Effect of Different Anesthesia and Puncture Methods of Percutaneous Kyphoplasty on More Than 90-Year-Old Osteoporotic Vertebral Fracture: Advantages of the ERAS Concept.

Background: Percutaneous kyphoplasty (PKP) is an effective minimally invasive technique for the treatment of osteoporotic vertebral fracture (OVF) in recent years. This study focuses on the analysis of PKP surgery and anesthesia in osteoporotic vertebral facture patients over 90 years old with the concept of "enhanced recovery after surgery." Methods: This study reviewed 239 patients who were diagnosed with OVF retrospectively between October 2015 and June 2019. According to the method of anesthesia, these patients were divided into Group A (n = 125) and Group B (n = 114). According to the pedicle puncture approach, these patients were divided into Group C (n = 102) and Group D (n = 137). The anterior vertebral height (AVH) and local kyphosis angle (LKA) were used to evaluate the degree of vertebral damage and restoration. The visual analogue scale (VAS) and the Oswestry Disability Index (ODI) scores were used for assessing functional outcomes. Some parameters were used to assess the perioperative conditions such as operation time, amount of bone cement perfusion, intraoperative fluoroscopy times, anesthesia recovery time, time out of the bed, hospital stay, hospitalization cost, and complications. Results: The visual analogue scale (VAS), Oswestry Disability Index (ODI), anterior vertebral height (AVH), and local kyphosis angle (LKA) 1 day, 1 year after surgery, and at the last follow-up all showed significant improvement (P < 0.05) in comparison with those before surgery both in Groups A and B and Groups C and D. The ODI 1 day after surgery was significantly better in Group B than Group A (P < 0.05). Compared with Group B, Group A required longer time of anesthesia, operation time, anesthesia recovery time, time to get out of bed, and length of hospital stay and more hospitalization costs (P < 0.05). Group D required longer operation time, longer time to get out of bed, more bone cement volume, fluoroscopy time, and more operation hospitalization costs compared with Group C (P < 0.05). Conclusion: We recommend unilateral puncture under local anesthesia for OVF in the patients aged over 90 from the perspective of rapid recovery.

Occipitocervical Fusion via Cervical Pedicle Fixation Assisted with O-arm Navigation.

OBJECTIVE: To describe the clinical outcomes of occipitocervical fusion (OCF) using cervical pedicle fixation with assistance of O-arm navigation and present its clinical feasibility. METHODS: From January 2015 to December 2016, eight patients with a variety of diagnoses were surgically treated with occipitocervical fusion using cervical pedicle screws under O-arm navigation. All patients received full workup consisting of clinical and radiological assessments. Perioperative parameters including operating time, intraoperative blood loss, postoperative complications, surgical outcomes were recorded. Postoperative data were acquired resorting to the scheduled follow-up 3, 6 and 12 months after their discharge and annually afterwards. The Japanese Orthopaedic Association (JOA) Scores and American Spinal Injury Association (ASIA) Scale were used to evaluate neurological function. The accuracy of screw placement was classified according to a modified classification of Gertzbein and Robbins. The fusion status was evaluated in reference to the Bridwell's posterior fusion grades. RESULTS: The patient cohort comprised of five males and three females, with the average age of 51.9 years (range from 18 to 74 years). The patients all showed indications for OCF and were performed with polyaxial screws through cervical pedicles. The average operation time was 274 min (range from 226 to 380 min), with the intraoperative blood loss of 437.5 mL and the blood transfusion volume of 481.3 mL. The average follow-up time was 23.5 months (range from 17 to 32 months). All patients exhibited radiographic evidence of osseous fusion by X-ray and computed tomography (CT) at the final follow-up. No neurovascular complications were found during the follow-up time, and the clinical symptoms were observed to be significantly improved in all the patients. Thirty-four cervical pedicle screws were implanted within the eight patients, with the accuracy of cervical pedicle screw placements as 94.1% (32/34), among which, two pedicle screws were found to broken through the cervical pedicles that were evaluated as Grade II. CONCLUSIONS: Occipitocervical fusion via cervical pedicle fixation assisted with O-arm navigation is a feasible and safe procedure with a vast range of indications.

Minimally Invasive Pedicle Screw Fixation Combined with Percutaneous Kyphoplasty Under O-Arm Navigation for the Treatment of Metastatic Spinal Tumors with Posterior Wall Destruction.

