Clinical Outcome of Chemotherapy and Radiation Therapy Versus Chemotherapy, Radiation Therapy, and Multilevel Vertebroplasty or Kyphoplasty for Multiple Myeloma.

BACKGROUND: Vertebral augmentation including vertebroplasty and kyphoplasty may restore function without interfering with the therapeutic regimen of patients with multiple myeloma. We sought to evaluate the effects of adding multilevel vertebral augmentation to conventional therapy protocols for patients with multiple myeloma. MATERIALS AND METHODS: Forty-four patients recently diagnosed with multiple myeloma were randomly assigned to two groups. One group received multilevel vertebral augmentation (kyphoplasty or vertebroplasty) in addition to conventional therapy (MVA), and the other group received conventional therapy alone (CTA). Patients were evaluated before treatment and at 3 months, 6 months, 1 year, 2 years, 3 years, 4 years, and 5 years after treatment by using the Oswestry Disability Index (ODI), the Stanford Score (SS), and the Spinal Instability Neoplastic Score (SINS). RESULTS: The mean ODI, SS, and SINS were nearly equal before treatment, being 34.19 (68.38%), 4.58, and 12.30, respectively, for the MVA group and 32.29 (64.58%), 4.63, and 13.88, respectively, for the CTA group. There were significant differences in the ODI, SS, and SINS between the two groups at all follow-up intervals. The ODI and SINS were statistically significantly different between the two groups (P=.020 and P<.001, respectively). There was an insignificant difference in SS between the two groups. CONCLUSION: This study found that performing kyphoplasty and vertebroplasty in addition to conventional therapy for patients with multiple myeloma resulted in enhanced morbidity and functional outcomes. [Orthopedics. 202x;4x(x):xx-xx.].

Percutaneous femoral de-rotational varus osteotomy for the treatment of acetabular dysplasia: surgical technique.

Pediatric acetabular dysplasia is common in orthopedic practice. Femoral de-rotational varus osteotomy (FDVO) is one of the surgical options suggested for treatment. In this article, we describe a simplified surgical technique of performing FDVO percutaneously using a pediatric Limb Reconstruction System external fixator, and we discuss the advantages and disadvantages of the technique.

Unique case of successful surgical treatment of recurrent spinal epidural hematoma after lumbar disc surgery in a Glanzmann thrombasthenia patient.

We report a case of recurrent postoperative spinal hemorrhage after lumbar disc surgery in a Glanzmann thrombasthenia patient.

Assessment of Quality of Life for Scheuermann's Kyphosis Patients with Cobb's Angle 50°-65° Treated Conservatively or Surgically in North Jordan: A Prospective Comparative Study.

Background: Scheuermann's disease is the most common cause of hyperkyphosis of the thoracic spine during the adolescence period. It causes neck and lower back pain, restriction of lung expansion, traction of the spinal cord, increased vulnerability to vertebral fracture, and a hump. Patients with curves < 60° are treated conservatively, while surgery is used for patients with curves > 60°. The purpose of this prospective cohort study was to assess the quality of life and functional changes in conservatively or surgically treated Scheuermann's disease patients with a curve size of 50°-65° in north Jordan. Methods: Sixty-three adolescent patients with Scheuermann's kyphosis (aged between 10 and 18 years) were treated at our hospital between January 2014 and August 2018. All patients were investigated clinically, radiologically (Cobb's angle), and functionally (Oswestry Disability Index [ODI], Scoliosis Research Society 22 revision [SRS-22r] questionnaire, and pulmonary function test [PFT]) pre- and post-treatment (final follow-up). Patients were randomly selected for treatment method (conservative versus surgical). Results: There were 31 patients (mean age, 15.48 ± 2.50 years) and 32 patients (mean age, 16.19 ± 1.51 years) treated conservatively and surgically, respectively. Mean ± standard deviation of ODI, SRS-22r, and Cobb's angle of the surgical group improved from 16.8% ± 14.3%, 3.5 ± 0.5, and 58.75° ± 3.59°, respectively, pre-surgery to 13.4% ± 10.8%, 4.2 ± 0.5, and 41.53° ± 3.94°, respectively, post-surgery, while those of the conservative group became worse from 12.6% ± 13.4%, 3.9 ± 0.7, and 56.1° ± 3.3°, respectively, to 20.1% ± 13.6%, 3.5 ± 0.7, and 58.8° ± 5.8°, respectively. The surgical group showed better improvement in all scores than the conservative group (p < 0.05), as well as in PFT. Conclusions: Surgical treatment of Scheuermann's kyphosis with curves of 50°-65° resulted in better QOL, Cobb's angle, and PFT than conservative treatment. This was because of lower patient cooperation in the conservative management group, which made the curve less flexible for exercises and bracing.

