Long-Term Outcomes of Posterior Lumbar Interbody Fusion Using Stand-Alone Ray Threaded Cage for Degenerative Disk Disease: A 20-Year Follow-Up

STUDY DESIGN: Retrospective study. PURPOSE: To analyze outcomes of posterior lumbar interbody fusion (PLIF) stand-alone cages. OVERVIEW OF LITERATURE: PLIF for degenerative disk disease using stand-alone cages has lost its popularity owing to implant-related complications and pseudoarthrosis. METHODS: We analyzed the records of 45 patients (18 women, 27 men), operated between January 1994 and December 1996, with a mean follow-up of 18 years 3 months (20 years 3 months–22 years 3 months). Clinical outcomes were measured using visual analogue score (VAS), Oswestry disability index (ODI), Odom's criteria, and radiological measurements of fusion rate, Cobb angle, and implant-related complications conducted at the preoperative evaluation, hospital discharge, 12-month follow-up, and final follow-up. RESULTS: Preoperative mean VAS (back) was 6.9 and VAS (radicular) was 7.2, with mean improvements (p <0.05) of 2.9 and 3.1, respectively, at the final follow-up. Median preoperative ODI was 64.5, with a mean improvement to 34 and 42 at the 12-month and final follow-ups, respectively (p <0.05). Odom's criteria at the 12-month follow-up were excellent in 11.2% patients, good in 57.7%, fair in 31.1%, and poor in none of the patients; at the final follow-up, no patient was classified as excellent, 71.1% as good, 22.2% as fair, and 6.7% as poor (p <0.05). Pseudoarthrosis was observed in five patients (11.1%), of whom, three (6.6%) required re-operation. Preoperative disk height was 9.23 mm, which increased to 13.33 mm in the immediate postoperative evaluation and was maintained at 10.0 mm at the final follow-up (p <0.05). The preoperative mean L1–S1 Cobb angle was 34.7°, which changed to 44.7° in the immediate postoperative evaluation and dropped to 39.7° at the final follow-up (p <0.005). CONCLUSIONS: PLIF stand-alone cages were associated with good clinical outcomes. Although the fusion rate was excellent, maintenance of disk heights and a lordotic alignment were not achieved in the long term.

efficacy of a percutaneous expandable titanium device in anatomical reduction of vertebral compression fractures of the thoracolumbar spine

To evaluate the feasibility of a minimally invasive technique using a titanium expandable device to achieve anatomical restoration of vertebral compression fractures [VCF] of the thoracolumbar spine. This prospective study included 27 patients diagnosed with VCF [Magerl classification A.1.2, A.1.3, and A.3.1] of the thoracolumbar spine treated with percutaneous cement augmentation using the SpineJack[registered] device. The study was conducted in Valladolid University Hospital, Valladolid, Spain from January to December 2012, with a minimum one-year follow up. Preoperative evaluation included visual analogue scale [VAS] for pain, and radiological assessment of the VCF using 3-dimensional computed tomography [3D-CT] scans for measurements of vertebral heights and angles. The patients were followed at 3, 6, and 12 months with clinical VAS and radiological assessments. The procedure was performed in 27 patients with a mean age of 55.9 +/- 17.3 years, 55.6% females. All patients underwent surgery within 6 weeks from time of injury. No procedure related complications occurred. Pain measured by VAS score decreased from 7.0 preoperatively to 3.2 within 24 hours, and remained 2.2 at 3 months, 2.1 at 6 months, and 1.5 at 12-months follow-up [p<0.05]. Mean height restorations for the anterior was 3.56 mm, central was 2.49, and posterior vertebral was 1.28 mm, and maintained at 12-months follow-up [p=0.001]. This new percutaneous technique for VCF has shown good clinical results in pain control and the possibility to reduce both vertebral kyphosis angles and fractured endplates seen in 3D-CT scans assessment method. Further studies are needed to confirm those results on larger cohorts with long-term follow up

Prevalence of cervical ribs and elongated transverse processes in Saudi Arabia

To describe the prevalence of the full spectrum of transverse process elongation and cervical ribs for the first time in over a decade in a Saudi population, trying to assess any changes in the interim. A cross-sectional hospital based study was conducted at King Abdulaziz University Hospital, Jeddah, Saudi Arabia in the 3-month period between October and December 2010. The study comprised a radiologic review of 1,000 consecutive chest radiographs of adults from the digital database looking for the presence of cervical ribs and elongated transverse processes. Our study showed that cervical ribs are present in 3.4% of our population; a female to male ratio was 2.01 to 1. They were bilateral in 41% of those afflicted individuals. Elongated transverse processes were present in 23%. The prevalence of cervical ribs and elongated transverse processes in our population is higher than that reported in other populations. It also shows an interim increase in prevalence when compared with a previous study on our population more than a decade back

Current management of traumatic intracranial hypertension: a systematic approach

Traumatic brain injury [TBI] is a major cause of mortality and morbidity in Arab countries in general, and in Saudi Arabia in particular. The efficacy and safety of most of the interventions used in the management of patients with TBI lack class I evidence and remain unproven. A search was established using a subject heading "head injury", "Traumatic brain injury" and combined headings "brain injury and Saudi Arabia" and "brain injury and middle east". The authors used the national library of medicine database to analyze these treatment options and the therapeutic goals of lowering intracranial pressure. This review describes the systematic approach and current management practices including surgical interventions and various treatment modalities for traumatic intracranial hypertension. The results provide recommendations for intensivists and emergency physicians in Arab countries managing head injured patients. Details of these advocated treatments can be found through the literature references

