Antithrombotic therapy and spinal surgery: a retrospective cohort study of 289 consecutive elderly patients with degenerative lumbar stenosis

OBJECTIVE

Lumbar spinal stenosis (LSS) is a disabling degenerative process of the spine, mainly affecting older patients. LSS manifests with low-back and leg pain and neurogenic claudication. Disability and impairment in activities of daily living are consequences of the progressive narrowing of the lumbar spinal canal. Surgical decompression has been shown to be superior to conservative management. Nonetheless, intraoperative and postoperative blood loss in elderly patients taking antiplatelet or anticoagulant drugs owing to cardiovascular comorbidities may be a special issue. This study describes and compares early outcomes after surgical procedures in different groups of patients receiving antithrombotic drugs.

METHODS

The authors' study retrospectively recruited 289 consecutive patients aged ≥ 65 years who received lumbar decompression for spinal stenosis between January 2021 and May 2022. First, 183 patients taking antiplatelet therapy were divided into two groups according to the rationale for use: primary versus secondary prophylaxis of cardiovascular events (group 1 vs group 2). Primary prevention was stopped preoperatively, or secondary prevention was not discontinued during the perioperative period. Secondly, 106 patients who were not taking antiplatelet mediation were divided into two groups, depending on whether preoperative low-molecular-weight heparin had not been administered or had been (group A vs group B). Intraoperative blood loss, surgical time, and postoperative hospitalization were analyzed.

RESULTS

No significant statistical differences were observed between groups 1 and 2 in terms of intraoperative blood loss and time of surgery, or between groups A and B in terms of all analyzed variables. No early or delayed complications were observed, perioperatively or during the postoperative 3-month follow-up period.

CONCLUSIONS

The results of this study suggest that the use of anticoagulant and antiplatelet therapies in elective decompressive surgery could be devoid of early complications and could be safely continued perioperatively.

The Goutallier Classification System: How does Paravertebral Adipose Degeneration Change in Patients with Symptomatic Lumbar Spinal Stenosis?

STUDY DESIGN

Retrospective, observational study.

OBJECTIVE

To determine the relationship between the Goutallier Classification System (GS) and anthropometric, clinical, and radiological features in 168 patients with lumbar spinal stenosis (LSS).

BACKGROUND

There is no agreement on a classification system that is both reliable and easy to use for describing the severity of fatty degeneration in the paravertebral muscles of the lower back in patients with symptomatic lumbar spinal stenosis. This study aimed to determine the statistical relationship between the GS and anthropometric, clinical, and radiological factors in 168 patients with LSS.

METHODS

This study was conducted on 168 patients with LSS scheduled for elective decompressive surgery. A control group of 110 healthy individuals was enrolled. The study assessed paralumbar musculature fatty infiltration using GS on preoperative Magnetic Resonance Imagin (MRI). We evaluated the statistical association between patient age, Body Mass Index (BMI), preoperative Oswestry Disability Index (ODI) questionnaire, and cross-sectional areas (CSAs) of the dural sac and lumbar paraspinal muscles. Multivariate analysis was performed to adjust for confounding.

RESULTS

This study enrolled 168 patients with symptomatic LSS (95 men, 73 women; mean±standard deviation; range); age: 67,81±9,38; (32,78 - 92,34) years; BMI: 28,29±3,36; (19,95 - 38,10) kg/m2. The control group was comprised of 110 healthy patients (61 men and 49 women). Age, sex, BMI, and ES-CSA were not significantly different between the two groups. We found a direct relationship between GS grade and age, and an inverse relationship between GS grade and DS-, LM-, ES-, and PM-CSAs. (Table 2 and Fig. 5). Univariate analyses showed the variables statistically related to a higher GS grade included patient age, (P<0.001), ODI (P=0.136), DS-CSA (P=0.011), LM-CSA (P< 0.001), ES-CSA (P<0.001), and PM-CSA (P<0.001). Multivariate least squares analysis showed the GS grade to be influenced by patient age (P=0.01), LM-CSA (P=0.002), ES-CSA (P=0.002), and PM-CSA (P=0.003).

CONCLUSIONS

GS shows great potential as a tool for evaluating fat infiltration in the paralumbar muscles. This measure does not correlate with the ODI and BMI, but is related to all radiological parameters and patient age. Further prospective studies are required to establish a link between preoperative and postoperative outcomes in the setting of paraspinal fat infiltration.

Multiple univariate analysis of radiologic and clinical features on 168 patients with lumbar spinal stenosis: what is the role of the erector spinae in the development of a patient's disability?