Using deep transfer learning to detect scoliosis and spondylolisthesis from x-ray images.

Recent years have witnessed wider prevalence of vertebral column pathologies due to lifestyle changes, sedentary behaviors, or injuries. Spondylolisthesis and scoliosis are two of the most common ailments with an incidence of 5% and 3% in the United States population, respectively. Both of these abnormalities can affect children at a young age and, if left untreated, can progress into severe pain. Moreover, severe scoliosis can even lead to lung and heart problems. Thus, early diagnosis can make it easier to apply remedies/interventions and prevent further disease progression. Current diagnosis methods are based on visual inspection by physicians of radiographs and/or calculation of certain angles (e.g., Cobb angle). Traditional artificial intelligence-based diagnosis systems utilized these parameters to perform automated classification, which enabled fast and easy diagnosis supporting tools. However, they still require the specialists to perform error-prone tedious measurements. To this end, automated measurement tools were proposed based on processing techniques of X-ray images. In this paper, we utilize advances in deep transfer learning to diagnose spondylolisthesis and scoliosis from X-ray images without the need for any measurements. We collected raw data from real X-ray images of 338 subjects (i.e., 188 scoliosis, 79 spondylolisthesis, and 71 healthy). Deep transfer learning models were developed to perform three-class classification as well as pair-wise binary classifications among the three classes. The highest mean accuracy and maximum accuracy for three-class classification was 96.73% and 98.02%, respectively. Regarding pair-wise binary classification, high accuracy values were achieved for most of the models (i.e., > 98%). These results and other performance metrics reflect a robust ability to diagnose the subjects' vertebral column disorders from standard X-ray images. The current study provides a supporting tool that can reasonably help the physicians make the correct early diagnosis with less effort and errors, and reduce the need for surgical interventions.

Primary Diffuse Large B Cell Lymphoma of Bone: A Single-Center Experience.

Background: Primary diffuse large B-cell lymphoma of the bone (PB-DLBCL) is a rare type of extra-nodal lymphoma. This study aimed to examine the clinical characteristics, outcomes, treatment modalities and risk of central nervous system relapse (CNSR) among adult Jordanian patients with PB-DLBCL. Methods: This retrospective study included patients aged >16 years who were diagnosed with PB-DLBCL and treated at our hospital between 2002 and 2021. Clinical characteristics, treatment modalities, outcomes and CNSR events were extracted from the hospital's data system and analysed. Patients were categorised into unifocal (UF) and multifocal (MF) PB-DLBCL groups according to the number of bone sites involved. The involvement of only one site was defined as UF, whereas the involvement of two or more sites was defined as MF. Results: In total, 12 patients were diagnosed with PB-DLBCL. Their median age was 47.5 years (range, 17-80 years). The male:female ratio was 1:1. There were eight patients in the UF PB-DLBCL group and four in the MF PB-DLBCL group. All patients received treatment with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone. In the UF PB-DLBCL group, the male:female ratio was 5:3, the median age was 41 years, and the follow-up duration was 9-135 (mean, 83.3) months. In the MF PB-DLBCL group, the male:female ratio was 1:3, the median age was 51.5 years, and the survival time was 3-11 (mean, 7) months. Three patients with vertebral UF PB-DLBCL underwent early vertebroplasty without complications. The most common site involved was the vertebral column. Most patients with UF PB-DLBCL achieved complete remission (CR), whereas no patients with MF PB-DLBCL achieved CR. Conclusion: PB-DLBCL is rare in adult Jordanian patients. UF PB-DLBCL is more common than MF PB-DLBCL. Patients with UF PB-DLBCL had a good prognosis. Patients with MF PB-DLBCL had a high international prognostic index score, risk of CNSR and short survival time.

A Simultaneous Rupture of the Patellar Tendon and the Con-tralateral Quadriceps Tendon in a Patient with Chronic Renal Failure Undergoing Long Term Hemodialysis.

