Interspinous implants (X Stop, Wallis, Diam) for the treatment of LSS: is there a correlation between radiological parameters and clinical outcome?

Neurogenic intermittent claudication, caused by lumbar spinal stenosis (LSS), usually occurs after the age of 50 and is one of the most common degenerative spinal diseases in the elderly. Among patients over the age of 65 with LSS, open decompression is the most frequently performed spinal operation. The recently introduced interspinous spacers are a new alternative under discussion. In this retrospective study, we reviewed medical records and radiographs of patients with LSS and NIC treated from June 2003 to June 2007. All included patients (n = 129) were treated with interspinous implants (X Stop Wallis, or Diam). Evaluations of pain, using a visual analog scale (VAS), and radiographic signs, using two-plane X-rays of the lumbar spine, were performed preoperatively (preop), postoperatively (postop) and after discharge (FU 2-3). Gender ratio (m:w) was 1.1:1. Mean age of the patients was 60.8 +/- 16.3 years. Foraminal height, foraminal width, foraminal cross-sectional area, intervertebral angle, as well as anterior and posterior disc height changed significantly (P < 0.0001) after implantation of the interspinous device. Postoperatively, symptom relief (VAS) was significant (P < 0.0001). The X Stop implant improved (in some cases significantly) the radiographic parameters of foraminal height, width, and cross-sectional area, more than the Diam and Wallis implants; however, there was no significant difference among the three regarding symptom relief. FU 1 was on average 202.3 +/- 231.9 and FU 2 527.2 +/- 377.0 days postoperatively. During FU, the radiological improvements seemed to revert toward initial values. Pain (VAS) did not increase despite this "loss of correction." There was no correlation between age and symptom improvement. There was only very weak correlation between the magnitude of radiographic improvement and the extent of pain relief (VAS). The interspinous implant did not worsen low-grade spondylolisthesis. Provided there is a strict indication and fusion is not required, implantation of an interspinous spacer is a good alternative to treat LSS. The interspinous implant offers significant, longlasting symptom control, even if initially significant radiological changes seem to revert toward the initial values ("loss of correction").

Two-year results of interspinous spacer (X-Stop) implantation in 175 patients with neurologic intermittent claudication due to lumbar spinal stenosis.

The clinical outcome of patients with symptomatic lumbar spinal stenosis (LSS) was assessed during a follow-up period of 2 years after X-Stop implantation. The X-Stop is the most commonly used interspinous distraction device in patients with neurogenic intermittent claudication due to LSS. Between 2003 and 2007, more than 1,000 patients were examined in our centre with symptoms of intermittent claudication due to spinal stenosis. Between February 2003 and June 2007, in 175 of these patients an X-Stop device was implanted in one or two levels. Patients were clinically evaluated regularly during a follow-up period of up to 4 years using the VAS (leg pain) score and the Oswestry disability index. The mean VAS (leg pain) score in these 175 patients was reduced from 61.2% preoperatively to 39.0% at the first clinical follow-up examination at 6 weeks postoperatively. The mean VAS score at 24 months postoperatively was 39.0%. Oswestry score was 32.6% preoperatively, 22.7% at 6 weeks, and 20.3% at 24 months postoperatively on average. In eight out of the implanted 175 patients, the X-Stop had to be removed and a microsurgical decompression had to be performed because of unsatisfactory effect of the interspinous distraction device. Our single-centre results indicate not only a satisfactory short-term, but also a good long-term effect during a follow-up period of 2 years. Functional MRI examinations provide helpful, positional-dependent preoperative information. More than any radiological feature, the typical clinical picture of positional-dependent claudication with a relief of symptoms during flexion is the most important factor for appropriate patient selection. The interspinous device does not replace microsurgical decompression in patients with massive stenosis and continuous claudication, but offers a save, effective and less invasive alternative in selected patients with spinal stenosis. Concerning the operative technique, a minimally invasive implantation with preservation of the interspinous ligament is appropriate. Functional (upright-) MRI examinations were able to demonstrate the positional-dependent stenosis. If available, fMRI represents the most helpful radiologic examination in assessing the outcome of interspinous spacer implantation.

Nevirapine-induced toxic epidermal necrolysis and toxic hepatitis treated successfully with a combination of intravenous immunoglobulins and N-acetylcysteine.

We describe a case of an HIV-seropositive patient presenting with a severe stomatitis that initially improved with anti-infective agents. Only 13 days after the onset of the stomatitis, the patient developed rapidly progressive constitutional symptoms and a cutaneous eruption. He was diagnosed with a Stevens-Johnson syndrome (SJS) caused by the antiretroviral drug nevirapine (NVP). Despite meticulous supportive care and withdrawal of all drugs, his situation worsened and developed into a toxic epidermal necrolysis (TEN), or Lyell's syndrome, complicated by a toxic hepatitis. Treatment with a novel combination of intravenous immunoglobulins (IVIG) and N-acetylcysteine (NAC) resulted in an exceptionally fast recovery. A literature research revealed no other cases of patients treated with both NAC and IVIG for the combination of TEN and toxic hepatitis. Because of the rapid clinical recovery, this approach merits further investigation. This case report also illustrates the importance of early suspicion of SJS when an HIV-infected patient treated with nevirapine presents with stomatitis.