BACKGROUND

The weakening of paraspinal muscles in the paravertebral area may play a role in developing central lumbar spinal stenosis, resulting in lower back discomfort.

OBJECTIVE

The study thoroughly examined the correlation between the Oswestry Disability Index, Dural Sac cross-sectional area, Schizas grading Scale, Body Mass Index, and the cross-sectional areas of Erector Spinae, Multifidus, and Psoas muscles. The findings were also compared between patients with central Lumbar Spinal Stenosis and healthy individuals.

STUDY DESIGN

Retrospective monocentric observational study.

METHODS

The study recruited 168 consecutive patients aged 60 or older diagnosed with central Lumbar Spinal Stenosis between January 2020 and July 2022. The patients' condition was evaluated by administering a preoperative Oswestry Disability Index questionnaire, measuring their Body Mass Index, and performing preoperative Magnetic Resonance Imaging. The analyzed parameters were the cross-sectional area of paraspinal muscles at the L4-L5 level, dural sac cross-sectional area, and Schizas grading Scale at the most stenotic level, using multiple linear univariate analyses. Two groups of healthy individuals were recruited: Group A (under 60 years old) and Group B (over 60 years old). The same data extrapolated from these groups were compared with those of patients with central lumbar stenosis using a two-tailed Mann-Whitney test.

RESULTS

As the Erector Spinae degenerates, the Oswestry Disability Index tends to increase. Similarly, an increase in Body Mass Index is often accompanied by a decrease in the cross-sectional area of the Erector Spinae. Low dural sac cross-sectional area is statistically linked to a reduced Multifidus cross-sectional area. Interestingly, the Schizas grading scale does not appear to correlate with changes in the cross-sectional area of the paraspinal muscles. Additionally, there is no significant difference in the cross-sectional area of the Psoas muscle between individuals with central lumbar spinal stenosis and healthy individuals.

CONCLUSIONS

Our study found that degeneration of the Erector Spinae plays a crucial role in the progression of perceived disability in Lumbar Spinal Stenosis. Prospective studies should investigate the long-term evolution of paraspinal muscles in decompressed patients.

A challenging recurrent thoracic disc herniation

Background

Thoracic disc herniations are rare and occur at the rate of 1/1,000,000/year. Surgical approach must be individually tailored to the size, location, and consistency of the herniated disc. Notably, here, we report the unusual recurrence of a thoracic herniated disc.

Case Description

In 2014, a 53-year-old female presented with thoracic back pain, and paraparesis, attributed to an magnetic resonance imaging/computed tomography (CT)-documented left paramedian T8-T9 calcific disc herniation. She underwent a left hemilaminectomy/costotrasversectomy following which she experienced complete regression of her symptoms. Notably, the postoperative radiological studies at that time demonstrated some residual although asymptomatic calcific disc herniation. Eight years later, she again presented, but now with the chief complaint of difficulty breathing. The new CT scan showed a new calcified herniated disc fragment superimposed on the previously documented residual disc. Through a posterolateral transfacet approach, she underwent resection of the disc complex. An intraoperative CT scan confirmed complete removal of the recurrent calcified disc herniation. Following the second surgery, the patient fully recovered and remains asymptomatic.

Conclusion

A 53-year-old female first presented with a left-sided T8/T9 thoracic calcified disc herniation that was initially partially resected). When another larger fragment appeared 8 years later, superimposed on the previously documented residual disc, it was successfully removed through a posterolateral transfacet approach completed with CT guidance and neuronavigation.

Cervical spine arachnoid cyst complicated by spontaneous intracystic hemorrhage: Case report and review of the literature

Background:

Spinal intradural extramedullary arachnoid cysts represent about 1–3% of all primary spinal space-occupying lesions often causing spinal cord and/or radicular nerve compression. Spontaneous intralesional hemorrhages are extremely rare and are typically found within intracranial arachnoid cysts. Here, a 55-year-old female presented with a spontaneous hemorrhage into a cervical spine arachnoid cyst warranting surgical intervention (i.e., fenestration/excision/occlusion).

Case Description:

A 55-year-old female presented with 3 weeks of dull pain in the cervicothoracic region. She subsequently developed paresthesias and progressive lower extremity weakness with (urinary incontinence. The cervical magnetic resonance revealed a right anterolateral intradural extramedullary “cystic” lesion extending from C7 to T2; it contained a heterogeneous signalon T2W sequences, and a fluid-fluid level was documented on the T2-GRE and FLAIR sequences. At surgery, consisting of a laminectomy, two hemorrhagic cystic lesions were identified and removed. Histological findings were consistent with hemorrhagic into an arachnoid cyst.

