Additive effects of eldecalcitol in poorly responding long-term bisphosphonate treatment for osteoporosis

OBJECTIVES: We examined whether eldecalcitol (ELD) provided additive bone mineral density (BMD) and bone turnover marker gains in patients undergoing long-term bisphosphonate (BP) usage, especially in osteoporotic individuals exhibiting a poor response to BPs. METHODS: Forty-two post-menopausal patients with primary osteoporosis and low lumbar BMD (L-BMD) and/or bilateral total hip BMD (H-BMD) values receiving long-term BP treatment were prospectively enrolled. Serum bone alkaline phosphatase (BAP) was measured as a bone formation marker and urinary N-terminal telopeptide of type I collagen (NTX) was assessed as a bone resorption marker. L-BMD, H-BMD, and femoral neck BMD (N-BMD) were recorded before, at the commencement of, and during ELD administration. RESULTS: BAP and urinary NTX were significantly decreased by BP therapy prior to ELD. ELD addition further significantly decreased the bone turnover markers (both p < 0.01). The mean L-BMD increase rate was 0.2% (p = 0.81) from 2 to 1 years before ELD administration, −0.7% (p = 0.30) during the year before ELD, and 2.9% (p < 0.01) during 1 year of ELD. Similar findings were observed for the mean increase rate of H-BMD, with values of 0.2% (p = 0.55), −0.7% (p < 0.01), and 1.2% (p < 0.01), respectively. The mean N-BMD increase rate was significantly increased after ELD administration (1.1%, p = 0.03) despite no gains by BP therapy alone. CONCLUSIONS: This study suggests that ELD addition may be useful for osteoporotic patients exhibiting a diminished long-term BP therapy response.

Challenges of Transarticular Screw Fixation in Young Children: Report of Surgical Treatment of a 5-Year-Old Patient's Unstable Os-Odontoideum

Surgical procedures for atlantoaxial (C1–C2) fusion in young children are relatively uncommon. The purpose of this study was to report on a surgical treatment for a case of atlantoaxial instability caused by os-odontoideum in association with quadriparesis and respiratory paralysis in a 5-year-old girl. We present the patient's history, physical examination, and radiographic findings, describe the surgical treatment and a five year follow-up, and provide a literature review. The instability was treated by halo immobilization, followed by C1–C2 transarticular screw fixation using a computed tomography-based navigation system. At the five year follow-up, the patient had made a complete recovery with solid union. The authors conclude that C1–2 transarticular screw fixation is technically possible as in a case of atlantoaxial instability in a five-year-old child.

Comparison of Clinical and Radiological Results of Posterolateral Fusion and Posterior Lumbar Interbody Fusion in the Treatment of L4 Degenerative Lumbar Spondylolisthesis

STUDY DESIGN: Multicenter analysis of two groups of patients surgically treated for degenerative L4 unstable spondylolisthesis. PURPOSE: To compare the clinical and radiographic outcomes of posterolateral fusion (PLF) and posterior lumbar interbody fusion (PLIF) for degenerative L4 unstable spondylolisthesis. OVERVIEW OF LITERATURE: Surgery for lumbar degenerative spondylolisthesis is widely performed. However, few reports have compared the outcome of PLF to that of PLIF for degenerative L4 unstable spondylolisthesis. METHODS: Patients with L4 unstable spondylolisthesis with Meyerding grade II or more, slip of >10degrees or >4 mm upon maximum flexion and extension bending, and posterior opening of >5 degree upon flexion bending were studied. Patients were treated from January 2008 to January 2010. Patients who underwent PLF (n=12) and PLIF (n=19) were followed-up for >2 years. Radiographic findings and clinical outcomes evaluated by the Japanese Orthopaedic Association (JOA) score were compared between the two groups. Radiographic evaluation included slip angle, translation, slip angle and translation during maximum flexion and extension bending, intervertebral disc height, lumbar lordotic angle, and fusion rate. RESULTS: JOA scores of the PLF group before surgery and at final follow-up were 12.3+/-4.8 and 24.1+/-3.7, respectively; those of the PLIF group were 14.7+/-4.8 and 24.2+/-7.8, respectively, with no significant difference between the two groups. Correction of slip estimated from postoperative slip angle, translation, and maintenance of intervertebral disc height in the PLIF group was significantly (p<0.05) better than those in the PLF group. However, there was no significant difference in lumbar lordotic angle, slip angle and translation angle upon maximum flexion, or extension bending. Fusion rates of the PLIF and PLF groups had no significant difference. CONCLUSIONS: The L4-L5 level posterior instrumented fusion for unstable spondylolisthesis using both PLF and PLIF could ameliorate clinical symptoms when local stability is achieved.

