life via a 36-item Short Form Health Survey and document risk factors, a physical examination to record height and body weight, and bone mineral density (BMD) of the hip and spine using dual-energy X-ray absorptiometry (DXA).

Results

The mean age of the patients was 77.9 years old. Compared with the controls, the patients with first-incident hip fracture had a lower level of education, increased body height, higher parity, no experience of estrogen therapy, prior history of diabetes mellitus and rheumatoid arthritis, walking aid use, less weight-bearing exercise, and steroid use. Total hip BMD was a stronger predictor than BMD at different sites. Quality of life was significantly higher in the control group at the baseline and 4-month follow-up.

Conclusions

Quality of life was related to the first-incident hip fracture. The increased risk of falls, lower level of education, and total hip BMD are the strongest predictors of first-incident hip fracture in Asian elderly postmenopausal women.

Correlation of quality of life with risk factors for first-incident hip fracture in postmenopausal women

AIM

The aim of this study was to identify the correlation between health-related quality of life (HRQOL) and risk factors of first-incidence hip fracture in postmenopausal women.

METHODS

This case-control study included 99 postmenopausal women with first-incident hip fracture and 101 women without hip fracture who were matched according to age. Evaluation consisted of clinical factors, 36-item Short-Form Health Survey (SF-36) and dual-energy X-ray absorptiometry for bone mineral density of hip and spine.

RESULTS

The mean age of patients with an accidental first-incident hip fracture was 78.0 years. Patients with hip fractures had significantly lower scores for SF-36 domains at enrollment and 4-month follow up compared with the controls. Mental health also deteriorated significantly 4 months after hip fracture. Aside from lower HRQOL, clinical factors, including increased body height, no experience with estrogen therapy, rheumatoid arthritis, use of walking aids, less weight-bearing exercise, and diuretics use, were significant risk factors for hip fracture in univariate analysis. After multivariate adjustment, only the use of walking aids and decreased physical component summary were independent risk factors of hip fracture. Besides aging, use of walking aids, weight-bearing exercise, and psychological medication were the main factors affecting HRQOL when considering their relationship with hip fractures.

CONCLUSION

The occurrence of first-incidence hip fracture is highly associated with HRQOL. Aside from aging, clinical factors affecting HRQOL correlated with hip fracture incidence. Thus, in elderly women, exercise or physical therapy to improve physical function and mental support is crucial and should be considered the most important factors for first-incidence hip fracture prevention.

Fluoroscopy-guided percutaneous vertebroplasty for symptomatic loosened pedicle screw and instrumentation-associated vertebral fracture: an evaluation of initial experiences and technical note

OBJECTIVE For symptomatic loosened pedicle screws and instrumentation-associated vertebral fracture, extensive surgery to remove the pedicle screws and extend the instrumentation, along with the reinsertion of more pedicle screws, is usually the treatment of choice. After such a surgery, however, similar complications will still be encountered. In this study the authors propose minimally invasive percutaneous cement augmentation under fluoroscopic guidance as a salvage procedure that eliminates the inherent risks of conventional extensive surgery. METHODS The records for 10 consecutive patients who had undergone fluoroscopy-guided percutaneous cement augmentation for loosened pedicle screws and instrumentation-associated vertebral fractures were reviewed. The procedures, performed with the patients under local anesthesia, were basically similar to vertebroplasty except for the preexisting pedicle screws. The trocar was inserted under fluoroscopic guidance, along the path of the loosened pedicle screw, using the latero-pedicular approach. The visual analog scale (VAS) and radiographic images were used for clinical outcome assessment at 3, 6, and 12 months after surgery. RESULTS The mean follow-up period was 14.3 months. The mean postoperative hospital stay was 1.2 days. There was neither cement leakage into the posterior neuroforamen nor neurological complication in this series. The mean VAS score improved from 5.9 preoperatively to 2.5 at the last follow-up (p = 0.02). Eight patients obtained satisfactory results and 2 needed revision open surgery. CONCLUSIONS The results demonstrate that minimally invasive fluoroscopy-guided percutaneous vertebroplasty is technically feasible and can be performed safely and effectively for symptomatic loosened pedicle screws and instrumentation-associated vertebral fracture.

Surgical outcome of atypical subtrochanteric and femoral fracture related to bisphosphonates use in osteoporotic patients with or without teriparatide treatment

Background

Atypical subtrochanteric fracture and femoral fracture have been considered to be rare complications related to long-term bisphosphonates use. A reduced bone turnover rate may lead to delayed bone healing. Limited data have revealed that teriparatide treatment may reverse the effect of bisphosphonates and be effective in bone healing.

