Occipital condyles congenital dislocation and condylus tertius: an unstable association revealing a new abnormality of the craniocervical junction.

STUDY DESIGN: A case report. OBJECTIVE: To describe a unique craniocervical junction anomaly and its implications both on mobility and stability of the skull base. SUMMARY OF BACKGROUND DATA: Congenital variations in the craniocervical junction (CVJ) are rare and frequently symptomless. Mild traumas may commonly rouse symptoms which help to unveil such anomalies through radiological investigations. METHODS: A 73-year-old woman developed a monoparesis of the right arm after a mild craniofacial trauma. Neurological examination revealed hyper-reflexia in the upper limbs, confirming the strength impairment in the right one. Radiology showed a post-traumatic bulbo-medullary contusion sustained by a unique and unstable association of the first occipital condyles congenital dislocation ever reported with a rare condylus tertius. The patient underwent posterior decompression and occipitocervical screw-rod fixation and fusion. Clinico-radiological follow-up highlighted a gradual recovery of the neurologic impairment and the posterior decompression with resolution of the spinal cord contusion. RESULTS: Although apparently stable the hyperostosis and the irregularly shaped condylar surfaces behind the 3-points mechanism of skull base support played a critical role in determining axial instability. The imbalance due to skull-cervical spine malpositioning may consequently trigger a vicious cycle of development of osteophytes leading to spinal cord narrowing with neurologic decline. A surgical strategy providing for posterior decompression and fixation satisfied the need to solve both bulbo-medullary constriction and skull base instability. CONCLUSION: Clinical evidences about CVJ anomalies are lacking and symptoms, when present, tend to be vague. Although extremely rare clinicians should be aware of CVJ variations by engaging to improve their knowledge of imaging anatomy, embryology, CVJ basic craniometry and anatomic relationships. Studies on developmental control genes may offer future perspectives of early diagnosis and targeted treatments. LEVEL OF EVIDENCE: 4.

Vertebral body compression fracture after percutaneous pedicle screw removal in a young man.

Hazards and potential complications associated with pedicle screw insertions have been reported. In contrast, complications due to implant removal are rarely described. An unreported case of acute vertebral body compression fracture following pedicle screw removal in a young man occurred during an episode of forceful coughing. Spinal implants need to be removed in cases of complications, pain or tissue irritation, and removal is mandatory when fixation involves L2 or the lower segments. Complications associated with spinal implant removal are rare but possible, and patients must be informed of this potential risk.

Two cases of Brown-Séquard syndrome in penetrating spinal cord injuries.

INTRODUCTION: Brown-Séquard syndrome due to a stab injuries is uncommon and results from a lesion in one half of the spinal cord. BACKGROUND: The role of surgery in the treatment of penetrating spinal injury often remain controversial. AIM: To discuss the current diagnostic and therapeutic approach for these types of injuries. MATERIALS AND METHODS: The Authors describe two rare cases of Brown-Séquard syndrome due to civilian stab injuries differently treated. Mechanism of damage, clinical features and neurological outcome are reported. RESULTS: The recovery of neurological function in the first case indicates that the spinal tracts were injured by a contusion, rather than by a direct injury as in the second case. Moreover, surgery was required in the second patient to remove the weapon and to stabilize the spine, presenting bony and ligamentous instability. DISCUSSION: The diagnostic and therapeutic management are debated. An overview on clinical research in sperimental medical treatment of spinal cord injury was considered to evaluate future possible approaches to these injuries. CONCLUSIONS: As the neurologic improvement depends on the type and severity of the spinal cord damage, the indications for acute surgical management are limited and conservative management should be preferred.

The role of surgical treatment in the rehabilitation protocols of thoraco-lumbar spine injuries.