OBJECTIVE: To evaluate the safety and efficacy of O-arm-guided minimally invasive pedicle screw fixation combined with percutaneous kyphoplasty for metastatic spinal tumors with posterior wall destruction. METHODS: Patients who underwent minimally invasive pedicle screw fixation combined with percutaneous kyphoplasty for pathological vertebral fractures with posterior wall defects from January 2015 to December 2017 were followed up for 1 year. Visual analogue scale (VAS), SF-36 scores, middle vertebral height, posterior vertebral height, and the accuracy of pedicle screws were assessed preoperatively, postoperatively, and 1 year after surgery. The operation time, time from operation to discharge, blood loss, volume of bone cement, and leakage of bone cement were recorded. RESULTS: Twenty-three patients (13 females and 10 males) who met our criteria were followed up for 1 year. The operation time of these patients was 162.61 ± 33.47 min, the amount of bleeding was 230.87 ± 93.76 mL, the time from operation to discharge was 4.35 ± 2.42 days, and the volume of bone cement was 3.67 ± 0.63 mL. The VAS score decreased from 7.04 ± 1.07 to 2.65 ± 0.93 before surgery (P = 0.000) and remained at 2.57 ± 0.79 1 year after surgery. Compared with the preoperative SF-36 scores for physical pain, physiological function, energy, and social function, the postoperative scores were significantly improved (P = 0.000). The height of the middle vertebral body increased from 14.47 ± 2.96 mm before surgery to 20.18 ± 2.94 mm (P = 0.000), and remained at 20.44 to 3.01 mm 1 year after surgery. The height of the posterior vertebral body increased from 16.56 ± 3.07 mm before operation to 22.79 ± 4.00 mm (P = 0.000), and 22.45 ± 3.88 mm 1 year after surgery. The 23 patients had a total of 92 pedicle screws; 85 screws were Grade A and 7 screws were Grade B. There was no leakage of bone cement after surgery. CONCLUSION: In the short term, O-arm-guided minimally invasive pedicle screw fixation combined with kyphoplasty is safe and effective in the treatment of metastatic spinal tumors with posterior wall destruction.

High expression of survivin in sacral chordoma.

Chordoma is a rare and invasive malignant tumor which primarily relies on surgical treatments. Anticipation of its recurrence and patient survival longevity has been a critical issue of the treatments. This retrospective study examined the survivin expression of sacral chordoma in 30 patients undergoing surgery in our hospital from January 2000 to July 2010, and compared it with chordoma recurrence. Survivin expression was 70 % positive in 30 patients. The positive expression of survivin with recurrence was significantly higher than that without recurrence (p = 0.017) and was inversely related to the continuous disease-free survival time (p < 0.001). Survivin expression was associated with recurrence. The correlation suggested that the survivin expression could be used as an independent predictor of recurrence and could be a potential bio-target gene of angiogenesis in sacral chordoma.

Value of bone scan imaging in determining painful vertebrae of osteoporotic vertebral compression fractures patients with contraindications to MRI.

OBJECTIVE: To assess the value of bone scan imaging in determining painful vertebrae of osteoporotic vertebral compression fractures (OVCFs) patients with contraindications to MRI. METHODS: Twenty-three OVCFs patients with contraindications to MRI, diagnosed and treated in our hospital between December 2007 and November 2010, were enrolled in this retrospective study. There were 18 females and five males, aged from 57 to 87 years, with a mean age of 69.5 years. All patients underwent X-ray, CT scans examinations and bone scan to determine painful vertebrae. After the painful vertebra was defined, percutaneous kyphoplasty (PKP) was performed. Efficacy of PKP was assessed with visual analog (VAS) pain scale and the Oswestry Disability Index (ODI) preoperatively, postoperatively and during final follow-up assessments. RESULTS: The painful vertebrae shown on radiological films did not accord with those found based on bone scan imaging, with a high rate of incongruent findings (27.3%, 9/33). Radiological films showed 33 vertebrae with fractures, but only 26 vertebrae (22 patients) were selected as painful vertebrae for PKP based on bone scan imaging. There were statistically significant differences in mean VAS and ODI between the preoperative and the postoperative assessments; no significant differences were observed between postoperative and final follow-up assessments. CONCLUSIONS: For the OVCFs patients with contraindications to MRI, bone scan imaging could be used to determine painful vertebrae, which is an effective method.

Expression of vascular endothelial growth factor and matrix metalloproteinase-9 in sacral chordoma.

