Spinal cord ischemia after endovascular embolization of a type II endoleak following endovascular aneurysm repair.

BACKGROUND: We report a rare case of severe spinal cord ischemia with neurological consequences in a patient who presented after endovascular treatment of a type II endoleak following endovascular aneurysm repair. METHODS AND RESULTS: An enlarging abdominal aortic aneurysm post-endovascular aneurysm repair was detected owing to a persistent type II endoleak caused by a communication between the iliolumbar and L4 lumbar artery for which the patient underwent supraselective embolization with particles and coils. Immediately after the procedure, the patient experienced an acute onset of neurological symptoms in the right lower limb while limb arterial perfusion remained unaffected. Magnetic resonance imaging-magnetic resonance angiography revealed an acute ischemic process at the L2-L4 level. Further follow-up revealed persistence of the endoleak, and the patient was referred to our institution for open surgical treatment. CONCLUSIONS: To the best of our knowledge, this is the first report of severe spinal cord ischemia after transcatheter embolization of the feeding iliolumbar branches of a type II endoleak. Care must be taken during embolization of the feeding artery of type II endoleaks, which may also supply the spinal cord, to minimize the risk of possible spinal cord ischemia.

Bacterial wound contamination during simple and complex spinal procedures. A prospective clinical study.

BACKGROUND CONTEXT: Spinal procedures have a potential of intraoperative contamination. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) have been used to diagnose postoperative infections after spinal surgery. However, it has not been demonstrated if there is an association between surgical site contamination and clinical manifestation of postoperative infection based on inflammatory markers and patients' clinical course. PURPOSE: The purpose of this prospective study was to evaluate the association between surgical site contamination and the development of a postoperative infection in simple and complex surgical procedures. C-reactive protein and ESR levels were observed. The correlation between their values, surgical time, type of surgical procedures, and contaminated surgical sites was investigated. STUDY DESIGN: Prospective clinical study. PATIENT SAMPLE: The study consisted of 40 patients divided into two groups. Group A included 20 patients (mean age, 46.2 years; 12 women and 8 men) who underwent an open discectomy for a lumbar herniated disc. Group B consisted of 20 patients (mean age, 67.9 years; 11 women and 9 men) who underwent a decompression and instrumented fusion for lumbar spinal stenosis. They were followed up for an average of 26.7 months (range, 11-40 months). OUTCOME MEASURES: Samples were obtained for cultures in standard time intervals during surgery. The types of bacteria cultured were evaluated, and CRP and ESR levels were measured. METHODS: Simple lumbar discectomy (Group A, 20 patients) and instrumented lumbar decompression for degenerative lumbar stenosis (Group B, 20 patients) were performed in a prospective consecutive series of patients. All patients were operated by the same surgeon in the same operating room. Surgical site preparation in each patient was done by a standard manner. Samples were obtained for cultures in standard time intervals during surgery. C-reactive protein and ESR levels were measured preoperatively on the 3rd, 7th, and 21st postoperative days, and the clinical course of each patient was recorded. RESULTS: From 40 patients, three patients in Group A and five patients in Group B, a total of eight patients (20%) had positive cultures for bacteria. There was no statistical significance between contamination and duration of surgery in both groups. None of the patients with positive intraoperative cultures developed any clinical signs of superficial or deep postoperative spinal infection, and no additional antibiotic treatment was administered. Three patients with negative cultures developed a postoperative infection. There were no differences in CRP and ESR values between patients with contamination and noncontamination in both groups. C-reactive protein and ESR levels were significantly elevated in complex procedures (Group B) than in simple procedures (Group A). Statistical analysis of CRP and ESR values in both groups and types of bacteria cultured intraoperatively are presented. CONCLUSIONS: The results of this study demonstrate that intraoperative contamination can occur during simple and complex spinal procedures. In the absence of postoperative signs of infection in patients with intraoperative contamination, there is no need of continuing antibiotic treatment. Postoperative kinetics of CRP and ESR showed to be the same in patients with and without intraoperative contamination. Higher levels of inflammatory markers were noted in complex spinal procedures where instrumentation was applied.

Case report: subarachnoid anesthesia for kyphoplasty: is anesthesia adequate?

We performed a prospective pilot study of subarachnoid anesthesia for kyphoplasty in 11 nonrandomized patients. Subarachnoid anesthesia was administered at the level of the best palpable intervertebral space below L3. Patients received intrathecally either hyperbaric or plain bupivacaine with or without fentanyl. Five patients experienced pain during the surgical procedure and received supplemental IV analgesia. One patient felt pain from the pressure on the ribs while in the prone position. The remaining patients were comfortable. In no patient was respiratory compromise or deep sedation observed. We conclude that subarachnoid anesthesia may be an adequate technique for kyphoplasty.