BACKGROUND: Rehabilitation is a crucial issue in the management of spinal cord injuries (SCI) but, in these patients, the primary treatment can bias the outcome of recovery protocols. AIM: Purpose of this paper is to review our case load in the treatment of surgical failures and to define the role of surgery in thoraco-lumbar injuries rehabilitation. PATIENTS AND METHODS: Between 2000 and 2009 seventy patients with post-traumatic paraplegia were referred to Surgical Department as rehabilitation was unfeasible due to inadequate spine injury treatment. Forty-six had had surgery, 24 were treated conservatively Twenty-five patients had a thoracic lesion, 9 a lumbar lesion and 36 a lesion of the thoraco-lumbar junction. A total of 44 surgical procedures were performed (by anterior, posterior or anterior-posterior). RESULTS: On postoperative imaging sagittal alignment was found good in 93% of cases and acceptable in 7%. All patients regained the sitting position within 5 days after surgery. Wound healing problems requiring revision were observed in 4 cases. Major complications were a cerebro spinal fluid (CSF) leakage and a massive pulmonary embolism case in the early post-op. CONCLUSIONS: Wrong primary treatment frequently leads to demanding revision procedures with increased risks for the patient and more than double costs for the health care system. Whatever the technique a stable spine is the target in surgery of SCI allowing a quick and effective rehabilitation without external orthosis.

Aneurysmal bone cyst of the mobile spine: the therapeutic role of embolization.

PURPOSE: Our aim is to define the role of embolization in the treatment of aneurysmal bone cyst of the spine in order to include this option in the decision making process. METHODS: From April 2004 to November 2009, seven patients with primary aneurysmal bone cyst of the mobile spine treated by embolization have been prospectively followed-up. All clinical presentations and imagings were recorded. There are many options of embolic agent and techniques used, but all aim to devascularize the tumor. The therapeutic protocol includes: embolization repeated every 8 weeks until the appearance of radiographic signs of healing. Complications, rate of healing and clinical outcome were analyzed. RESULTS: The number of embolizations varied from one to a maximum of seven without related intra- or post-operative complications. One patient, after four selective arterial embolizations, underwent direct percutaneous injection of embolic agents into the cyst. A clinical and radiographical response was achieved in all patients who were found alive and completely free of disease at mean follow-up of 46 months after last treatment and nobody crossed to surgical option. CONCLUSION: Embolization seems to be the first option for spinal aneurysmal bone cyst treatment because of the best cost-to-benefit ratio. It is indicated in intact aneurysmal bone cyst, when diagnosis is certain, when technically feasible and safe and when no pathologic fracture or neurologic involvements are found. If embolization fails, other options for treatment would still be available.

Posterior lumbar fusion by peek rods in degenerative spine: preliminary report on 30 cases.

PURPOSE: Pre-curved peek rods to support posterior lumbar fusion have been available in the market since 4 years. Potential advantages using this new technology are increased load sharing on the anterior column promoting interbody fusion, reduced stress on bone-screw interface decreasing the rate of screw mobilization and, in the long term, reduced incidence of adjacent level disc degeneration. METHODS: The authors retrospectively reviewed 30 cases in which posterior fusion was supported by peek rods, analyzing early complications, rate of fusion and clinical outcome. RESULTS: At an average follow-up of 18 months, both clinical and radiographic results were satisfactory with only one case requiring surgical revision for a mechanical complication. CONCLUSIONS: The semi-rigid systems can now be considered a viable option in the lumbar degenerative disease, although clinical evaluations are necessary in the longer term.

Minimally invasive percutaneous fixation in the treatment of thoracic and lumbar spine fractures.

We studied 51 patients with 64 fractures of the thoracolumbar and lumbar spine undergoing the surgical treatment by percutaneous trans-pedicular fixation and stabilization with minimally invasive technique. Patient follow-up ranged from 6 to 28 months (mean 14.2 months) and the patients were assessed by clinical and radiographic evaluation. The results show that percutaneous trans-pedicular fixation and stabilization with minimally invasive technique is an adequate and satisfactory procedure to be used in specific type of the thoracolumbar and lumbar spine fractures.

Outcomes of C1 and C2 posterior screw fixation for upper cervical spine fusion.