Conclusion:

Only rarely hemorrhages develop in intraspinal intradural extramedullary spinal arachnoid cysts.

Computed Tomography-Guided Posterolateral Transsacral Ala Approach to Presacral L5 Schwannoma: Technical Note

BACKGROUND

Presacral schwannomas are rare benign tumors that may reach large size before becoming symptomatic. Total surgical removal has been considered the best treatment option. Tumors arising from the presacral area are commonly managed through anterior approaches, whereas posterior approaches are used for pure intrasacral tumors or large lesions with both intrasacral and presacral extension, alone or in combination with anterior approaches.

METHODS

We describe a quick and minimally invasive navigation-guided posterolateral approach to a right presacral L5 schwannoma. The lesion was microsurgically removed through high-speed drilling of the upper portion of the right sacral ala, under intraoperative neurophysiologic monitoring.

RESULTS

The postoperative course was unremarkable, and the patient experienced improvement in his sensory disturbance. Postoperative magnetic resonance imaging and computed tomography scan showed the complete excision of the lesion and the removal of the upper sacral ala with preservation of the right L5-S1 articular complex. The histologic examination confirmed a schwannoma (World Health Organization grade I).

CONCLUSIONS

The posterolateral transsacral ala approach may represent a minimally invasive option in the surgical management of presacral well-circumscribed benign tumors. Spinal navigation could be properly used to facilitate lesion exposure and to minimize the bone removal. The intraoperative neurophysiologic monitoring is an essential tool for the preservation of the lumbosacral nerve roots.

The use of bipolar PlasmaKinetic resectoscope in endoscopic resection of the prostate: our experience

Prostatic endoscopic resection (TURP) is a reference method in the treatment of prostatic obstruction.

In the past decades, the method used a monopolar resectoscope. In the last years, various technologies have been studied to improve the efficacy of endoscopic resection. As per our experience, we have thence ascertained the variations of the hematic crasis and of the mictional asset in TURP patients treated with bipolar knives.

20 patients underwent bipolar plasmakinetic resection of the prostate. Their age ranged between 58 yrs and 82 yrs (av: 70.2 yrs), the adenoma volume, checked with TR ultrasound scanning, was between 33 and 44 cc (av: 37.6), the Qmax was between 6.4 and 9.0 mL/min (av.: 7.42 mL/min). A 24Ch resectoscope and spinal anesthesia were used. Bleeding during resection was never relevant; therefore resection never had to be stopped. After about 36 hours from surgery, the patients’ sanguification was checked again: a 6.53% reduction of the number of erythrocytes, compared to pre-surgery data, was observed, together with a 6.73% decrease of hemoglobin concentration, and a 6.3% decrease of hematocrit. Continuous irrigation was suspended during the first day, catheter was removed on the 48th hour in 15 cases, and on the 72nd in 5 cases: the patients were discharged on day 3 in 16 cases, and on day 4 in 4 cases. A flux evaluation was performed after 3 months, which showed a Qmax between 16.6 and 24 mL/min (av.: 19.11), with a significant increase in the maximum flow rate.

The use of the new technologies in prostatic endoscopic resection has allowed us to improve the efficacy of such a method. Above all, the use of a bipolar electrosurgical knife enables us to associate a basal hemostasis with the resection of the prostatic tissue. Thus, the hematic loss is low, as we have been able to ascertain also in our own experience. This gave us the possibility to quickly stop continuous irrigation and to early remove the catheter. This way, hospitalization was sensibly reduced (av. 76.8 hours). The maximum flow rate, in the short term, has been good. We have been able, in our experience, to assess that this technology represents a useful guarantee to improve the results of prostatic endoscopic resection.

Sexual rehabilitation with intracavernous PGE1 injections and oral drug administration in diabetic patients non-responder to oral therapy alone

Diabetes is an important risk factor in erectile dysfunction (ED), acting via several mechanisms. We assessed the efficacy of intracavernous injections (ICI) rehabilitation and oral systematic therapy in diabetic patients, as well as the response of controls to oral therapy ‘on demand’.

Materials and Methods

Sixteen diabetic patients with ED were treated with vasoactive drugs orally when needed, without satisfactory erections. The patients underwent then ICI rehabilitation with PGE1 20 mcg twice weekly for 4 weeks, followed by the administration of oral drugs twice weekly for 4 weeks. Before and after rehabilitation, the patients completed a detailed anamnestic protocol to study their libido (always present); they answered questions Q3 and Q4 of the IIEF questionnaire. During ICI, a study with dynamic echocolordoppler (ECCD) was carried out. All patients had Type 2 diabetes: 10 were treated with oral antidiabetics, 4 were treated with insulin, and in the other 2 patients, treated with insulin, a sensitive neuropathy of the lower limbs was diagnosed. Fourteen patients were treated with antihypertensive drugs.