Methods

We reviewed patients with atypical subtrochanteric and femoral fracture related to bisphosphonates use between January 2008 and December 2014. Thirteen female patients were enrolled. Radiographic findings were compatible with the characteristics of atypical fracture. Surgical intervention was performed for all, and teriparatide use was advised postoperatively. Outcome measures included perioperative results, and clinical and radiographic outcome.

Results

Of the 13 female patients enrolled, 10 had subtrochanteric and 6 had proximal femoral fracture; 3 had bilateral fractures. The mean age of the patients at surgery was 70.15±6.36 years. Most fractures (68.8%) presented prodromal thigh pain. All patients were treated with an intramedullary fixation system without severe complications. The patients were divided into 2 groups based on whether they had received treatment with teriparatide or not. The mean time to bone union was 4.4 months in the teriparatide-treated group, and 6.2 months in the non-teriparatide-treated group (p=0.116). Six patients (75%) in the teriparatide-treated group and 4 (50%) in the non-teriparatide-treated group (p= 0.3) achieved bone union within 6 months. The means of the modified Harris Hip Score and Numerical Rating Scale were significantly better in the teriparatide-treated group at postoperative 6 months. Seven patients had the same ability to walk at the 1-year follow-up as they did before the atypical fracture.

Conclusions

Teriparatide treatment in patients with atypical fracture may help in fracture healing, hip function recovery, and pain relief in this reduced bone turnover patient group.

Psychometric evaluation of the Oswestry Disability Index in patients with chronic low back pain: factor and Mokken analyses

Background

Disputes exist regarding the psychometric properties of the Oswestry Disability Index (ODI). The present study was to examine the reliability, validity, and dimensionality of a Chinese version of the ODI version 2.1 in a sample of 225 adult orthopedic outpatients with chronic low back pain [mean age (SD): 40.7 (11.4) years].

Methods

We conducted reliability analysis, exploratory bifactor analysis, confirmatory factor analysis, and Mokken scale analysis of the ODI. To validate the ODI, we used the Short-Form 36 questionnaire (SF-36) and visual analog scale (VAS).

Results

The reliability, and discriminant and construct validities of the ODI was good. The fit statistics of the unidimensional model of the ODI were inadequate. The ODI was a weak Mokken scale (H_s = 0.31).

Conclusions

The ODI was a reliable and valid scale suitable for measurement of disability in patients with low back pain. But the ODI seemed to be multidimensional that was against the use of the raw score of the ODI as a measurement of disability.

Characterization of a novel caudal vertebral interbody fusion in a rat tail model: An implication for future material and mechanical testing

Background

Of the proposed animal interbody fusion models, rat caudal discs have gained popularity in disc research due to their strong resemblance to human discs with respect to geometry, composition and mechanical properties. The purpose of this study is to demonstrate an efficient, repeatable and easily accessible animal model of interbody fusion for future research into mechanical testing and graft materials.

Methods

Twelve 12-week-old female Sprague–Dawley (SD) rats underwent caudal interbody fusion of the third and fourth coccygeal vertebrae of the tail. Serial radiological evaluation, and histological evaluation and manual palpation after sacrifice were performed to assess the fusion quality. Mechanical testing of functional units (FUs) of non-operated and operated segments was compared using a three-point bending test.

Results

At postoperative 12 weeks, callus formation was observed at the fusion sites in all rats, with the mean radiological evaluations of 2.75/3 according to the Bransford classification. Newly formed bone tissue was also observed in all rats with the mean histological score of 5.85/7, according to the Emery grading system. No palpable gaps and obvious change of bending stiffness was observed in the operated segments. The mean bending stiffness of the FUs was statistically higher than that of the control FUs (26.57 ± 6.71 N/mm vs. 12.45 ± 3.21 N/mm, p < 0.01).

Conclusion

The rat caudal disc interbody fusion model proved to be an efficient, repeatable and easily accessible model. Future research into adjuvant treatments like growth factor injection and alternative fusion materials under conditions of osteoporosis using this model would be worthwhile.