To achieve stable fixation of the upper cervical spine in posterior fusions, the occiput is often included. With the newer techniques, excluding fixation to the occiput will retain the occiput-cervical motion, while still allowing a stable fixation. Harms's technique has been adapted at our institution and its effectiveness for indications such as C2 complex fractures and tumors using C1 or C2 as endpoints of a posterior fixation are reviewed. Fourteen cases were identified, consisting of one os odontoideum; four acute fractures and four non-unions of the odontoid; three tumors and two complex fractures of C2 vertebral body, and one C2-C3 post-traumatic instability. One misplaced screw without clinical consequences was the only complication recorded. Screw loosening or migration was not observed at follow-up, showing a stable fixation.

[The surgical treatment of renal cell carcinoma metastases to the vertebrae: intra-operative anesthesia related problems]. / Il trattamento chirurgico delle metastasi vertebrali da carcino- ma renale: problematiche anestesiologiche intraoperatorie.

AIMS: Analysis of the intra-operative anesthesia related problems were compared during intra-lesional or extra-lesional surgeries for patients with metastatic renal cell carcinoma to the spine. MATERIALS AND METHODS: We retrospectively collected and analyzed the hemodynamic data on 30 patients who had undergone surgical intervention. Twenty patients had an intra-lesional excision of the metastatic lesion in the vertebra, whereas for the rest, an en-bloc wide or marginal margin resection was carried out. RESULTS: The surgical time for the en-bloc resections was much longer, and thus also the exposure to the anesthesia, but lesser variability within the data on blood pressure and pulse as compared with intra-lesional curettage. There was also more blood loss with the intra-lesional surgeries. CONCLUSIONS: En-bloc resections of the vertebral tumors not only give better oncological local control, but also have less compromising effects on the patient, especially with respect to the intra-operative hemodynamics. In selected cases, en-bloc resections present a good option of treatment in vertebral metastases, and especially in highly vascular tumors such as the renal cell carcinoma metastases.

Solitary plasmacytoma of the spine: a 22 years follow-up case report.

BACKGROUND AND OBJECTIVES: Plasmacytoma is a systemic malignancy and it is the most frequent primary tumor affecting the skeleton. Progression from solitary plasmacytoma to systemic diffusion is reported to be 65-100% in 15 years. A case report of a rare 22-year follow-up of a thoracic solitary plasmacytoma is here presented. MATERIAL AND METHODS: Clinical case analysis, radiographs, magnetic resonance images and histological sections of the lesion are discussed. Repeated surgical interventions were required due to progression and local recurrence of disease. RESULTS: Although the inadequate surgical treatment, low response to chemotherapy and radiation therapy, and many local recurrences, no systemic diffusion of the disease was observed in 22 years. DISCUSSION: Aggressive surgery may be indicated in young patients with isolated lesion and good prognostic factors. Palliative surgery remains necessary in order to decompress the cord and to stabilize the spine.

Acute paraplegia by epidural abscess: full neurological recovery following surgical decompression.

Authors report a case of acute paraplegia due to an epidural spinal abscess caused by a heroin injection that happened four months before. A complete neurological recovery is obtained by surgical decompression and antibiotic therapy despite the preoperative neurological status. The need for a surgical stabilization following extensive laminectomy is discussed.

Giant cell tumor of the upper cervical spine: transmandibular-translingual access. Clinical case.

The authors describe the clinical case of a patient aged 18 years affected with giant cell tumor (GCT) at C3 who came to the surgical unit of Orthopaedics and Traumatology at the Ospedale Maggiore in Bologna after being treated by surgery elsewhere. Particular attention is paid to surgical access by means of median transmandibuloglossotomy used in order to obtain a sufficiently wide surgical field that can adequately expose the vertebral segment affected by neoplastic disease. In particular, possible complications that may be observed postsurgery can be compared to other surgical approaches to the upper cervical spine and above all that there are no permanent clinical sequelae.

Fractures and dislocations of the lower cervical spine: surgical treatment. A review of 83 cases.