Dandy walker malformation and hypertrophic cardiomyopathy. Unusual fatal association

Dandy Walker malformation [DWM] is a rare congenital brain anomaly characterized by cystic dilation of the fourth ventricle and hypoplasia of the cerebellar vermis. Other extracranial anomalies can be associated, including cardiac defects. We report a rare patient with DWM associated with progressive heart failure secondary to hypertrophic cardiomyopathy. He was diagnosed at 2 months of age and died 5 months later. We conclude that hypertrophic cardiomyopathy can be associated with DWM with poor prognosis. A careful cardiac evaluation is needed in all infants with DWM for early recognition of such potentially serious associated cardiac malformations

Mixed germ cell tumours of the pineal region

Intracranial mixed germ cell tumours, particularly with the occurrence of germinoma and teratoma components, are very rare. On many occasions, the diagnosis is only reached after a second surgical resection of what is believed to be a tumour recurrence. The authors report two young adolescent males who presented with headache, vomiting and Parinaud's syndrome. Cranial CT and MRI scans demonstrated a large heterogeneous pineal region tumour. Through a supracerebellar infratentorial approach, in both patients, a complete excision of the tumour was achieved of a histopathologically proven mixed germ cell tumour, predominantly teratoma with elements of germinoma. The patients received adjuvant chemotherapy and radiotherapy and remained tumour free during their follow-up. The authors discuss the management of this rare entity and emphasize the importance of detailed histopathological examination

Idiopathic intracranial hypertension. Atypical presentation

To describe the clinical features of 5 patients with rare atypical presentation of idiopathic intracranial hypertension [IIH], and propose the possible mechanism of this atypical presentation. We carried out a retrospective study of 5 patients admitted at King Khalid National Guard Hospital, Jeddah, Kingdom of Saudi Arabia with IIH during the period from January 2001 to December 2005. All were females with their age ranges from 24 to 40 years. The clinical presentations, and the laboratory and imaging studies were analyzed. The opening pressures of the lumbar puncture tests were documented. All patients were presented with headache. One had typical pain of trigeminal neuralgia, and one with neck pain and radiculopathy. Facial diplegia was present in one patient, and 2 patients had bilateral 6th cranial neuropathy. Papilledema was present in all patients except in one patient. Imaging study was normal in all patients, and they had a very high opening pressure during lumbar puncture, except in one patient. All patients achieved full recovery with medical therapy in 6 to 12 weeks with no relapse during the mean follow up of 2 years. Atypical findings in IIH are rare and require a high index of suspicion for early diagnosis

Spinal intramedullary tuberculoma

Spinal intramedullary tuberculosis is a rare disease entity. The authors report two healthy adult patients presented with progressive paraparesis due to histologically proven intramedullary tuberculomas. The spinal magnetic resonance imaging [MRI] scans revealed intensely enhancing intramedullary lesion. Surgery was performed through laminectomy and complete resection was achieved. Both patients improved after surgery with normal motor power and follow-up MRI showed complete excision

Functional hemispherectomy for the treatment of intractable seizures

Hemispherectomy is the most successful operation for the control of seizures in a very select group of patients with infantile hemiplegia and intractable epilepsy. The efficacy of anatomical hemispherectomy has been offset to some degree by the fact that up to one third of those operated upon will subsequently develop obstructive hydrocephalus, and the so-called superficial subpial cerebral hemosiderosis, with potentially fatal complications. This review article details the operative technique of a modified "functional" hemispherectomy. In essence, the technique consists of removing the central [Rolandic] cortex and the temporal lobe of the affected hemisphere and leaving the remainder of the hemisphere intact, but neurogenically disconnected from the remaining brain

Impressions and experience of nonneurologists in neurology

Neurological disorders are common in Saudi Arabia and the demand for trained neurologists is strong. We aimed to study the impressions and experiences of general physicians in the neurology field and examine their referral practices. We included attendees of the [neurology for non-neurologists] symposium, which took place from 14-15 October 2004 at King Faisal Specialist Hospital and Research Center in Jeddah, Kingdom of Saudi Arabia. We designed a structured 24-item questionnaire to examine their demographics, training, practice, and referral patterns. One hundred and eight participants registered for the symposium, with 69 [64%] questionnaires returned. Attendee's ages were 23-60 years [mean 35], with 53% being males. There were 46% consultants and specialists, 33.5% trainees, 14.5% students, and 6% other health professionals. Most physicians [62%] practiced in the field of general practice or internal medicine and 62% received a structured neurology rotation during training. Patients with neurological complaints constituted 29.5% of those seen in their practice, and they referred 33.3% to neurology. Only 13.5% and 15.5% were highly confident in diagnosing and treating these patients. Those who reported seeing many patients with neurological complaints [4 on the Likert scale] were 18.8 times more likely to feel highly confident in their diagnoses [95% confidence interval [CI]: 3-195, p=0.0002] and 23 times more likely to feel highly confident in their management [95% CI: 3.6-236, p=0.0005]. Many physicians [20.5%] had no direct access to a neurologist for referrals. Many general physicians were not highly confident in diagnosing and treating neurology patients. Given the limited number of neurologists, we recommend appropriate neurological training of generalists