Effects of Strontium Ranelate on Spinal Interbody Fusion Surgery in an Osteoporotic Rat Model

Osteoporosis is a bone disease that afflicts millions of people around the world, and a variety of spinal integrity issues, such as degenerative spinal stenosis and spondylolisthesis, are frequently concomitant with osteoporosis and are sometimes treated with spinal interbody fusion surgery. Previous studies have demonstrated the efficacy of strontium ranelate (SrR) treatment of osteoporosis in improving bone strength, promoting bone remodeling, and reducing the risk of fractures, but its effects on interbody fusion surgery have not been adequately investigated. SrR-treated rats subjected to interbody fusion surgery exhibited significantly higher lumbar vertebral bone mineral density after 12 weeks of treatment than rats subjected to the same surgery but not treated with SrR. Furthermore, histological and radiographic assessments showed that a greater amount of newly formed bone tissue was present and that better fusion union occurred in the SrR-treated rats than in the untreated rats. Taken together, these results show significant differences in bone mineral density, PINP level, histological score, SrR content and mechanical testing, which demonstrate a relatively moderate effect of SrR treatment on bone strength and remodeling in the specific context of recovery after an interbody fusion surgery, and suggest the potential of SrR treatment as an effective adjunct to spinal interbody fusion surgery for human patients.

Correlation between zoledronic acid infusion and repeat vertebroplasty surgery in osteoporotic patients

Objective The incidence of bone fractures rapidly increases as people age, mostly due to bone loss resulting from osteoporosis. The purpose of this study is to compare the rates of repeat vertebroplasty in osteoporotic patients treated with or without zoledronic acid (ZOL) infusion following initial vertebroplasty. Research design and methods We conducted a retrospective chart review of osteoporotic patients who underwent vertebroplasty from June 2009 to June 2012. Patients with existing vertebral fracture(s) were retrospectively divided into two groups according to whether or not they received zoledronic acid infusion after initial vertebroplasty. Zoledronic acid infusion was intravenously administered once a year for three consecutive years, as a single 5 mg dose in 100 mL solution infused over at least 15 minutes. The primary efficacy variable was the number of patients requiring repeat vertebroplasty procedures after the initial surgery due to subsequent vertebral fractures. The Cox proportional hazards model was used to compare the risk ratios of repeat vertebroplasty between these two groups. Results A total of 1646 patients, including 456 males and 1190 females (age range: 65-89 years), were enrolled. Compared to the 1595 patients who did not receive osteoporosis medication, the 51 patients treated with zoledronic acid infusion demonstrated a significantly lower rate of repeat vertebroplasty. In the ZOL-treated group, only 4% of the patients (2/51) required a second vertebroplasty, compared to 13% (206/1595) in the non-ZOL-treated group (p = 0.032). Conclusions The results indicate that osteoporotic patients who undergo vertebroplasty are significantly less likely to require reoperation if treated with zoledronic acid infusion. However, since the number of male patients in the ZOL-treated group was limited, and since Taiwan's National Health System program does not cover the cost of receiving zoledronic acid infusions for male patients, the conclusion seems to be less certain for male osteoporotic patients.

Risk factor for first-incident hip fracture in Taiwanese postmenopausal women

OBJECTIVE

The variation in hip fracture risk between countries is greater than 10-fold. The present study aimed at identifying risk factors that resulted in the first occurrence of hip fracture in Taiwanese postmenopausal women.

MATERIALS AND METHODS

A case-control study with a patient group of 50 postmenopausal women, who were admitted to Keelung Chang Gung Hospital, Keelung, Taiwan due to the first incident of accidental hip fracture, was used to examine potential risk factors, including bone mass. Fifty women without hip fracture, selected from those undergoing general health evaluation at the Gynecology Outpatient Clinic at Keelung Chang Gung Hospital, were used as the control group and were matched to the case patients according to age. Evaluation consisted of a questionnaire, interview to document risk factors, physical examination (to record body height and body weight), and examination [dual-energy X-ray absorptiometry used to measure bone mineral density (BMD) of the hip and spine].

RESULTS

The average age of participants of both groups was 79.6 years. Lower level of education, younger age at menopause, increased body height, weight-bearing exercise less than three times per week, and lower BMD were associated with first-incident hip fracture. Total hip BMD was a stronger predictor than the BMD of different sites. Participants in the control group had a significantly higher prevalence of chronic diseases and a history of cataracts or glaucoma compared with those in the patient group.

CONCLUSION

While total hip BMD is the strongest predictor of hip fracture, increasing awareness of osteoporosis prevention by educating people about good lifestyle habits and how to maintain BMD is prioritized for preventing the first-incident hip fracture in Taiwanese women.