The authors examine 83 consecutive cases of fracture and dislocation of the lower cervical spine submitted to surgery over a period of 5 years. Sixty-five patients were monitored with minimum 5-months follow-up, 5 died, 13 could not be traced. Lesions were classified based on the method proposed by Argenson3 with the purpose of identifying guidelines for surgical treatment. Thus, different methods are proposed based on the type of lesion and on any neurologic deficit. Intersomatic fusion with anterior approach is the method of choice in most lesions. The exception to this is monoarticular dislocations that cannot be reduced, so that reduction by posterior approach associated with discectomy and anterior fusion are recommended. Circumferential fusion is proposed for traumatic spondylolistheses, complete dislocations with unsatisfactory anterior reduction, in lesions in flexion-extension and rotation associated with complete spinal cord injury, in order to favor functional rehabilitation free from ortheses. The need to review many cases of traumatic lesions of the lower cervical spine (LCS) collected over a relatively short period of time derives from the need to identify guidelines that will help the surgeon in his or her choice of the type of surgery to perform on the patient with emergency injury. The basic premise, as for other sites of traumatic injury, resides in an efficient classification (corresponding to the anatomic injury and of immediate and intuitive application) to which options for treatment may be related. In particular, an evaluation of the type of approach (anterior, posterior, combined) and of the sequence of surgical stages is essential to obtaining effective results with an acceptable complication rate. Finally, treatment must be definitive, and in cases of severe spinal cord injury it must allow for rapid rehabilitation and freedom from the use of ortheses.

Symptomatic vertebral hemangioma: the treatment of 23 cases and a review of the literature.

It is the purpose of this study to analyze a group of 23 patients affected with hemangioma in one or more metameres of the vertebral column. On the basis of clinical examination and instrumental testing in time (minimum follow-up 12 months, maximum 217 months) the following treatment options are discussed: medical treatment and clinical monitoring closer in time; palliative surgical treatment whether or not associated with embolization of vascular afferences of the lesion and adjuvant treatment; intralesional surgical treatment whether or not associated with embolization of the vascular afferences of the lesion and adjuvant treatment. Skeletal hemangioma is a hamartomatous proliferation of vascular tissue, more precisely of endothelial tissue. This is demonstrated by its anatomical identity with other tissues and the existence of exceptional skeletal and multiple tissue hemangiomatosis that begin during childhood. Hemangioma is the benign tumor that is most frequently localized in the spine, involving about 10% of the world population, as reported in the literature on autoptic studies. It is often a solitary lesion, usually localized in the vertebral body, although it may extend to the posterior arch. There is predilection for the thoracic region of the spine, while it less frequently occurs in the cervical and lumbar spines. Generally, it remains asymptomatic throughout the entire life of the subject, so much so that it is often difficult to establish the onset of the lesion. Symptomatic hemangiomas (less than 1% of all hemangiomas) are those that are accidentally discovered via radiograms; they are most often observed during adult age. The most common treatment used for vertebral hemangioma associated with pain is radiotherapy, even if clinical observation represents a reasonable choice. Surgical treatment, preceded when possible by embolization of the vascular afferences of the lesion, is often associated with radiation therapy in cases where there is neurologic compression in addition to pain. It was the purpose of this study to analyze the long-term results obtained in a group of 23 patients affected with symptomatic vertebral hemangioma.

Reconstruction of the anterior column of the thoracic and lumbar spine with a carbon fiber stackable cage system.

A carbon fiber stackable cage system is presented to promote the reconstruction of the anterior column after vertebrectomy or corpectomy in tumor and trauma surgery. Modularity, immediate stability, early fusion of the graft, radiolucency, and no risk of disease transmission are the main advantages of this system.

Osteoid osteoma of L4: excision by videoendoscopy.

It is the purpose of this study to demonstrate how in the surgical treatment of vertebral osteoid osteoma a video-aided mini-invasive method may be used as an alternative to modern percutaneous X-ray-CT-guided mini-invasive methods such as radiocoagulation, interstitial photocoagulation with laser injection. Reported here is the case of a female aged 13 years where instrumental testing showed the presence of an osteoid osteoma involving the internal surface of the lamina of L3 and spreading in the lumen of the vertebral canal. Once we established that it was impossible to carry out the aforementioned mini-invasive percutaneous treatment because of the closeness of the osteoid osteoma to the nervous structures, thus risking complications, the only procedure that could guarantee complete removal of the tumor was open aminarthrectomy. But to reduce surgical aggressiveness to a minimum, we decided to proceed by means of a video-aided mini-invasive method with the purpose of limiting hospitalization and recovery time in order to obtain economically favorable results.