Results

Before rehabilitation, the mean responses to questions 3 and 4 of the IIEF (International Index of Erectile Function) questionnaire were 1.6 and 1.5 respectively; after rehabilitation, the mean responses were 2.68 and 2.5, respectively. The ECCD test showed an arterial component in 4 cases and a high end-diastolic velocity (EDV) in 14 cases. Four patients (25%), 2 of which had neuropathy, and 2 were in advanced age, did not respond to PGE1 or to oral therapy, 4 patients (25%) (2 treated with insulin and 2 by oral therapy) responded to ICI but not to oral therapy, while 8 patients (50%) showed a good response to both injectable and oral therapy, with good Q3 and Q4 scores.

Conclusions

Good endothelial function appears to be essential for the maintenance of acceptable erectile function. Diabetes has a negative effect on this function, as does hypoxia and low perfusion. Based on the principle that a good erection improves endothelial function, we tried to determine if oral systematic and intracavernous rehabilitation would improve erectile function in diabetic patients. The results indicate that diabetes interferes with erectile function, compromising the effects of the vasoactive drugs. However, integrated systematic rehabilitation appears to allow a good erectile response to both intracavernous and oral therapy in a large number of cases. Therefore, we support this kind of rehabilitative protocol in the treatment of ED in diabetic patients.

Power Doppler Ultrasonografy (Pdu) as an Additional Tool to Increase Reliability of Systematic Biopsy of the Prostate

Diagnosis of prostate cancer has until recently relied primarily on eight core TR biopsy.

Tests are being carried out to verify whether PDU can effectively aid such diagnosis thereby reducing the number of biopsies and tissue samplings.

This has also been our attempt.

Two groups of patients were examined for increased PSA with or without a palpable prostatic nodule. The first group was composed by 52 patients between 55 and 83 years of age (av. 69.57) with PSA values between 0.87 and 94.91 ng/mL (r.8.085) of which 29 (55.75%) showed a palpable nodule. All patients underwent prostatic eight core TR ecobiopsy.

The second group was composed by 56 patients between 49 and 84 years of age (av.69.19) with PSA values between 1.14 and 59.7ng/mL (r.8.74) of which 33 (58.97%) showed a palpable nodule. This group of patients underwent a PDU just before TR biopsy in order to assess prostatic blood supply and locate possible alterations. Prostatic volume in both groups was never higher than 50 cc. Of the first group 25 patients (48.08%) were prostate cancer positive. Of the second group 31 patients (55.36%) were positive to a biopsy for prostate cancer. In addition 22 out of the 31 showed a vascular irregularity.

From the evidence above (tests carried out by the same operator with two homogeneous groups of patients-Wilcoxon test-) it is clear that PDU usefully worked in diagnosing a higher number of prostate cancers.

Diagnostic sensitivity and specificity was markedly increased by the association of PDU and TR biopsy.

The Role of Histopathologic Grading in the Staging of Localized Prostate Cancer

One of the most important parameters in the staging of prostate Cancer is the Gleason Grading, although the Gleason assessed In biopsy is not always the same as the final grading. We have therefore tried to find out whether the use of histopathologic grading might offer some extra information about the biological nature of prostate Cancer. 53 patients underwent a radical open prostatectomy for prostate Cancer. Mean age was 66.16ys; pre-biopsy PSA was 1.92-47 ng/mL.

Histopathologic grading was assessed on the biopsy tissue, while grading, Gleason and the pathological stage were assessed on the operation piece.

The 53 patients were classified according to their bioptic grading (BG), postoperative grading (PG), stage and PSA. BG=PG in 33 cases (62.26%).

17 patients (30.07%) showed a BG<PG and 3 (3.77%) BG>PG.

If we analyze such data according to the stage: 1T1c:GB=GP. 9T2a: 6(66.6%)GB=GP, 2GB<GP and 1GB>GP.

19T2b:10(52.63%)GB=GP, 9(47.3%)GB<GP. 11T2c:11GB=GP. 13T3: 5GB=GP, 6GB<GP and 2GB>>GP. Prostate carcinoma staging still shows a large number of limits related to the unpredictability of neoplasm behaviour. The present trend is to use several parameters. We think that the use of the histopathologic grade can be a useful tool to be added to the ones we already employ. We think histopathologic grading should be used with other grading methods, instead of replacing Gleason, which is still quite effective.