Exposure of Prebiopsy Antibiotics Influence Bacteriological Diagnosis and Clinical Outcomes in Patients With Infectious Spondylitis

The benefit of prebiopsy empirical antibiotics for patients with infectious spondylitis and the effect on clinical outcome are not well known. This study assessed the impact of prebiopsy empirical antibiotics in patients with infectious spondylitis. We retrospectively reviewed 41 adult in-patients with infectious spondylitis who received percutaneous endoscopic debridement and drainage (PEDD) at a tertiary care hospital from August 2002 to August 2012. The average patient age was 55.2 years old and causative bacteria were identified in 32 out of 41 biopsy specimens (78.0%) via the PEDD procedure, which has good diagnostic efficacy comparable to open biopsy. Seventeen patients (41.5%) received prebiopsy empirical antimicrobial therapy, and these patients were less likely to have positive cultures than those who did not receive preoperative antibiotics (64.7% vs 87.5%, P = 0.04). Patients with positive cultures had a better infection control rate (78.1% vs 67.7%) and were less likely to undergo subsequent open surgery. Patients given preoperative antibiotics were more likely to need subsequent open surgery (35.3% vs 16.7%, P = 0.02). From multivariate logistic analysis showed age at diagnosis to be an independent risk factor for the need of further surgery. There were no major complications following the PEDD procedure, except 2 patients had transient paresthesia in the affected lumbar segments. Prebiopsy empirical antibiotic therapy was associated with lower positive culture rate and an increased need for subsequent open surgery. Patients with positive cultures were more likely to have initially adequate treatment, better infection control, and better clinical outcome.

The fusion rate of demineralized bone matrix compared with autogenous iliac bone graft for long multi-segment posterolateral spinal fusion

Background

Although autogenous iliac bone graft (AIBG) remains the gold standard for spine fusion, harvesting morbidity has prompted the search for alternatives especially for multi-segment fusion. This study aimed to evaluate the efficacy of using demineralized bone matrix (DBM) as a substitute of AIBG for long instrumented posterolateral fusion (≧ three-level fusion).

Methods

A total of 47 consecutive patients underwent laminectomy decompression, and multi-level instrumented posterolateral fusions were reviewed. Group 1 comprised 26 patients having DBM with autologous laminectomy bone (ALB). Group 2 consisted of 21 patients having AIBG with ALB. The fusion success evaluation was based on findings using the 12-month anteroposterior and dynamic plain radiographs.

Results

Gender, age, and the number of fusion levels were similar for both groups. 21 of 26 (80.8 %) patients in group 1 and 18 of 21 (85.7 %) patients in group 2 were observed to achieve solid bony fusion. There was no statistical difference in the fusion success (p = 0.72). Blood loss was significantly more in group 2 (p = 0.02). The duration of the hospital stays and operative times being longer for group 2, but the difference was not significant.

Conclusions

DBM combined with ALB and osteoconductive materials is as effective as an autologous iliac bone graft with respect to long multi-segment posterolateral fusion success. DBM can be used as an effective bone graft substitute and may decrease morbidities associated with iliac bone graft harvest.

Association of depression with sleep quality might be greater than that of pain intensity among outpatients with chronic low back pain

PURPOSE

No study to date has compared the associations of pain intensity, depression, and anxiety with insomnia among outpatients with chronic low back pain (CLBP). This study aimed to investigate this issue.

PATIENTS AND METHODS

A total of 225 outpatients with CLBP were enrolled from a general orthopedics clinic. The Insomnia Severity Index was used to evaluate sleep quality. Major depressive disorder (MDD) and anxiety disorders were diagnosed using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision, Axis I Disorders. Two psychometric scales were used to evaluate depression and anxiety. The Visual Analog Scale was employed to assess pain intensity. Multiple linear regressions were performed to determine the association of insomnia with pain intensity, depression, and anxiety.

RESULTS

Among the 225 subjects, 58 (25.8%) had clinical insomnia; 83 (36.9%) had severe low back pain; 49 (21.8%) had MDD, including 21 (9.3%) with a current major depressive episode (MDE); and 52 (23.1%) had anxiety disorders. More than half (56.9%) of the subjects with CLBP and clinical insomnia had MDD and/or anxiety disorders. Subjects with a current MDE or anxiety disorders had greater severities of pain and insomnia as compared with subjects without these conditions. After controlling for demographic variables, MDE was more strongly associated with insomnia than severe low back pain; moreover, the severity of depression had a greater association with insomnia than pain intensity.