Aneurysmal bone cyst of the mobile spine: report on 41 cases.

STUDY DESIGN: Forty-one cases of aneurysmal bone cyst of the mobile spine were retrospectively reviewed. OBJECTIVES: To evaluate the role of surgical and nonsurgical treatment of aneurysmal bone cyst of the spine. SUMMARY OF BACKGROUND DATA: Ten to 30% of aneurysmal bone cysts arise from the mobile spine, frequently occurring in pediatric patients. The course of the disease depends on the aggressiveness of the tumor, as well as the treatment. Intralesional surgery seems to be an effective treatment, as well as radiotherapy and embolization. METHODS: All charts, radiographs, and images were reviewed. The composite information provided by this review allowed for oncologic and surgical staging of these cases. Thirty-two patients underwent curettage (14 of them followed by radiotherapy), four were submitted to selective arterial embolization, three received radiotherapy alone, and two underwent en bloc-excision. RESULTS: All patients were found alive and disease free at final follow-up evaluation. Two recurrences followed one incomplete curettage and one embolization. The combination of curettage and radiotherapy, although effective, showed the greatest incidence of late axial deformity. Selective arterial embolization was curative in three of four cases and did not affect the possibility of surgery in case of local recurrence. CONCLUSIONS: If confirmed on larger series, selective arterial embolization seems to be the first treatment option for spine aneurysmal bone cyst, because of the low cost-to-benefit ratio. Diagnosis must be certain, based on pathognomonic radiographic pattern or on histologic study.- In case of neurologic involvement, pathologic fracture, technical impossibility of performing embolization, or local recurrence after at least two embolization procedures, complete intralesional excision would be the therapy of choice.

Chondrosarcoma of the mobile spine: report on 22 cases.

STUDY DESIGN: A retrospective review of 22 cases of chondrosarcoma arising from the mobile spine. OBJECTIVE: To evaluate the role of oncologic and surgical staging in correlating management and outcome of chondrosarcoma involving the spine. SUMMARY OF BACKGROUND DATA: Approximately 10% of chondrosarcomas arise from the mobile spine, occurring mainly in adults, particularly elderly men. The course of the disease depends on the aggressiveness of the tumor, but also is influenced by the management. Intralesional surgery is followed almost constantly by local recurrence even with adjuvant therapy. METHODS: All charts, radiographs, and images were reviewed. The composite information provided by this review allowed for oncologic and surgical staging of the reviewed cases. According to Enneking criteria, the surgical procedures were defined as curettage (piecemeal excision) or en blocexcision. The margins were submitted to histologic study and reported as intralesional, marginal, or wide. - As primary management, 10 intralesional curettages (follow-up period, 2-119 months; average, 61 months) and 12 en bloc excisions (follow-up period, 39-207 months; average, 97 months) were performed. A total of 33 procedures were performed, including the management of the recurrences (18 curettages and 15 en bloc excisions: one for soft tissue recurrence). A clinical and radiographic follow-up period of of 2 to 236 months (average, 81 months; minimal follow-up period for survivors, 30 months; average follow-up period for survivors, 115 months) was available for all the patients. RESULTS: Three recurrences occurred in 14 patients treated by en bloc excision at onset or for recurrence, two in cases of histologically proven contaminated or intralesional margins. All but one patient were alive at final follow-up evaluation. Conversely, all the patients treated by one or more curettages (with or without adjuvant radiation therapy) had at least one recurrence, and 8 of 10 of these patients died of the disease. At final follow-up evaluation, nine patients had died of the disease; nine were continuously disease free (but one had died of another unrelated malignancy); and four were symptom free after management for recurrences (one was found alive 155 months after a soft-tissue metastasis en-bloc excision). CONCLUSIONS: En bloc excision, with wide or marginal histologic margins, is the suggested management for chondrosarcomas of the spine. Early diagnosis and careful surgical staging and planning are necessary for conducting adequate management. However, tumor contamination of the specimen margins, even in a small area, or spreading of the tumor myxoid content can worsen the prognosis.