BACKGROUND: Quadriceps or patellar tendon rupture incidence is relatively low, especially simultaneous bilateral rupture, which usually reported as a complication of chronic systemic disorders such as renal failure. OBJECTIVE: Herein, we report a case of bilateral knee extensor mechanism ruptured in a patient with chronic renal failure on long standing hemodialysis. CASE PRESENTATION: A 38-year-old white male, a known case of chronic renal failure on long term hemodialysis, presented to our clinic with clinical signs of bilateral simultaneous knee extensor tendons rupture. After proper workup simultaneous quadriceps and contralateral patellar tendons rupture diagnosis was made. The patient was managed with surgical repair of the tendons and within few days after the surgery he started physiotherapy and rehabilitation program, using walking crutches partial weight bearing mobilization was allowed, and a gradual increase of knee flexion within brace was applied. He used the knee braces and the walking crutches for two months, to ensure complete healing of the repaired tendon with a sufficient strength to allow full weight bearing. At four-year follow-up, complete bilateral knee extensor tendons healing and both knees functional outcome was satisfactory. CONCLUSION: A simultaneous rupture of quadriceps and contralateral patellar tendons is a rare event in patients with chronic renal failure undergoing long term hemodialysis. With early surgical intervention and good physiotherapy, the patient usually has good recovery of both knees function.

The Effectiveness of Autograft Used in Anterior Cruciate Ligament Reconstruction of the Knee: Surgical Records for the New Generations of Orthopedic Surgeons and Synthetic Graft Revisit.

OBJECTIVE: In this article, we aim to revisit the synthetic graft and review the advantages and disadvantages between different types of grafts for patients who underwent anterior cruciate ligament (ACL) reconstruction in a tertiary medical institute for the new generations of surgeons. PATIENTS AND METHODS: Retrospectively, we identified 115 patients who underwent arthroscopic ACL reconstruction between 2006 and 2009. We were able to retrieve 74 patients from them. The 74 patients were divided into 32 patients who underwent primary arthroscopic ACL reconstruction with hamstring and patellar tendon autograft and 42 cases with an active biosynthetic composite (ABC) ligament. The mean the follow-up period for both groups was 7 years. The following information was obtained: standard demographic information (age, sex), clinical presentation, presence of trauma, associated injuries, types of grafts (autograft versus synthetic graft) and postoperative complications. Moreover, functional and clinical outcomes in addition to the satisfaction of patients using the international knee documentation committee (IKDC) score and knee injury and osteoarthritis outcome score (KOOS) were measured. RESULTS: We found that the natural (autograft) was better in terms of clinical and functional outcome than the synthetic one (the scores of KOOS and IKDC were better in natural grafts). Furthermore, the immediate postoperative results for the pivot and Lachman tests were better in natural grafts. On the other hand, the rate of re-rupture was similar for both groups. However, the long-term inflammatory changes and stiffness that is attributed to the immunological reactions were more in the synthetic grafts. CONCLUSION: This study revisited the synthetic graft and provided evidence that the natural grafts are more beneficial with less complications, as they had better immediate and long-term postoperative clinical and functional outcomes. We recommend the utilization of autograft as first choice and the synthetic not to be used given the current criteria.

Severe thoracolumbar congenital kyphosis treated with single posterior approach and gradual "in situ" correction.

BACKGROUND: Congenital kyphosis results from the failed formation of the vertebrae during the embryonic period and may be associated with cardiac, urogenital, or spinal cord anomalies. Surgical treatment is the best choice through anterior, posterior, or both approaches. OBJECTIVES: This study aims to evaluate the effect of posterior gradual correction using the "in situ" bender to correct severe thoracolumbar congenital kyphosis with or without osteotomy or excision of the vertebra. METHODS: Twenty-five patients with an age range of 2-23 (mean ± SD = 12.58 ± 6.03) years with severe thoracolumbar kyphosis were treated surgically at our institution between 2004 and 2013. Pedicle screwing, osteotomy, and gradual "in situ" bending through the single posterior approach were the choices of treatment. Cobb's angle, patient's height, and SRS-22r were used to evaluate the patients preoperatively and postoperatively. Follow-up periods were 35-136 months. RESULT: Cobb's angle pre-surgery range was 35-180 (81.48 ± 39.1) degrees improved post-surgery to 0-45 (21.72 ± 13.47) degrees (p-value <0.0001). The range of patients' standing height pre-surgery was 79-170 (142.42 ± 24.85) centimeters increased after surgery to 81-175 (147.76 ± 26.33) centimeters (p-value <0.0001). SRS-22r pre-surgery range was between 2.12 and 3.904 (3.2 ± 0.77) and improved post-surgery to 4.16 and 4.96 (4.59 ± 0.29) (p-value = 0.046). CONCLUSION: Gradual correction with the "in situ" bender with or without osteotomy through the single posterior approach can give satisfying clinical (patients' standing height and SRS-22r scores) and radiological (Cobb's angle) results to treat severe congenital thoracolumbar kyphosis.