CONCLUSION

The association of depression with insomnia was not inferior to that of pain intensity with insomnia. Among patients with CLBP and insomnia, integration of depression and anxiety treatment into treatment of pain might help to improve sleep quality.

Depression: An important factor associated with disability among patients with chronic low back pain

OBJECTIVE

The study aimed to compare the associations of pain indices, depression, anxiety, and somatic symptoms with disability among outpatients with chronic low back pain (CLBP).

METHOD

Consecutive orthopedics outpatients with CLBP in a medical center were enrolled. The Oswestry Disability Index and physical functioning and role limitations-physical of the Short-Form 36 were used as disability indices. The Hospital Anxiety and Depression Scale (HADS) and the Depression and Somatic Symptoms Scale were employed. Pain intensity was rated using a visual analogue scale. Multiple linear regressions were used to determine the impacts of these independent factors related to disability.

RESULTS

Among 225 participants (122 male, 103 female) with CLBP, patients with major depressive disorder and associated leg symptoms of CLBP had higher disability indices. A tendency was noted that depression (HADS-depression) had the highest correlation to the three disability indices, followed by pain intensity, anxiety, and somatic symptoms. After controlling for demographic variables, HADS-depression explained the highest variance of disability, followed by pain intensity.

CONCLUSION

Depression was the most powerful factor associated with disability of CLBP among depression, anxiety, and somatic symptoms. Depression should be evaluated when investigating disability among patients with CLBP.

Mesenchymal stem cells expressing baculovirus-engineered BMP-2 and VEGF enhance posterolateral spine fusion in a rabbit model

BACKGROUND CONTEXT

Mesenchymal stem cell (MSC)-based cell therapy and gene transfer have converged and show great potential for accelerating bone healing. Gene therapy can provide more sustained expression of osteogenic factors such as bone morphogenetic protein-2 (BMP-2). We previously demonstrated that low-dose BMP-2 enhanced spinal posterolateral fusion by MSCs in a rabbit model. Herein, we genetically modified rabbit MSCs with a recombinant baculovirus encoding BMP-2 (Bac-CB) and vascular endothelial growth factor (Bac-VEGF) seeded into porous scaffolds to enhance spinal fusion.

PURPOSE

This study evaluates the success rate of the MSC-based cell therapy and gene transfer approach for single-level posterolateral spine fusion. We hypothesize that combining three-dimensional tricalcium phosphate (TCP) scaffolds and genetically modified allogeneic MSCs with baculovirus-mediated growth factor expression would increase the success rate of spinal fusion.

STUDY DESIGN

The study design was based on an animal model (approved by the Institutional Animal Care and Use Committee) using 18 adult male New Zealand rabbits.

METHODS

This study included 18 male New Zealand rabbits, weighing 3.5 to 4 kg. Allogeneic bone marrow-derived MSCs were isolated and genetically modified with Bac-CB and Bac-CV seeded onto TCP scaffolds (MSC/Bac/TCP). The animals were divided into three groups according to the material implanted into the bilateral L4-L5 intertransverse space: TCP scaffold (n=6), MSC/TCP (n=6), and MSC/Bac/TCP (n=6). After 12 weeks, the rabbits were euthanized for radiographic examination, manual palpation, and histologic study.

RESULTS

Bilateral fusion areas in each animal were evaluated independently. The radiographic fusion rates at 12 sites were 0 of 12 in the TCP scaffold group, 4 of 12 in the MSC/TCP group, and 10 of 12 in the MSC/Bac/TCP group. By manual palpation, there were zero solid fusions in the TCP scaffold group, two solid fusions in the MSC/TCP group, and five solid fusions in the MSC/Bac/TCP group. Fusion rates were significantly greater in the MSC/Bac/TCP group.

CONCLUSIONS

The results indicate the potential of using baculovirus as a vector for gene/cell therapy approaches to improve bone healing and support the feasibility of using allogeneic MSCs for inducing bone formation and intertransverse process fusion.

Influence of lumbar curvature and rotation on forward flexibility in idiopathic scoliosis

BACKGROUND

Lumbar spine facet joints are arranged sagittally and mainly provide forward flexibility. Rotation of the lumbar vertebral body and coronal plane deformity may influence the function of lumbar forward flexibility. We hypothesize that the more advanced axial and coronal plane deformity could cause more limitation on forward flexibility in patients with idiopathic scoliosis.