The treatment of thoracic and lumbar spine fractures: a study of 123 cases treated surgically in 101 patients.

For a total of 123 thoracolumbar traumatic lesions treated surgically in 101 patients over approximately 2 years (all monitored clinically and radiographically up to consolidation by follow-ups after from 6 to 26 months, mean 10 months) the technique used, complications and treatment are reported. The treatment procedure included: emergency surgery decompression, osteosynthesis, and fusion (posterior and possibly intersomatic); immediate recovery of function and loading; clinical and radiographic monitoring within 4-6 weeks, and possible anterior fusion in case of insufficient reconstruction of the anterior column. The complications observed out of 123 fractures were: collapse of the implant (4 cases), infection (5 cases), liquoral fistula (1 case), transitory paralysis of the abdominal muscles homolateral to the lombotomic incision (1 case), TVP (2 cases), bronchial pneumonia (2 cases), paralytic ileum (1 case). There was no sagittal deformity (secondary kyphosis) except for 5 cases of mechanical collapse that were resolved with a new operation. Neurologic deficit was caused by fracture in 49 patients (40% of the fractures or 48% of the patients). Six patients out of 30 affected with spinal cord lesion (20%) and 15 out of 19 affected with cone and/or cauda lesion (79%) improved. There was no progression of the neurologic findings after surgery. The authors conclude by proposing a protocol of posterior osteosynthesis for the use of a system in titanium made up of pedicle screws and hooks connected to a pair of cylindrical bars joined together.

The use of the carbon-fiber reinforced modular implant for the reconstruction of the anterior column of the spine. A clinical and experimental study conducted on 42 cases.

The conservative treatment of neoplasms of the locomotor apparatus means the production of bone defects that may be filled with prostheses, bone grafts, systems of osteosynthesis. In the vertebral column, reconstruction of the resected elements--in the case of total vertebrectomy--requires the combination of anterior and posterior implants. It is the purpose of this study to analyze a group of 42 patients who, after accurate and uniform oncological (Enneking) and surgical (Weinstein-Boriani-Biagini) staging, were submitted to excision of one or more vertebral bodies for the treatment of neoplastic pathology, with reconstruction by prosthetic carbon fiber modular implant in order to obtain immediate stability, and to stimulate solid intervertebral fusion by bone grafts introduced inside the prosthesis. Thirty of the 42 patients presented with primary malignant tumor, 3 with benign tumor, 6 with solitary metastases, and 3 with plasmacytoma. In 32 cases, en bloc resection of the vertebral body was carried out (vertebrectomy) with combined anterior and posterior access in 29 patients (69.0%), and by posterior approach alone in 3 cases (7.1%). Ten intralesional corporectomies were carried out, 8 by anterior approach, 2 by posterior approach. The carbon prosthesis was filled with cortical and cancellous bone grafts in 38 cases. At a mean clinical and instrumental follow-up obtained 26 months after surgery for all of the patients, the use of a carbon prosthesis did not cause short- or long-term mechanical complications. The results of our study tend to affirm that the use of a carbon fiber modular implant may fill any loss of bone substance of the vertebral column, that it allows for immediate weight-bearing, and that if favors bone fusion. Some particular features of the carbon prosthesis favorably adapt to the surgical method of vertebrectomy: 1. The various components of the prosthesis may adapt to any type of bone resection of the vertebral body, even in unexpected situations; 2. Connection to posterior instrumentation in total vertebrectomies avoids the use of an anterior plate, thus reducing the time required for reconstruction of the anterior column, eliminating necessary surgical procedures in the segmental vascular structures. Finally, the radiolucency of the prosthesis allows for an easy evaluation of the formation of bone within and around the implant up to definitive anterior fusion and, of no less importance, early diagnosis of any local recurrence.