Comparison of migration behavior between single and dual lag screw implants for intertrochanteric fracture fixation.

BACKGROUND: Lag screw cut-out failure following fixation of unstable intertrochanteric fractures in osteoporotic bone remains an unsolved challenge. This study tested if resistance to cut-out failure can be improved by using a dual lag screw implant in place of a single lag screw implant. Migration behavior and cut-out resistance of a single and a dual lag screw implant were comparatively evaluated in surrogate specimens using an established laboratory model of hip screw cut-out failure. METHODS: Five dual lag screw implants (Endovis, Citieffe) and five single lag screw implants (DHS, Synthes) were tested in the Hip Implant Performance Simulator (HIPS) of the Legacy Biomechanics Laboratory. This model simulated osteoporotic bone, an unstable fracture, and biaxial rocking motion representative of hip loading during normal gait. All constructs were loaded up to 20,000 cycles of 1.45 kN peak magnitude under biaxial rocking motion. The migration kinematics was continuously monitored with 6-degrees of freedom motion tracking system and the number of cycles to implant cut-out was recorded. RESULTS: The dual lag screw implant exhibited significantly less migration and sustained more loading cycles in comparison to the DHS single lag screw. All DHS constructs failed before 20,000 cycles, on average at 6,638 +/- 2,837 cycles either by cut-out or permanent screw bending. At failure, DHS constructs exhibited 10.8 +/- 2.3 degrees varus collapse and 15.5 +/- 9.5 degrees rotation around the lag screw axis. Four out of five dual screws constructs sustained 20,000 loading cycles. One dual screw specimens sustained cut-out by medial migration of the distal screw after 10,054 cycles. At test end, varus collapse and neck rotation in dual screws implants advanced to 3.7 +/- 1.7 degrees and 1.6 +/- 1.0 degrees , respectively. CONCLUSION: The single and double lag screw implants demonstrated a significantly different migration resistance in surrogate specimens under gait loading simulation with the HIPS model. In this model, the double screw construct provided significantly greater resistance against varus collapse and neck rotation in comparison to a standard DHS lag screw implant.

Varicosities as an etiology of tarsal tunnel syndrome and the significance of tinel's sign: report of two cases in young men and a review of the literature.

Two cases of tarsal tunnel syndrome in two young men with surgical and radiologic details are reported. The role of varicosities as a cause of tarsal tunnel syndrome and the significance of Tinel's sign are discussed through a large review of the literature.

The natural history of a mistreated ipsilateral Galeazzi and Monteggia lesion: report of a case 39 years post-injury.

Galeazzi injury combined with ipsilateral Monteggia lesion is extremely rare. A 45-year-old male patient with a mistreated Galeazzi lesion combined with an ipsilateral Monteggia fracture at the age of 6 is presented. Thirty-nine years post-injury his elbow was asymptomatic and stable and his distal radioulnar and radiocarpal joints were also asymptomatic. The strength of the limb was equal to the unaffected contralateral upper limb and he was able to work manually as a waiter for the last 20 years without any problem. The only obvious defect was a 30 degrees lack of elbow flexion and a 10 degrees lack of forearm pronation in comparison to the normal side.

Balloon kyphoplasty for the treatment of pathological vertebral compressive fractures.