METHODS

Between January 2011 and August 2011, 85 patients with adolescent idiopathic scoliosis were enrolled in this study. The proximal thoracic, major thoracic, thoracolumbar/lumbar (TL/L), and lumbar (L1/L5) curves were measured by Cobb's method. Lumbar apical rotation was graded using the Nash-Moe score. Lumbar forward flexibility was measured using the sit and reach (S and R) test. Statistical analysis was performed using one-way analysis of variance (ANOVA), Spearman's and Pearson's correlation coefficients.

RESULTS

The mean age was 16.1 ± 2.84 years. The mean proximal thoracic, major thoracic, TL/L, and L1/L5 curves were 17.61° ± 8.92, 25.56° ± 11.61, 26.09° ± 8.6, and 15.10° ± 7.85, respectively. The mean S and R measurement was 25.56 ± 12.33 cm. The magnitude of the TL/L and L1/L5 curves was statistically positively related to vertebral rotation (r(s) = 0.580 and 0.649, respectively). The correlation between the S and R test and both the TL/L and L1/L5 curves was negative (r(p) = -0.371 and -0.595, respectively). Besides, the S and R test also demonstrated a significant negative relationship with vertebral rotation (rs = -0.768).

CONCLUSION

In patients with idiopathic scoliosis, spinal deformity can diminish lumbar forward flexibility. Higher lumbar curvature and rotation lead to greater restriction of lumbar flexion.

Combined anterior lumbar interbody fusion and instrumented posterolateral fusion for degenerative lumbar scoliosis: indication and surgical outcomes

Background

Traditional approaches to deformity correction of degenerative lumbar scoliosis include anterior-posterior approaches and posterior-only approaches. Most patients are treated with posterior-only approaches because the high complication rate of anterior approach. Our purpose is to compare and assess outcomes of combined anterior lumbar interbody fusion and instrumented posterolateral fusion with posterior alone approach for degenerative lumbar scoliosis with spinal stenosis.

Methods

Between November 2002 and November 2011, a total of 110 patients with degenerative spinal deformity and curves measuring over 30°were included. Of the 110 patients who underwent surgery, 56 underwent the combined anterior and posterior approach and 54 underwent posterior surgery at our institution. The following were the indications of anterior lumbar interbody fusion: (1) rigid or frank lumbar kyphosis, (2) anterior or lateral bridged traction osteophytes, (3) gross coronal and sagittal deformity or imbalance, and (4) severe disc space narrowing that is not identifiable when performing posterior or transforaminal lumbar interbody fusion. The clinical outcomes were evaluated using the Oswestry disability index and the visual analog scale. The status of fusion were assessed according to the radiographic findings.

Results

All patients received clinical and radiographic follow-up for a minimum of 24 months, with an average follow-up of 53 months (range, 26–96 months). At the final follow-up, the mean ODI score improved from 28.8 to 6.4, and the mean back/leg VAS, from 8.2/5.5 to 2.1/0.9 in AP group and the mean ODI score improved from 29.1 to 6.2, and the mean back/leg VAS, from 9.0/6.5 to 2.3/0.5 in P group. The mean scoliotic angle changed from 41.3° preoperatively to 9.3°, and the lumbar lordotic angle, from 3.1° preoperatively to 35.7°in AP group and the mean scoliotic angle from 38.5 to 21.4 and the lumbar lordotic angle from 6 to 15.8 in P group. There were significant differences in sagittal (P = 0.009) and coronal (P = 0.02) plane correction between the two groups.

Conclusions

Our results demonstrate that combined anterior lumbar interbody fusion and instrumented posterolateral fusion for adult degenerative lumbar scoliosis effectively improves sagittal and coronal plane alignment than posterior group and both group were effectively improves clinical scores.

Comparison of two-stage open versus percutaneous pedicle screw fixation in treating pyogenic spondylodiscitis

Background

Percutaneous pedicle screw instrumentation is a minimally invasive surgical technique; however, the effects of using percutaneous pedicle screw fixation in treating patients with spinal infections have not yet been well demonstrated. The aim of this study, therefore, was to determine whether percutaneous posterior pedicle screw instrumentation is superior to the traditional open approach in treating pyogenic spondylodiscitis.

Methods

We retrospectively reviewed data for 45 patients treated for pyogenic spondylodiscitis with anterior debridement and interbody fusion followed by a second-stage procedure involving either traditional open posterior pedicle screw fixation or percutaneous posterior pedicle screw fixation. Twenty patients underwent percutaneous fixation and 25 patients underwent open fixation. Demographic, operative, and perioperative data were collected and analyzed.