Mini Open Foraminotomy for Cervical Radiculopathy: A Comparison of Large Tubular and TrimLine Retractors

STUDY DESIGN: Retrospective chart review. PURPOSE: A comparison of mini open foraminotomy (MOF) for cervical radiculopathy using either large tubular (LT) or TrimLine (TL) retractors. OVERVIEW OF LITERATURE: Posterior foraminotomy relieves compression of the cervical nerve root in radiculopathy patients. However, invasion of the paravertebral muscle may cause major problems in these patients. To address these problems, we performed MOF. METHODS: Twenty cervical radiculopathy patients (16 male and 4 female) who underwent MOF between May 2004 and August 2011 were assigned to LT and TL groups. Each group contained 10 subjects. Surgical and clinical outcomes were compared. RESULTS: The average operating time in the TL group was significantly shorter than that in the LT group. The final follow-up mean neck disability indices significantly improved compared to the preoperative values (LT group, 12.0+/-7.8 vs. 28.0+/-9.4; TL group, 6.0+/-5.9 vs. 21.9+/-10). The final follow-up neck pain visual analog scale (VAS) scores also decreased significantly from the preoperative of 8.0+/-1.5 and 2.5+/-2.5 to the final follow-up values of 2.2+/-2.2 and 1.0+/-2.5 in the LT and TL groups, respectively. The recovery rate for the neck pain VAS score was 70.0+/-31.9 in the LT group and 87.0+/-32.0 in the TL group, thus suggesting no significant difference between the two groups. CONCLUSIONS: MOF with the TL retractor is an easy and safe procedure. Furthermore, the use of the TL retractor allows for a minimally invasive and effective surgical treatment of cervical radiculopathy patients.

Mid-Term Results of Computer-Assisted Cervical Pedicle Screw Fixation

STUDY DESIGN: A retrospective study. PURPOSE: The present study aimed to evaluate mid-term results of cervical pedicle screw (CPS) fixation for cervical instability. OVERVIEW OF LITERATURE: CPS fixation has widely used in the treatment of cervical spinal instability from various causes; however, there are few reports on mid-term surgical results of CPS fixation. METHODS: Record of 19 patients who underwent cervical and/or upper thoracic (C2-T1) pedicle screw fixation for cervical instability was reviewed. The mean observation period was 90.2 months. Evaluated items included Japanese Orthopaedic Association (JOA) score and C2-7 lordotic angle before surgery and at 5 years after surgery. Postoperative computerized tomography was used to determine the accuracy of screw placement. Visual analog scale (VAS) for neck pain and radiological evidence of adjacent segment degeneration (ASD) at the 5-year follow-up were also evaluated. RESULTS: Mean JOA score was significantly improved from 9.0 points before surgery to 12.8 at 5 years after surgery (p=0.001). The C2-7 lordotic angle of the neutral position improved from 6.4degrees to 7.8degrees at 5 years after surgery, but this was not significant. The major perforation rate was 5.0%. There were no clinically significant complications such as vertebral artery injury, spinal cord injury, or nerve root injury caused by any screw perforation. Mean VAS for neck pain was 49.4 at 5 years after surgery. The rate of ASD was 21.1%. CONCLUSIONS: Our mid-term results showed that CPS fixation was useful for treating cervical instability. Severe complications were prevented with the assistance of a computed tomography-based navigation system.

Comparison of Spinous Process-Splitting Laminectomy versus Conventional Laminectomy for Lumbar Spinal Stenosis

STUDY DESIGN: Seventy-five patients who had been treated for lumbar spinal stenosis (LSS) were reviewed retrospectively. PURPOSE: Invasion into the paravertebral muscle can cause major problems after laminectomy for LSS. To address these problems, we performed spinous process-splitting laminectomy. We present a comparative study of decompression of LSS using 2 approaches. OVERVIEW OF LITERATURE: There are no other study has investigated the lumbar spinal instability after spinous process-splitting laminectomy. METHODS: This study included 75 patients who underwent laminectomy for the treatment of LSS and who were observed through follow-ups for more than 2 years. Fifty-five patients underwent spinous process-splitting laminectomy (splitting group) and 20 patients underwent conventional laminectomy (conventional group). We evaluated the clinical and radiographic results of each surgical procedure. RESULTS: Japanese Orthopaedic Association score improved significantly in both groups two years postoperatively. The following values were all significantly lower, as shown with p-values, in the splitting group compared to the conventional group: average operating time (p=0.002), postoperative C-reactive protein level (p=0.006), the mean postoperative number of days until returning to normal body temperature (p=0.047), and the mean change in angulation 2 years postoperatively (p=0.007). The adjacent segment degeneration occurred in 6 patients (10.9%) in the splitting group and 11 patients (55.0%) in the conventional group. CONCLUSIONS: In this study, the spinous process-splitting laminectomy was shown to be less invasive and more stable for patients with LSS, compared to the conventional laminectomy.