Sacral chordoma is a vessel-rich and infiltrative tumor, but the fundamental knowledge of its biological behavior remains unknown. This study was designed to investigate the expression levels and contributions of vascular endothelial growth factor (VEGF) and matrix metalloproteinase-9 (MMP-9) in the angiogenesis and recurrence of sacral chordoma and their correlations. An immunohistochemical method was used to investigate the expression of VEGF, MMP-9, and microvascular density (MVD) in 36 patients with sacral chordoma. Their differences in expressions were statistically analyzed and their correlations with angiogenesis and recurrence were evaluated. The mean MVD of sacral chordomas was significantly higher than that of the adjacent normal tissues (P = 0.033). Immunoreactivity for VEGF and MMP-9 was significantly higher in sacral chordoma tissues than in adjacent normal tissues (P = 0.008, P = 0.005). The mean MVD of VEGF and MMP-9 were statistically higher in positive group than in negative group (P = 0.015, P = 0.004), respectively . Moreover, a significant correlation was found between the VEGF and MMP-9 (P = 0.002). The log-rank test revealed that continuous disease-free survival time (CDFS) was significantly shorter in the MMP-9-positive group than in the MMP-9-negative group (P = 0.019), but the difference in the VEGF-positive group and the VEGF-negative group was not statistically significant (P = 0.938). Our data suggest that VEGF and MMP-9 might act with a synergistic effect and can positively regulate the angiogenesis in sacral chordoma. Positive expression of MMP-9 might indicate the local recurrence of sacral chordoma. The result suggests that some specific drugs which inhibit VEGF, MMP-9, or their receptors may have a good therapeutic effect for sacral chordoma.

Risk factors for postoperative wound infections of sacral chordoma after surgical excision.

STUDY DESIGN: A retrospective study, analyzing the risk factors for postoperative wound infections of the sacral chordoma after surgical excision. OBJECTIVE: To determine the preoperative, intraoperative, and patient characteristics that contribute to an increased risk of postoperative wound infection in patients undergoing sacral chordoma resection. SUMMARY OF BACKGROUND DATA: Postoperative wound infection after spinal operations is a dreaded complication. The risk factors have been investigated earlier, but the patients with sacral chordoma may be distinct. METHODS: Between January 1992 and December 2007, 45 patients with sacral chordomas were treated with surgical resection. Data regarding preoperative and intraoperative risk factors for postoperative wound infection were evaluated using univariate analysis and multivariable conditional logistic regression. Odds ratios with 95% confidence intervals and P values were calculated. RESULTS: Of the 45 patients with sacral chordoma, 16 (35.6%) acquired postoperative wound infection. Significant risk factors associated with postoperative wound infection in the univariate analysis included the following: albumin <3.0, previous surgery, operating time, instrumentation, and surgical team. Albumin<3.0, operating time >6 hours, and previous surgery were statistically significant in the multivariable model. CONCLUSIONS: Patients undergoing sacral tumor surgery may be at greater risk for developing wound complications. In this study, it seems that albumin<3.0, operating time >6 hours, and previous surgery may predict those patients that were more prone to developing postoperative wound infection. Using a single surgical team and no instrumentation seems to provide protection against postoperative wound infection in this patient population.

[Balloon kyphoplasty for osteoporotic vertebral compression fractures with osteonecrosis].