Giant cell tumor of bone: Unusual features of a rare tumor.

Giant cell tumor of bone is a benign tumor with an aggressive behavior. Its typical subarticular location and high recurrence risk can be associated with significant morbidity. Although benign, it can rarely metastasize especially to the lungs. Also, it can be multicentric in less than 1% of patients. Late malignant transformation, although rare, can occur with a very poor prognosis. This series reports on these unusual and challenging features and management considerations of giant cell tumor of bone. This retrospective study included review of the medical records of patients with a confirmed histopathological diagnosis of giant cell tumor of bone. A total of 25 patients (16 females and 9 males) with a mean age of 34.5 years were included; 22 had primary tumors, while 3 were referred with recurrent tumors. Pain was the most common presenting symptom. Most patients had grade III tumors. Tumors around the knee were the most common. Multicentric tumors were detected in three patients. Twenty-three patients (20 primary giant cell tumor of bone and 3 with recurrence) received treatment. Most patients (15/23) were treated with intralesional curettage with or without adjuvants. Seven patients had wide excision. Recurrence was seen in 45% (9/20) of primary giant cell tumor of bone especially with difficult anatomical locations. Most recurrences occurred more than 4 years after treatment. Pulmonary nodules were detected in four patients; two of them showed resolution during follow-up. One patient developed secondary sarcoma transformation with a fatal outcome. Giant cell tumor of bone was more common in females. Long bones were more affected, especially around the knee. Intralesional curettage was the most frequently used treatment. Recurrence was associated with inadequate tumor resection (especially in difficult anatomical location), younger age, male gender, and advanced local tumor grade. Denosumab can be used in the treatment of pulmonary metastasis, multicentric and recurrent giant cell tumor of bone. Due to late recurrence and malignant transformation, a prolonged follow-up is warranted.

Epidermal inclusion cyst of the knee.

Epidermoid cysts are asymptomatic, slowly enlarging, firm to fluctuant, dome-shaped lesions. Epidermoid cysts frequently appear on the trunk, neck, face, and scrotum, behind the ears and in the palmoplantar region. We review all the cases of epidermoid cyst of the knee and present a case of non-traumatic-induced epidermal cyst in the popliteal fossa of a 66-year-old male with 10-year history of right knee swelling, which appeared firstly as a small mass 2 × 2 cm in the popliteal aspect of the knee. The mass was increasing gradually in size until 2 years ago when it increased suddenly to gain the dimensions of 4 × 6 cm. MRI of the right knee revealed a well-defined cystic lesion in the subcutaneous tissue measuring about 7 × 5 × 5 cm containing internal debris and septations. He underwent complete surgical excision of the mass. The pathological results revealed an epidermal inclusion cyst. To the best of our knowledge, this is the second description for epidermal inclusion cyst involving the popliteal fossa. We were able to retrieve three cases of epidermal cyst of the knee from the literature since its first description in 2004. Including our case, we had a total of four cases of epidermal cyst of the knee. Three males and one female constituted the patients' sample. The mean age for the patients is 55. The epidermal cyst occurred equally in both knees. The popliteal fossa was the location for two epidermal cysts. Similarly, the prepatellar region was the location for another two cysts.

Horizontal gaze palsy and progressive scoliosis with two novel ROBO3 gene mutations in two Jordanian families.