BACKGROUND: Previous clinical studies have shown the safety and effectiveness of balloon kyphoplasty in the treatment of pathological vertebral compression fractures (VCFs). However, they have not dealt with the impact of relatively common comorbid conditions in this age group, such as spinal stenosis, and they have not explicitly addressed the use of imaging as a prognostic indicator for the restoration of vertebral body height. Neither have these studies dealt with management and technical problems related to surgery, nor the effectiveness of bone biopsy during the same surgical procedure. This is a prospective study comparing preoperative and postoperative vertebral body heights, kyphotic deformities, pain intensity (using visual analogue scale) and quality of life (Oswestry disability questionnaire) in patients with osteoporotic vertebral compression fractures (OVCFs) and osteolytic vertebral tumors treated with balloon kyphoplasty. METHODS: Thirty-two consecutive patients, 27 OVCFs (49 vertebral bodies [VBs]) and 5 patients suffering from VB tumor (12 VBs) were treated by balloon kyphoplasty. The mean age was 68.2 years. All patients were assessed within the first week of surgery, and then followed up after one, three and six months; all patients (27 OVCFs and 5 tumor patients) were followed up for 12 months, 17 patients (14 OVCFs and 3 tumors) were followed up for 18 months and 9 patients (8 OVCFs and 1 tumor) were followed up for 24 months (mean follow up 18 months). The correction of kyphosis and vertebral heights were measured by comparing preoperative and postoperative radiographic measurements. RESULTS: Thirty-one patients (96.9%) exhibited significant and immediate pain improvement: 90% responded within 24 h and 6.3% responded within 5 days. Daily activities improved by 53% on the Oswestry scale. In the OVCF group, kyphosis correction was achieved in 24/27 patients (89.6%) with a mean correction of 7.6 degrees . Anterior wall height was restored in 43/49 VBs (88%) (mean increment of 4.3 mm), and mid vertebral body height was restored in 45/49 VBs (92%) (mean increment of 4.8 mm). Edema (high intensity signal) on short tau inversion recovery (STIR) was evidenced in all OVCF patients who experienced symptoms for less than nine months and was associated with correction of deformity. Cement leakage was the only technical problem encountered; it occurred in 5/49 VBs (10.2%) of the osteoporotic group and 1/12 VBs (8.3%) of the tumor group but had no clinical consequences. The incidence of leakage to the anterior epidural space was 2%. Spinal stenosis was present in three patients (11.1%) who responded successfully to subsequent laminectomy. Retrieval of tissue samples for biopsy was successful in 10/15 cases (67%). New fractures occurred in the adjacent level in 2/27 OVCF patients (7.4%). CONCLUSIONS: Associated spinal stenosis with OVCF should not be overlooked; STIR MRI is a good predictor of deformity correction with balloon kyphoplasty. The prevalence of a new OVCF in the adjacent level is low.

Shoulder hemiarthroplasty in the management of humeral head fractures.

The results of hemiarthroplasty for shoulder fracture were evaluated in 26 patients, 20 women and 6 men with a mean age of 64.7 +/- 8.2 years. The follow-up period was 2 to 7 years. Cofield prostheses were used for the first 10 patients and subsequently 9 Global and 7 Aequalis prostheses were implanted, all cemented. The clinical outcome was assessed using the Constant-Murley scale. The mean score, at the last follow-up, was 70.4 +/- 16.4 (39-96). Mean forward elevation of the arm was 150 degrees (300-175 degrees), mean abduction was 145 degrees (30 degrees -170 degrees), and mean external rotation was 30 degrees (10 degrees-45 degrees). In most of the cases internal rotation corresponded with a position of the dorsum of the hand at the L3 vertebrae. The patients in our series achieved their optimal clinical result within the first 6 months after operation. Shoulder hemiarthroplasty is a worthwhile procedure, giving predictable results provided the patients have been carefully selected, the individual anatomy of the shoulder is restored and an aggressive rehabilitation program is implemented during the first six months after surgery.

Minimally invasive surgery for ablation of osteoid osteoma of the spine.

STUDY DESIGN: Compare the effectiveness of two different techniques for the management of osteoid osteoma of the spine. OBJECTIVE: To describe the technique, feasibility, and indications of two different minimally invasive surgical methods for the treatment of osteoid osteoma of the spine. SUMMARY OF THE BACKGROUND DATA: Current treatment of osteoid osteoma of the spine is usually conventional surgical excision. The successful treatment of osteoid osteoma of the appendicular skeleton by percutaneous radiofrequency probe ablation is known; however, there have been only a few cases reported utilizing this method to treat osteoid osteoma of the spine. The high success rate of percutaneous transpedicle vertebral biopsy and diskectomy led us to believe this technique can also be applicable for the treatment of osteoid osteoma of the spine. METHODS: Two patients with symptomatic osteoid osteoma of the spine underwent two different surgical managements with local anesthesia. In one patient, the osteoid osteoma was localized in the apex of the right L4 superior articular process joint. Under computed tomography guidance he underwent radiofrequency coagulation with the use of a radiofrequency generator at 90 degrees for 240 seconds. The lesion in the second patient was located in the right pedicle of the T9 vertebra close to the exiting nerve root and was cored out by means of a special percutaneous instrument designed for percutaneous biopsy under fluoroscopic guidance. RESULTS: Both patients experienced immediate relief of pain, resumed their regular activities, and also remained free of symptoms after the 2.5- and 3-year follow-up. CONCLUSION: Minimally invasive surgery can successfully be applied in the treatment of osteoid osteoma of the lumbar spine. When the nidus is not adjacent to the neural elements radiofrequency thermal ablation can be an effective and safe treatment of osteoid osteoma in the spine.

Relevance of the restoration of humeral length and retroversion in hemiarthroplasty for humeral head fractures.

