Fusion of Multiple Segments Can Increase the Incidence of Sacroiliac Joint Pain After Lumbar or Lumbosacral Fusion.

STUDY DESIGN: A retrospective study. OBJECTIVE: To determine the risk factors for sacroiliac joint pain (SIJP) after lumbar or lumbosacral fusion. SUMMARY OF BACKGROUND DATA: Recently, the sacroiliac joint has gained increased attention as a source of pain after lumbar or lumbosacral fusion. We examined the factors related to the development of SIJP after lumbar or lumbosacral fusion. METHODS: In total, 262 patients who underwent lumbar or lumbosacral fusion from June 2006 to June 2009 were included in this study. All patients who did not show SIJP clinically in the preoperative screening period were considered. Of these patients, 28 newly developed SIJP. We investigated whether development of SIJP after lumbar or lumbosacral fusion is related to the presence of fusion involving the sacrum (floating fusion vs. fixed fusion) and the number of fused segments. RESULTS: The incidence of SIJP was higher with fixed fusion (13.1%) than with floating fusion (10.0%). With regard to the number of fused segments, the incidence of SIJP was 5.8% for one fused segment, 10.0% for two segments, 20.0% for three segments, 22.5% for at least four segments. Thus, the incidence was significantly higher when at least three segments were fused. Logistic regression analysis was performed to determine if the development of SIJP was related to the presence of fusion involving the sacrum or the number of fused segments. The analysis revealed that the number of fused segments was significantly associated with the development of SIJP. CONCLUSION: SIJP is a potential cause of low back pain after lumbar or lumbosacral fusion surgeries. Our study indicated that fusion of multiple segments (at least three) can increase the incidence of SIJP after lumbar or lumbosacral fusion. LEVEL OF EVIDENCE: Level 3.

Posterior-approach vertebral replacement with rectangular parallelepiped cages (PAVREC) for the treatment of osteoporotic vertebral collapse with neurological deficits.

STUDY DESIGN: A retrospective clinical study. OBJECTIVE: To assess the efficacy of a new spinal reconstruction technique (posterior-approach vertebral replacement with rectangular parallelepiped cages: PAVREC) for the treatment of osteoporotic late vertebral collapse with neurological deficits. SUMMARY OF BACKGROUND DATA: Poor bone quality and medically complicated situations obfuscate precise treatment for paraplegia caused by osteoporotic vertebral collapse. Recently, posterior-approach corpectomy and replacement with a cylindrical cage have been proposed. However, postoperative cage subsidence and kyphosis progression frequently occurs. METHODS: Surgical invasiveness, perioperative complications, and clinical and radiographic outcomes in a total of 19 consecutive patients with osteoporosis (7 men and 12 women; mean age, 75 y) who underwent PAVREC with a mean follow-up period of 45.6 months (range, 16-79 mo) were reviewed. The affected vertebral levels ranged from T12-L4. The mean bone mineral density of the femoral neck was 0.611±0.077 g/cm(2) (mean±SD). RESULTS: Mean operative time was 261 minutes (range, 155-326 min). Mean blood loss was 664 mL (range, 197-1595 mL). There were no reported surgical complications. Neurological deficits evaluated with the Frankel grading score improved >1 grade after surgery in all patients. Mean preoperative visual analog scale scores for back or leg pain (7.2; range, 6-9) significantly improved after surgery (1.4; range, 0-2) (P<0.05). Local kyphosis improved from a mean of 24.6 degrees before surgery to a mean of 1.5 degrees after surgery (P< 0.05), and it was maintained at a mean of 2.5 degrees at the final follow-up. Although screw loosening, cage subsidence, and subsequent vertebral fracture were seen in several cases, no additional surgeries were needed. Solid bony fusion was confirmed in all cases. CONCLUSIONS: PAVREC provided a satisfactory clinical and radiologic outcome without severe complications. This procedure can be a treatment option for osteoporotic vertebral collapse and an alternative to an anterior-approach or single posterior-approach reconstruction with a cylindrical cage.

Anterior Decompression and Shortening Reconstruction with a Titanium Mesh Cage through a Posterior Approach Alone for the Treatment of Lumbar Burst Fractures.

STUDY DESIGN: A retrospective study. PURPOSE: To examine the efficacy and safety for a posterior-approach circumferential decompression and shortening reconstruction with a titanium mesh cage for lumbar burst fractures. OVERVIEW OF LITERATURE: Surgical decompression and reconstruction for severely unstable lumbar burst fractures requires an anterior or combined anteroposterior approach. Furthermore, anterior instrumentation for the lower lumbar is restricted through the presence of major vessels. METHODS: Three patients with an L1 burst fracture, one with an L3 and three with an L4 (5 men, 2 women; mean age, 65.0 years) who underwent circumferential decompression and shortening reconstruction with a titanium mesh cage through a posterior approach alone and a 4-year follow-up were evaluated regarding the clinical and radiological course. RESULTS: Mean operative time was 277 minutes. Mean blood loss was 471 ml. In 6 patients, the Frankel score improved more than one grade after surgery, and the remaining patient was at Frankel E both before and after surgery. Mean preoperative visual analogue scale was 7.0, improving to 0.7 postoperatively. Local kyphosis improved from 15.7° before surgery to -11.0° after surgery. In 3 cases regarding the mid to lower lumbar patients, local kyphosis increased more than 10° by 3 months following surgery, due to subsidence of the cages. One patient developed severe tilting and subsidence of the cage, requiring additional surgery. CONCLUSIONS: The results concerning this small series suggest the feasibility, efficacy, and safety of this treatment for unstable lumbar burst fractures. This technique from a posterior approach alone offers several advantages over traditional anterior or combined anteroposterior approaches.