Results

The average operative time for the percutaneous procedure was 102.5 minutes, while the average time for the open procedure was 129 minutes. The average blood loss for the percutaneous patients was 89 ml versus a 344.8 ml average for the patients in the open group. Patients who underwent the minimally invasive surgery had lower visual analogue scale scores and required significantly less analgesia afterwards. After two years of follow-up, neither recurrent infection nor intraoperative complications, such as wound infection or screw loosening, were found in the percutaneous group. Moreover, there was no significant difference in outcome between the two groups in terms of Oswestry Disability Index scores.

Conclusions

Anterior debridement and interbody fusion with bone grafting followed by minimally invasive percutaneous posterior instrumentation is an alternative treatment for pyogenic spondylodiscitis which can result in less intraoperative blood loss, shorter operative time, and reduced postoperative pain with no adverse effect on infection control.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2474-15-443) contains supplementary material, which is available to authorized users.

Minimally invasive endoscopic treatment for lumbar infectious spondylitis: a retrospective study in a tertiary referral center

Background

Spinal infections remain a challenge for clinicians because of their variable presentation and complicated course. Common management approaches include conservative administration of antibiotics or aggressive surgical debridement. The purpose of this study was to evaluate the efficacy of percutaneous endoscopic debridement with dilute betadine solution irrigation (PEDI) for treating patients with lumbar infectious spondylitis.

Methods

From January 2005 to July 2010, a total of 32 patients undergoing PEDI were retrospectively enrolled in this study. The surgical indications of the enrolled patients included single-level infectious spondylodiscitis, postoperative infectious spondylodiscitis, advanced infection with epidural abscess, psoas muscle abscess, pre-vertebral or para-vertebral abscess, multilevel infectious spondylitis, and recurrent infection after anterior debridement and fusion. Clinical outcomes were assessed by careful physical examination, Macnab criteria, regular serologic testing, and imaging studies to determine whether continued antibiotics treatment or surgical intervention was required.

Results

Causative bacteria were identified in 28 (87.5%) of 32 biopsy specimens. Appropriate parenteral antibiotics for the predominant pathogen isolated from infected tissue biopsy cultures were prescribed to patients. Twenty-seven (84.4%) patients reported satisfactory relief of their back pain after PEDI. Twenty-six (81.3%) patients recovered uneventfully after PEDI and sequential antibiotic therapy. No surgery-related major complications were found, except 3 patients with transient paresthesia in the affected lumbar segment.

Conclusions

PEDI was successful in obtaining a bacteriologic diagnosis, relieving the patient’s symptoms, and assisting in the eradication of lumbar infectious spondylitis. This procedure could be an effective alternative for patients who have a poor response to conservative treatment before a major open surgery.

Advanced glycation end products in degenerative nucleus pulposus with diabetes

Diabetes mellitus (DM) has been clinically proved as a risk factor of disc degeneration, and the accumulation of advanced glycation end products (AGEs) is known to be potentially involved in diabetes. The purpose of this study is to investigate the effect of AGEs in the degeneration process of diabetic nucleus pulposus (NP) in rats and humans. Diabetic NP cells from rat coccygeal discs were treated with different concentrations of AGEs (0, 50, and 100 µg/ml) for 3 days, and mRNA expressions of MMP-2 and RAGE were measured by real-time RT-PCR. In addition, conditioned medium from NP cells was used to analyze protein expression of MMP-2 activity and ERK by gelatin zymography and Western blot. These experiments were repeated using human intervertebral disc samples. The immunohistochemical expression of AGEs was significantly increased in diabetic discs. In response to AGEs, an increase of MMP-2, RAGE, and ERK at both mRNA and protein expression levels was observed in diabetic NP cells. The findings suggest that AGEs and DM are associated with disc degeneration in both species. Hyperglycemia in diabetes enhances the accumulation of AGEs in the NP and triggers disc degeneration.

Percutaneous balloon kyphoplasty for the treatment of vertebral compression fractures

Background

Vertebral compression fractures (VCFs) constitute a major health care problem, not only because of their high incidence but also because of their direct and indirect negative impacts on both patients’ health-related quality of life and costs to the health care system. Two minimally invasive surgical approaches were developed for the management of symptomatic VCFs: balloon kyphoplasty and vertebroplasty. The purpose of this study was to evaluate the effectiveness and safety of balloon kyphoplasty in the treatment of symptomatic VCFs.