Sixteen patients, with a fracture of the upper humerus treated with hemiarthroplasty, were followed-up for 45.7 +/- 15.1 (20-72) months after surgery. The results were assessed using the Constant-Murley scale. The mean score was 75.8 +/- 15.7 (54-96) points out of a possible maximum of 100. At the time of their last follow-up they underwent CT of the fractured and contralateral humerus. Humeral length and retroversion were measured and evaluated. A very good final outcome (Constant score more than 71) was achieved in patients with a difference in retroversion less than 10 degrees and a difference in length less than 14 mm, between fractured and sound humerus. The mean difference in retroversion was 8.7 degrees and the mean difference in length was 0.65 cm, between fractured and sound humerus. We attribute the very good clinical outcome in our series to the quality of the anatomical reconstruction that was performed.

Effectiveness and pitfalls of percutaneous transpedicle biopsy of the spine.

Seventy-one percutaneous transpedicle biopsy specimens were taken from 68 patients with cervical, thoracic, lumbar, or sacral vertebral lesions, with the patients under local anesthesia. Sixty-one procedures were done with fluoroscopic guidance and seven procedures were done with computed tomography guidance. Twenty-one patients were diagnosed as having infectious spondylodiscitis, three had tuberculosis, two had coccidiomycosis, two had brucellosis, one had blastomycosis, one had an echinococcus cyst, six had primary neoplasms, 14 had metastatic neoplasms, five had osseous repair for insufficiency fractures, seven had osteoporotic fractures, and one had Paget's disease of bone. In the four remaining patients, the biopsy initially was negative but it was proven to be false-negative because of faulty biopsy technique. The percutaneous transpedicle approach for biopsy is safe, efficacious, and cost-effective. False-negative results and complications can be avoided when adhering to the technical details of this procedure.

Gertzbein and load sharing classifications for unstable thoracolumbar fractures.

From 1996 to 1998, 30 consecutive patients with Level 1 thoracolumbar spinal injury were classified and treated according to the Gertzbein classification and the load sharing classification. A posterior short segment pedicle screw implant was used in 21 patients; anterior decompression with strut grafting and application of the Kaneda device was used in three patients; and six patients were treated with short posterior instrumentation and an anterior strut graft. The average followup was 32 months (range, 24-50 months). The clinical outcome was satisfactory in 22 of 30 patients. Five of nine patients had neurologic improvement. Radiographic imaging findings showed a slight loss of reduction, but the clinical outcome of the patients was not affected. No pseudarthrosis and no implant failures were recorded. The Gertzbein classification correlates the type of fracture with the degree of mechanical instability and neurologic lesion. The load sharing classification correlates fracture comminution and displacement with mechanical stability and implant failure. Patient selection is a fundamental component for a successful outcome. The best candidates for surgery are cooperative patients who require spinal mobility, patients who are able to tolerate a two-stage reconstruction, and patients in good general health.

Serratia spondylodiscitis after elective lumbar spine surgery: a report of two cases.

STUDY DESIGN: This report describes two cases of acute spondylodiscitis, caused by, complicating two different conditions: microdiscectomy for herniated nucleus pulposus and decompressing laminotomy for spinal stenosis. OBJECTIVE: To describe a rare and life-threatening spinal infection and discuss its successful management. SUMMARY OF BACKGROUND DATA: To our knowledge, no published reports in the English language have described this potentially devastating infection as a complication of elective noninstrumented discectomy or decompressive laminotomy. METHODS: Two cases of a very early onset of acute spondylodiscitis, caused by, after minimally invasive lumbar spine surgeries are presented. The elapsed time between these two complications was 1 week. The clinical presentation was characteristically stormy in both cases. On postoperative day 2, the patients developed high fever with intense chills and concomitant acute low back pain rapidly increasing in severity. The overall clinical appearance was alarming. The patients were carefully investigated immediately and scrutinized for possible origin of the infection. Treatment consisted of prompt intravenous antibiotics and surgical debridement. RESULTS: The history and clinical manifestations of postoperative spondylodiscitis were corroborated with magnetic resonance imaging findings and bacteriologic and hematologic laboratory examination. Blood cultures revealed as the responsible pathogenic microorganism. The source of the pathogens was contaminated normal saline used for surgical lavage. Both patients were able to completely resume their previous occupations after aggressive surgical debridement/irrigation and 3 months of antibiotic treatment. CONCLUSIONS: may become a potential pathogen, causing severe spinal infection after elective surgery. For prompt diagnosis and effective treatment of this life-threatening infection, one should maintain high index of suspicion and should not procrastinate in initiating treatment, which should consist of appropriate intravenous antibiotics and surgical debridement.