Combined fractures of the odontoid process and upper thoracic spine: two case reports.

We describe two cases of combined fractures of the odontoid process and upper thoracic spine that have not been previously reported. The first patient, a 21-year-old man, sustained an odontoid process fracture with posterior displacement and a fracture-dislocation injury at T4/5 in a motorcycle accident. The second patient, a 66-year-old woman, fell from a cliff and sustained an odontoid process fracture with posterior displacement and a bursting fracture at T3 and T4 with rotation. The first patient exhibited complete paraplegia below the T5 level of the spinal cord. The second patient escaped neurological deficit. Both underwent anterior screw fixation of the odontoid process and posterior fusion of the upper thoracic spine. In both cases the cervical spine seemed to be in hyperextension, and the upper thoracic spine experienced sudden flexion and rotation forces.

Inverse relation between osteoporosis and spondylosis in postmenopausal women as evaluated by bone mineral density and semiquantitative scoring of spinal degeneration.

STUDY DESIGN: The relation between bone mineral density and severity of spondylosis was evaluated in postmenopausal women. OBJECTIVE: To examine the possible inverse relation between osteoporosis and spondylosis by evaluating the association between bone mineral density and osteophyte formation or intervertebral disc narrowing using a semiquantitative scoring system. SUMMARY OF BACKGROUND DATA: The literature contains studies demonstrating an inverse relation between osteoporosis and spondylosis as well as those documenting insufficient support for such a relation. However, in these studies, only limited-range grading systems (e.g., Grades 1-4) were used to evaluate the severity of spondylosis. METHODS: In this study, 104 postmenopausal women older than 60 years underwent bone mineral density measurement of the lumbar spine (anteroposterior, lateral, and midlateral) and proximal femur (femoral neck, trochanter, and Ward's triangle) using dual-energy x-ray absorptiometry. Raw data representing the semiquantitative osteophyte score and disc score as well as the number of vertebral fractures were obtained using spinal radiograph. Correlations between bone mineral density and the radiographic variable were then analyzed. RESULTS: Significant negative correlations were found between all bone mineral density data and the number of vertebral fractures (-0.524 < or r= r < or = -0.347; P < 0.05). Marginal/moderate positive correlations were observed between the osteophyte score and the bone mineral density data (0.263 < or = r < or = 0.580, P < 0.05), and between the disc score and the bone mineral density data (0.233 < or = r < or = 0.570, P < 0.05).CONCLUSIONS On the basis of the finding that spondylotic changes in postmenopausal women exhibit positive correlations not only with the lumbar bone mineral density, but also with the remote-site bone mineral density, this study supports the view that osteoporosis has an inverse relation with spondylosis.

Nontraumatic acute complete paraplegia resulting from cervical disc herniation: a case report.

STUDY DESIGN: A case report of nontraumatic acute complete paraplegia resulting from cervical disc herniation. OBJECTIVES: To describe a rare case of nontraumatic paraplegia resulting from enlargement of a herniated disc in the cervical spine and to outline appropriate management of a patient with severe spinal cord compression secondary to disc herniation with developmental spinal canal stenosis. SUMMARY OF BACKGROUND DATA: Acute progression of myelopathy into complete paraplegia resulting from disc herniation is rare. There are only four reported cases of nontraumatic acute myelopathy secondary to cervical disc herniation. No other report has described magnetic resonance imaging findings noted before and after the onset of acute myelopathy. METHODS: A cervical disc herniation at C6-C7 is reported in a 29-year-old man who had nontraumatic acute complete paraplegia. Neurologic and magnetic resonance imaging findings are evaluated and discussed. RESULTS: Disc herniation at C6-C7 enlarged nontraumatically, resulting in complete paraplegia. Emergent anterior decompression followed by secondary posterior multilevel decompression was performed. Magnetic resonance imaging studies revealed localized high signal intensity change in the spinal cord. No neurologic recovery was achieved 3 years post-surgery. CONCLUSION: We emphasize that there is a possibility of acute, irreversible progression of paralysis secondary to nontraumatic enlargement of cervical disc herniation with canal stenosis. In these cases, immediate early decompressive surgery is crucial to the prevention of severe myelopathy.

Combination of lumbar kyphosis, epidural lipomatosis, and perineural cyst as a cause of neurological deficit: a case report.

We describe the rare simultaneous occurrence of epidural lipomatosis and a perineural cyst at the same level, lumbar kyphosis, osteoporotic vertebral fractures, and neurological deficits. A 75-year-old corticosteroid-dependent female farmer presented with severe low back pain, progressive lumbar kyphosis, and inability to stand because of numbness and muscle weakness of both legs. Plain radiographs displayed markedly decreased bone density, significant lumbar kyphosis, and vertebral compression fractures of L2, L3, and L4. Magnetic resonance imaging of the lumbar spine revealed a perineural cyst at the L2-3 level, extensive epidural lipomatosis, and spinal canal stenosis. Laminectomy from L3 to L5 with resection of epidural fatty tissue restored her walking ability. We postulate that the osteoporotic fractures and epidural lipomatosis were induced by corticosteroid therapy. Preexisting degenerative lumbar kyphosis of the type commonly seen in elderly farmers could have promoted osteoporotic lumbar vertebral fractures at points where bending stress had been strongly exerted. The combination of a perineural cyst and epidural lipomatosis at the same level has not been reported previously.