Methods

Between July 2011 and June 2012, one hundred and eighty-seven patients with two hundred and fifty-one vertebras received balloon kyphoplasty in our hospital. There were sixty-five male and one hundred and twenty-two female patients with an average age of 74.5 (range, 61 to 95 years). The pain symptoms and quality of life, were measured before operation and at one day, three months, six months and one year following kyphoplasty. Radiographic data including restoration of kyphotic angle, anterior vertebral height, and any leakage of cement were defined.

Results

The mean visual analog pain scale decreased from a preoperative value of 7.7 to 2.2 at one day (p < .05) following operation and the Oswestry Disability Index improved from 56.8 to 18.3 (p < .05). The kyphotic angle improved from a mean of 14.4° before surgery to 6.7° at one day after surgery (p < .05). The mean anterior vertebral height increased significantly from 52% before surgery to 74.5% at one day after surgery (p < .05) and 70.2% at one year follow-up. Minor cement extravasations were observed in twenty-nine out of two hundred and fifty-one procedures, including six leakage via basivertebral vein, three leakage via segmental vein and twenty leakage through a cortical defect. None of the leakages were associated with any clinical consequences.

Conclusions

Balloon kyphoplasty not only rapidly reduced pain and disability but also restored sagittal alignment in our patients at one-year follow-up. The treatment of osteoporotic vertebral compression fractures with balloon kyphoplasty is a safe, effective, and minimally invasive procedure that provides satisfactory clinical results.

A retrospective study of treating thoracolumbar spine fractures in ankylosing spondylitis

Spinal fractures are commonly encountered in ankylosing spondylitis (AS) patients. This study compares the outcome of early surgical treatment with initial conservative treatment for thoracolumbar fractures in patients with AS. From 1996 to 2008, 28 patients with AS were treated either operatively or conservatively for thoracolumbar fractures; however, only 25 patients met the inclusion criteria with a minimum follow-up of 2 years. For surgically treated patients, posterior spinal instrumentation was performed using a transpedicle screw system. Nonsurgically treated patients wore a fracture brace. The demographic data, diagnosis, mechanism of injury, and neurological status were recorded, and fracture healing was assessed radiographically. The mean age was 54.2 ± 13.8 years (range 30-80 years). Six patients (Group A) received surgical intervention within 1 month. All of these fractures healed, and two of five patients showed neurologic improvement after surgery. Eight patients (Group B) had fractures that were missed. The delay in diagnosis resulted in pseudoarthrosis in all cases, and progressive neurologic deficits were identified in four cases. Eleven patients (Group C) received conservative treatment with bracing. Fracture union was achieved in three cases, and pseudoarthrosis occurred in eight cases. Operative treatment can achieve solid fusion and improve the neurological status, while conservative treatment may result in pseudoarthrosis and progressive neurologic deficit. The results suggest that AS patients with unstable spinal fractures should receive early surgical management to prevent further sequelae.

Computed tomography-based navigation-assisted pedicle screw insertion for thoracic and lumbar spine fractures

BACKGROUND

Incorrect placement of pedicle screws may lead to neurovascular injury, so the position is important for the reduction of spinal fractures. CT-based image-guided surgery has been promoted as a means to theoretically improve the accuracy of pedicle screw placement. Patients who underwent CT-based navigation-assisted pedicle screw fixation for thoracic or lumbar fractures were reviewed to evaluate the accuracy of pedicle screw placement for spinal fracture cases.

METHODS

A computed tomographic (CT)-based image-guided system (BrainLAB) was used for pedicle screw insertion in 14 patients with thoracic or lumbar spine fractures. The accuracy of pedicle screw placement was analyzed by the preoperative and postoperative Cobb's angle and sagittal screw angle with a review of radiographic images, and the penetration of the pedicle cortex by postoperative CT scans.

RESULTS

Under the guidance of CT-based navigation 102 screws were inserted. Cobb's angle was corrected to an average of 15 degrees in the 14 patients. The sagittal screw angle was less than 10 degrees for 92 (90.2 %) screws, and the overall average was 5 degrees. The results of the postoperative CT review showed only 3 (2.9 %) screws penetrated the pedicle cortex laterally and no screw penetrated medially. No iagtrogenic neurological injury was found.

CONCLUSION

The accuracy of pedicle screw placement is crucial for thoracolumbar spine fracture fixation. The placement of pedicle screws can be done accurately with the aid of a CT-based image-guided system. Furthermore, this opens the possibility for surgeons to reduce radiation exposure by eliminating the need for intraoperative fluoroscopy.