OBJECTIVE: To explore the clinical efficacy of the percutaneous balloon kyphoplasty for osteoporotic vertebral compression fractures with osteonecrosis. METHODS: The clinical data of 31 patients with osteoporotic vertebral compression fractures associated with osteonecrosis from January 2005 to January 2008 were analyzed retrospectively. There were 13 male and 18 female in this study. The mean age of the patients was 71 years (range from 57 to 84 years). The back pain lasted for 4.2 months (from 1 month to 10 years). Radiography, MRI and CT examination were performed. The patients were treated by percutaneous balloon kyphoplasty and the vertebral body tissue was extracted to perform common pathological examination. The anterior vertebral height was measured on a standing lateral radiograph before operation, after operation (one day after operation) and at the final follow-up. A Visual Analog Scale (VAS) and the Oswestry Disability Index (ODI) were chosen to evaluate pain status and functional activity. RESULTS: The mean follow-up was for 27 months (range, 18 to 48 months). The anterior vertebral body height of fracture vertebra was restored from (34.7 +/- 3.1)% preoperatively to (71.4 +/- 2.3)% postoperatively, and to (70.2 +/- 2.5)% at the final follow-up. There was a significant improvement between preoperative and postoperative values (P < 0.05) and no difference between postoperatively and at the final follow-up (P > 0.05). The VAS was 8.7 +/- 0.4 preoperatively, 2.3 +/- 0.7 postoperatively, and 1.9 +/- 0.2 at the final follow-up; and the ODI was 89.1 +/- 2.7 preoperatively, 31.7 +/- 3.1 postoperatively, and 29.1 +/- 2.7 at the final follow-up. There was statistically significant increment in the VAS and ODI postoperatively compared with preoperatively (P < 0.05), while there was no statistically significant differences between postoperatively and at the final follow-up (P > 0.05). There was a significant increment between preoperative and final follow-up values (P < 0.05). Asymptomatic cement leakage occurred in two cases. New vertebral fracture occurred in one case. CONCLUSION: Balloon kyphoplasty is a safe and effective procedure for osteoporotic vertebral compression fractures with osteonecrosis.

Pre-operative transarterial embolization for treatment of primary sacral tumors.

Pre-operative embolization of hypervascular spinal tumors can be helpful in tumour resection; however, few studies have been reported on its effectiveness in sacral tumors. We aimed to investigate the value of surgical excision with pre-operative transarterial embolization for primary sacral tumors and evaluate the long-term follow-up outcomes. Data were obtained from a consecutive series of 60 patients (33 female, 27 male) who had sacral tumors and who, between 1992 and 2007, underwent surgical excision in conjunction with arterial embolization. The evaluation parameters included intraoperative blood loss, transfusion, treatment, local recurrence and complications associated with surgery. All tumor masses were resected without intraoperative shock or death. The mean intraoperative blood loss was 1168.3mL (range: 200-5700mL) and the mean transfusion amount was 5.2 units (range: 0-35 units). Radical wide excision was performed on eight patients, marginal excision was conducted for 34 patients and intralesional excision was undertaken for the remaining 18 patients. The mean follow-up period was 75.2months (range: 15-180months). Nineteen (31.7%) patients developed local recurrences. Of the patients who had at least the second sacral roots and the unilateral S3 preserved, 33 (84.6%) had normal bladder function and 34 (87.2%) had normal bowel control. Pre-operative arterial embolization may significantly reduce the likelihood of intraoperative hemorrhage, and has the potential to assist surgeons in completing tumor resection and improving the outcomes for these patients.

Use of an integrated anterior cervical plate and cage device (PCB) in cervical anterior fusion.

The aim of this study is to evaluate an integrated cage and plate device (the plate cage Benezech, PCB) filled with autogenous bone in anterior cervical discectomy and fusion. The fused segment height, lordosis, and fusion were assessed by postoperative radiographic examination at different intervals. Patients were evaluated using Odom's criteria and the Short Form (SF)-36 Health Survey questionnaire. The mean follow-up duration was 4.1 years. Fusion was achieved in 90.0%, 96.0% and 100% of patients at 3 months, 6 months and at final visit, respectively. The fused segment height and lordosis were restored and maintained. Cage subsidence (3mm) occurred at one level and settling was observed at three levels. An excellent-to-good result was achieved in 81.8% of patients. The data from the SF-36 questionnaire revealed significant postoperative improvement (p<0.01) except for social function and mental health. This study suggests that patients instrumented with PCB can obtain good radiographic and clinical results and that PCB is a safe and effective device in cervical anterior fusion.

Review of current treatment of sacral chordoma.

Chordoma is a relatively rare, locally aggressive tumor which is known to arise from embryonic remnants of the notochord and to occur exclusively along the spinal axis, with a predilection for the sacrum. Although chordoma typically presents as a single lesion, a few cases of metastasis have been reported and the prognosis of such patients may be poor. Chordomas are slowly growing tumors with insidious onset of symptoms, making early diagnosis difficult. Recent improvements in imaging have provided valuable information for early diagnosis. The optimal treatment for sacral chordoma is en bloc sacral resection with wide surgical margins. Improvement in surgical techniques has widened the opportunities to provide effective treatment. However, the effects of adjuvant treatment options are still both unclear and controversial. Substantial progress has been made in the study of molecular-targeted therapy. The authors review the current surgical and adjuvant treatment modalities, including molecular-targeted therapy, available for management of sacral chordoma.