BACKGROUND: Horizontal gaze palsy and progressive scoliosis (HGPPS) is a rare autosomal recessive disorder due to mutations in ROBO3 gene. Patients have characteristic clinical and imaging findings. We report six patients from two families with this disorder with two novel mutations. MATERIALS AND METHODS: One patient from a non-consanguineous family and five patients from extended consanguineous families were clinically and radiologically examined. Blood samples from the patients and their parents were obtained and all the coding exons and flanking intronic sequences of the ROBO3 gene were amplified and subjected to bidirectional DNA sequencing. RESULTS: All six patients had the characteristic clinical and radiological findings of HGPPS. Genetic testing showed two novel mutations including frame-shift and nonsense. CONCLUSION: Two novel mutations in the ROBO3 gene were identified in two Jordanian families with six affected individuals. To our knowledge, this is the first molecular study of HGPPS in Jordan.

Anterior versus posterior approach to treat cervical spondylotic myelopathy, clinical and radiological results with long period of follow-up.

BACKGROUND: Cervical spondylotic myelopathy increases with age, but not all cases are symptomatic. It is usually diagnosed clinically and radiologically (X-ray and magnetic resonance imaging). Surgical treatment is indicated in severe symptomatic cases, while treatment controversy exists in the presence of less severe cases. Anterior and posterior approaches are generally used for decompression with no significant differences in the results of both. METHODS: A total of 287 patients of cervical spondylotic myelopathy were treated at our hospital between January 2004 and December 2015. Only 140 patients were eligible for our study. They had at least 5 years of follow-up using full clinical scores and radiological evaluation. They were divided into two groups: group I with 73 patients (aged 23-79 years) underwent posterior decompression, lateral mass instrumentation, and fusion, while group II with 67 patients (aged 33-70 years) underwent anterior decompression, instrumentation, and fusion. Neck Disability Index, local score, and X-ray were used in the evaluation of the patients. RESULTS: Preoperative mean ± standard deviation of Neck Disability Index of both the groups was 32.06 ± 6.33 and 29.88 ± 5.48, which improved in the last visit (>5 years) to 5.81 ± 7.39 and 2.94 ± 5.48 for groups I and II, respectively (p value <0.05). The local score of groups I and II was (P = 1, F = 21, G = 31, E = 19) and (P = 1, F = 12, G = 36, E = 18), which on discharge day improved to (P = 1, F = 4, G = 12, E = 55) and (P = 0, F = 3, G = 6, E = 58) at last follow-up, respectively. Fusion rate was nearly equal for both the groups during all the follow-up intervals and it was 91.1% and 91.7% in the last follow-up. CONCLUSION: There were no significant differences in the clinical and radiological results between the anterior and posterior approaches used in the surgical treatment of spondylotic cervical myelopathy. However, statistically significant results of Neck Disability Index of anterior approach were not clinically important and may be due to changes in the size and shape of the neck in group II.

Functional and Radiological Results of Proximal Femoral Nail Antirotation (PFNA) Osteosynthesis in the Treatment of Unstable Pertrochanteric Fractures.

Pertrochanteric femur fractures are considered amongst the most commonly encountered fractures in the geriatric age group. We evaluated radiographic and functional outcomes of patients with unstable pertrochanteric fractures treated with the proximal femur nail antirotation (PFNA). Between March 2013 and December 2015, fifty patients (28 male and 22 females with a mean age of 72.8 years (range, 20-94)) with unstable pertrochanteric fractures (AO 31.A2 and 31.A3) were fixed with the PFNA at our institution, and they were retrospectively evaluated. Forty one patients were treated with short PFNA and nine with long PFNA. Operative time ranged between 30 and 150 (average 73.60) min, blood loss ranged between 50 and 250 (average 80) milliliter and hospital stay ranged between 3 and 18 (6.86) days. The mean follow-up period was 18 months (range, 11-31). At final follow-up, solid union of all fractures had been achieved without any implant-related complications, the mean Harris Hip Score (HHS) was 79.34 ± 9.10 points and the mean neck-shaft angle was 127.2° ± 5.07°. No significant differences were encountered between the functional and radiographic outcomes of the PFNA with regards to the AO fracture classification and the implant version. PFNA is a recommended option for the treatment of unstable pertrochanteric fractures owing to its easy insertion, reduced blood loss, stable fixation and satisfactory functional and radiological outcomes.

Talar Neck Fracture with Dislocation Combined with Bimalleolar Ankle Fracture: A Case Report.