Myxopapillary Ependymoma of the Cauda Equina in a 5-Year-Old Boy

Myxopapillary ependymoma in childhood typically occurs in the central nervous system. There are few surgical cases of myxopapillary ependymoma of the cauda equina in children. We report a case of myxopapillary ependymoma of the cauda equina in a 5-year-old boy, who presented with leg pain and abnormal gait. Subtotal resection surgery was performed. Following the subtotal tumor resection, follow-up magnetic resonance imaging evaluation showed a recurrent tumor. As a result, we performed a second subtotal tumor resection and followed with postoperative radiation therapy. No further evidence of the disease has been noted elsewhere in the patient in over ten years of follow-up. Myxopapillary ependymoma of the cauda equina in a young boy was improved by subtotal tumor resection and postoperative radiation therapy.

Cervical Pedicle Screw Fixation Combined with Laminoplasty for Cervical Spondylotic Myelopathy with Instability

STUDY DESIGN: A retrospective study. PURPOSE: To evaluate the surgical results of cervical pedicle screw (CPS) fixation combined with laminoplasty for treating cervical spondylotic myelopathy (CSM) with instability. OVERVIEW OF LITERATURE: Cervical fixation and spinal cord decompression are required for CSM patients with instability. However, only a few studies have reported on CPS fixation combined with posterior decompression for unstable CSM patients. METHODS: Thirteen patients that underwent CPS fixation combined with laminoplasty for CSM with instability were evaluated in this study. We assessed the clinical and radiological results of the surgical procedures. The Japanese Orthopedic Association (JOA) scoring system was used to evaluate the clinical results. The percentages of sli p, difference in sli p angle between maximum flexion and maximum extension of unstable intervertebrae, and perforation rate of CPS were evaluated. RESULTS: The mean JOA scores before surgery, immediately after surgery, and at final follow-up were 9.1, 13.3, and 12.6, respectively. The mean percentages of sli p before surgery, immediately after surgery, and at final follow-up were 9.1%, 3.2%, and 3.5%, respectively; there were significant improvements immediately after surgery and at final follow-up. The difference in sli p angle between the maximum flexion and maximum extension of the unstable intervertebrae changed from 9.0degrees before surgery to 1.6degrees at the final follow-up. The perforation rate of CPS was 10.9%. CONCLUSIONS: The results suggest that CPS fixation combined with laminoplasty is an effective surgical procedure for treating CSM with instability.

A Case of Pyogenic Spondylodiscitis Caused by Campylobacter fetus for Which Early Diagnosis by Magnetic Resonance Imaging Was Difficult

The purpose of this case report was to report a rare case of pyogenic spondylodiscitis caused by Campylobacter fetus. A 37-year-old male presented with fever and low back pain. By lumbar magnetic resonance imaging (MRI), no abnormal finding was observed at the first presentation. However, low back pain was aggravated, and fever did not improve. Thus, lumbar MRI was repeated on the 26 day after the onset of symptoms, showing abnormal signals at vertebrae and disc spaces, and pyogenic spondylitis was diagnosed. The possibility of pyogenic spondylodiscitis should be taken into account if a patient presents with low back pain and fever, and areas of low signal intensity on a T1-weighted MRI should be carefully examined. When initial MRI does not reveal abnormal findings, repeated MRI after one or two weeks or, more favorably, immediate gadolinium enhancement MRI, are important for patients who have persistent low back pain and fever.

Computer-assisted C1-C2 Transarticular Screw Fixation "Magerl Technique" for Atlantoaxial Instability

STUDY DESIGN: A retrospective study. PURPOSE: To evaluate the surgical results of computer-assisted C1-C2 transarticular screw fixation for atlantoaxial instability and the usefulness of the navigation system. OVERVIEW OF LITERATURE: We used a computed tomography (CT)-based computer navigation system in planning and screw insertion in Magerl's procedure, which provides the most rigid atlantoaxial fusion, to avoid risk of vertebral artery (VA) tear by avoiding high-riding VA during screw insertion. METHODS: Twenty patients who underwent atlantoaxial fusion under the CT-based navigation system were studied. The mean observation period was 33.5 months. The evaluated items included the existence of VA stenosis by preoperative magnetic resonance angiography, surgical time, blood loss volume, Japanese Orthopaedic Association (JOA) score and Ranawat's pain criteria before surgery and at final follow-up, postoperative screw position evaluated by CT, and bony fusion. RESULTS: The mean operation time was 205 minutes, with the mean blood loss volume of 242 ml. The mean JOA score was 11.6 points before surgery and 13.7 at final follow-up. Occipital and/or cervical pain presented before operation was remitted or resolved in all patients. Evaluation of screw insertion by CT revealed correct penetration to atlantoaxial joints, with a perforation rate of 2.6%. There was no complication, including VA tear, and all patients who were followed-up during one year or more after surgery achieved bony fusion. Some subjects who appeared inappropriate for surgery from CT images were assessed as eligible for surgery based on the evaluation results obtained using the navigation system. CONCLUSIONS: It was demonstrated that the CT-based navigation system is an effective support device for Magerl's procedure.