La sindrome da incompetenza cavernosa e l'ipogonadismo secondario dell'andromiosi: Condizioni correlate o concomitanza occasionale?: Venous leakage syndrome and “andromiosis” hypogonadism: Are they correlated or are they an occasional coincidence?

The study of available case histories enables us to formulate some interesting hypotheses on the relationship between andropause hypogonadism and cavernous incompetence erectile deficit. Such conditions may well be connected to a similar degenerative or aging process which, provided both conditions are present, may be responsible for the worsening of the erectile deficit. Correction of the hormone deficit does not produce any recovery of spontaneous erectile activity but it significantly improves response to standard treatment for impotence.

Transitional cell carcinoma of the upper urinary tract: Our experience with regard to diagnosis

Transitional cell carcinoma of the upper urinary tract is rare and presents quite interesting diagnostic and therapeutic problems. Available case studies, in accordance with literature on the subject, show how diagnosis relies on the combination of several data obtained from both traditional radiological methods and complementary tests. The importance of urography and retrograde ureteropyelography in providing morphological information is therefore fundamental and should be emphasised. It is advisable, however, to combine these data with those from urinary cytology, ultrasonography and to a lesser extent from CT scan, to be more sure of the nature and the extent of the disease.

The association of radical prostatectomy and adjuvant hormone therapy can represent a valid option in the treatment of locally advanced prostatic cancer (T3b-c)?

Locally advanced prostatic cancer is a pathological condition not uncommonly found, especially during radical prostatectomy due to an understaged pathology. It is therefore important to find a pattern of therapeutic behaviour in order to be able to offer the patient the most suitable treatment. An analysis of current case histories tallies with other recent statistical evaluations and allows us to state with increasing certainty that the combination of radical prostatectomy, when technically feasible, with a supporting hormone therapy offers numerous advantages in terms of life span, free-from-disease intervals and quality of life compared to the single therapies. It is therefore interesting to examine the role that such therapy plays in the treatment of locally advanced prostatic cancer.

The combined implant of an endourethral prosthesis and artificial sphincter in post-operative urethral strictures involving the external sphincter

— Urethral strictures still represent one of the most difficult urological pathologies to treat. This report deals with two cases of post-operative urethral strictures involving the external sphincter treated with a combined implant of an endourethral prosthesis and an artificial sphincter AMS-800. Two years after the implant, the urodynamic equilibrium is satisfactory. The relatively high cost of the treatment requires really favourable results in particularly motivated subjects.

Pharmacocavernosometry as a functional diagnostic test of venous leakage

During 1994, 20 patients underwent pharmacocavernosometry because of suspected venous leakage. Only two patients showed evident signs of this syndrome. However, in another 10 patients, who did not show cavernosometric signs of venous leakage, cavernosography manifested opacity of the pudendal veins. Therapy for the two above-mentioned cases was surgical ligation of the crural vessels and of the dorsal vein. Short-term results have been substantially satisfactory. Analysing these cases and taking into account the latest bibliographic references, a prevalently functional pathogenesis of venous leakage can be proposed. Pharmacocavernosometry, as a functional diagnostic exam, although limited, could be the best test presently available to diagnose this syndrome. Cavernosography, being a more anatomic exam, could appear much less significant. The therapy to be proposed is surgery, on its own or supported by pharmacoprosthesis.

Priapism: Our Experience and a Literature Review

The series of cases which was taken into consideration, although statistically irrelevant, is in line with the most recently acquired bibliographic knowledge on the subject. It shows that, because of its growing incidence, priapism is a remarkably interesting syndrome; in addition, it shows the need to define diagnostic and therapeutic procedures which, taking the physiology of erection into consideration, allow both the morbid syndrome to be cured and its development foreseen.

[Correlation between the nucleolar organizer region in adenocarcinoma of the prostate and the Gleason system]

Using a silver staining, technique, Nucleolar Organizer Region-associated proteins (NORs) were studied on paraffin sections of 25 resected prostatic adenocarcinomas classified with Gleason grading and 11 hyperplastic lesions. Then 7 inclusions was selected for each grade of Gleason system and 7 inclusions of normal prostatic tissue. The mean numbers of argyrophilic nucleolar organizer regions (AgNORs) increased significantly (P less than 0.01) from normal prostatic tissue to Gleason 5. The data indicate that AgNORs counts may help distinguish between each grade of Gleason system. It was concluded that the AgNOR technique provides a significant kinetic evaluation of prostatic adenocarcinoma and its prognostic study.