BACKGROUND Fractures of the talus are uncommon injuries that usually involve the talar neck, rather than the talar body. This report is of a rare case of combined left talar neck fracture and adjacent joint dislocation with an ipsilateral bimalleolar ankle fracture. CASE REPORT A 37-year-old man presented with an injury to his left foot following a motor vehicle accident. When he presented to the hospital emergency department, his left foot and ankle were swollen, the overlying skin was intact but badly contused, and there was no neurovascular deficit. Radiographs of the left ankle showed a fracture of the talar neck and bimalleolar fracture. An initial closed reduction under anesthesia failed. Therefore, open reduction and rigid stabilization of all fractures were achieved surgically, followed by the application of an external fixator spanning the ankle and the subtalar joints. The external fixator was removed at six weeks, range of motion (ROM) exercises were commenced, and a non-weight-bearing mobilization protocol was continued for 12 weeks. At four-year follow-up, radiographs confirmed solid union of all fractures, and although avascular necrosis (AVN) of the talus and secondary ankle arthritis developed, the functional outcome was satisfactory. CONCLUSIONS The immediate management of talar neck fracture with dislocation combined with a bimalleolar fracture is important to prevent soft tissue complications and to improve the functional ROM of the ankle. However, AVN and post-traumatic osteoarthritis at both the ankle and the subtalar joints are still common sequelae of talus fracture.

A Symptomatic Case of Thoracic Vertebral Hemangioma Causing Lower Limb Spastic Paresis.

BACKGROUND Despite being the most common tumor of the spine, vertebral hemangioma is rarely symptomatic in adults. In fact, only 0.9-1.2% of all vertebral hemangiomas may be symptomatic. When hemangiomas occur in the thoracic vertebrae, they are more likely to be symptomatic due to the narrow vertebral canal dimensions that mandate more aggressive management prior to the onset of severe neurological sequelae. CASE REPORT An 18-year-old male presented to the emergency room with a one-month history of mild to moderate mid-thoracic back pain, radiating to both lower limbs. It was associated with both lower limb weakness and decreased sensation. There was no history of bowel or bladder incontinence. Neurological examination revealed lower limb weakness with power 3/5, exaggerated deep tendon reflexes, bilateral sustained clonus, impaired sensation below the umbilicus, spasticity, and a positive Babinski sign. A CT scan showed a diffuse body lesion at the 8th thoracic vertebra with coarse trabeculations, corduroy appearance, or jail-bar sign. The patient underwent decompression and fixation. Biopsy of permanent samples showed proliferation of blood vessels with dilated spaces and no malignant cells, consistent with hemangioma. Postoperatively, spasticity improved, and the patient regained normal power. CONCLUSIONS Symptomatic vertebral hemangiomas are rare but should be considered as a differential diagnosis. They can present with severe neurological symptoms. When managed appropriately, patients regain full motor and sensory function. Decompression resulted in quick relief of symptoms, which was followed by an extensive rehabilitation program.

Intracardiac Leakage of Cement During Kyphoplasty and Vertebroplasty: A Case Report.

BACKGROUND: Intracardiac leakage of bone cement after kyphoplasty and vertebroplasty is a rare and life-threatening complication. Cortoss, which is an injectable, non-absorbable, polymer composite that is designed to mimic cortical bone, can be used instead of cement. Here, we present the case of a patient with right intra-cardiac Cortoss embolization. CASE REPORT: A 28-year-old man known to have ulcerative colitis since the age of 15 and treated with corticosteroids for more than 4 years and with anti-immune drugs presented to our hospital complaining of back pain and decreased body height due to osteomalacia with failed conservative treatment. Kyphoplasty and vertebroplasty of the thoracic 10-12 and first lumbar vertebrae were done with any complications. Three months later, the patient underwent kyphoplasty and vertebroplasty of lumbar 2-5 vertebrae by injecting Cortoss instead of cement, which was complicated with paravertebral intravascular leakage. We stopped surgery and transferred him to the recovery room, where he had slight chest pain that resolved spontaneously without neurological deficit. Two days later he developed severe chest pain and chest X-ray showed a large white shadow at the right side of the heart and another 2 small shadows just lateral to it. Sudden deterioration of patient status necessitated an emergency echocardiogram, which showed pericardial tamponade and a perforated right ventricle. Aspiration of pericardial blood and emergency open heart surgery were done. He was discharged 4 days later and was followed up at an outpatient clinic. CONCLUSIONS: Cardiac embolism is a serious condition that can complicate vertebral kyphoplasty; it requires a high level of suspicion and immediate action, and may need open heart surgery to save the patient's life.

Comparison if the addition of multilevel vertebral augmentation to conventional therapy will improve the outcome of patients with multiple myeloma.

BACKGROUND: This was a prospective study to evaluate the effect of multilevel vertebral augmentation in addition to conventional therapy in multiple myeloma patients. METHODS: We treated 27 patients, whom were recently diagnosed to have multiple myeloma by two ways of treatment. Thirteen patients (group I) were treated with conventional therapy and 14 patients (group II) with adding vertebroplasty and kyphoplasty. Patients were evaluated pre-treatment and at half, one, two and 3-years post-treatment by using Oswestry Disability Index (ODI), the Stanford Score (SS) and the Spinal Instability Neoplastic Score (SINS). RESULTS: Mean values of ODI, SS and SINS were 31.9 (63.8%), 4.3 and 13.8 for group I and 33.2 (66.4%), 4.6 and 12.8 for group II before starting treatment. Group II showed improvement better than group I at all follow-up intervals with best results at first 6 months. P-values at the end of the study were ODI = 0.047, SS = 0.180 and SINS = 0.002. Mortality rates were equal of both groups (four patients of each group). CONCLUSION: Adding vertebral augmentation to conventional therapy improves multiple myeloma patients' quality of life, but didn't affect the mortality rate.

Analytical comparison study of the clinical and radiological outcome of spine fixation using posterolateral, posterior lumber interbody and transforaminal lumber interbody spinal fixation techniques to treat lumber spine degenerative disc disease.

BACKGROUND: Degenerative disc disease is a common cause of chronic and disabling back pain that requires surgical intervention, posterolateral and posterior instrumental fixation (PLF), posterior lumber interbody fusion (PLIF) and transforaminal lumber interbody fusion (TLIF) are the techniques used to deal with such a problem. OBJECTIVE: To compare the clinical and radiological outcome of the variable surgical techniques used to deal with Lumber degenerative disc disease and to recommend the technique of choice. METHODS: 120 patients were treated between 2003 and 2010 at king Abdullah university hospital for lumber disc disease. The patients were divided into three groups: Group I (PLF n = 30 [59 levels]); Group II (PLIF n = 40 [70 levels]); and Group III (TLIF n = 50 [96 levels]). All patients had the same pre- and postoperative clinical and radiological evaluations (using Stanford score and local criteria and Oswestry Disability Index [ODI],). All cases had three months and then yearly for five years follow ups. RESULTS: There was no observed difference in the rates of intra-operative complications (Group I: 10 %; Group II: 8 %; Group III: 14 %; p = 0.566) and postoperative complications (Group I: 13.3 %, Group II:17.5 %, Group III: 18 % with p = 0.332). Among the groups. There was a vital decrease in the ODI scores over time (p < 0.005) but no major difference among the groups at different follow-up times. Radiographic fusion rates for Groups I, II and III were 90 %, 92.5 % and 94 %, respectively. CONCLUSIONS: The surgical outcome of PLF, PLIF and TLIF used to treat degenerative disc disease is almost similar, there is no significant differences observed in complications and clinical outcomes. However, TILF may have better radiological outcome.

Osteoblastoma is a metabolically active benign bone tumor on 18F-FDG PET imaging.

We describe a case of a 9-y-old girl who on (18)F-FDG PET imaging was found to have a highly metabolically active sacral tumor with an average standarized uptake value of 6.2. The tumor was proven to be osteoblastoma by pathologic examination. Osteoblastoma is a relatively rare benign primary bone tumor and occurs predominantly in patients younger than 20 y. The most common area of involvement is the spine. Osteoblastoma has been reported to be metabolically active on (18)F-FDG PET imaging, with an average standarized uptake value of 3.2, which renders (18)F-FDG PET imaging unable to differentiate benign from malignant primary bone tumors. To our knowledge, only 5 cases of osteoblastoma evaluated by (18)F-FDG PET imaging have been reported in the literature; all were metabolically active on (18)F-FDG PET imaging. The objective of this case report is to show that a metabolically active primary bone tumor on (18)F-FDG PET imaging might be benign and not necessarily malignant.