Emergency Treatment of Cervical Vertebromedullary Trauma: 10 Years of Experience and Outcome Evaluation.

OBJECTIVE: The aim of the study is to identify and validate, through the recording of clinical and radiological data, the different surgical approaches and treatments valid for most subaxial cervical dislocation fractures and whether there is an advantage from using an anterior approach rather than a posterior approach and conversely.. MATERIAL AND METHODS: A retrospective study was carried out analyzing the case history of the last 10 years of vertebromedullary traumas treated at the spine surgery unit of the Policlinico Gemelli in Rome. Data on surgical timing, American Spinal Injury Association (ASIA) scores for neurological damage, and subsequent assessments on recovery, survival, and mortality were also examined. RESULTS: A total of 80 patients were treated: 50 by the posterior approach, 24 by the anterior approach, and six by the double approach. Our average follow-up time was 4.2 years. A prevalence of surgery with the posterior approach was noted. We observed the worsening of cervical kyphosis about 15 months after the trauma in two cases treated with the posterior approach alone. A second surgical treatment was performed in these patients. One of these patients underwent an anterior fusion; the other case underwent a posterior revision because the patient had ankylosing spondylitis. Although we found no statistically significant difference in outcomes between the various surgical treatments, in this retrospective study, we analyzed the characteristics and outcomes of cervical spine injuries that required surgical treatment. CONCLUSION: The aim of surgery in unstable cervical spine injuries should be to reduce and stabilize the damaged segment, maintain lordosis, and decompress when indicated. The optimal choice of surgical approach and treatment, or its superiority in terms of outcomes, remains a debated issue.

Conservative management of Anderson Type II odontoid fractures in octogenarians: is radiological union what we are searching for?

OBJECTIVE: The C2 odontoid fractures represent one of the most common cervical spine injuries. Stabilization and immobility are required for a correct treatment. However, in some cases surgical treatment is recommended. There are still no guidelines for Type II odontoid fractures management. The present study aims at determining how non-union could impact on mortality, functional and clinical outcomes in octogenarian patients conservatively treated. MATERIALS AND METHODS: The present investigation is a retrospective case series. All patients with diagnosis of Type II odontoid fractures, over 80 years and conservatively treated in our institution between January 2016 to April 2020 were potentially eligible for the study. The primary outcome was the bony fusion of the fracture after 3 months of conservative treatment. The secondary outcomes were clinical, functional outcomes and mortality. RESULTS: Sixty-four patients were eligible for the study according to inclusion and exclusion criteria. Computer Tomography (CT) evaluation performed 3 months after trauma showed complete fracture healing in 31 patients (48.4%, Fused), while 33 patients (51.6%) were evaluated as non-fused. Among these, 6 months after the CT evaluation, 14 patients were classified as stable, while 19 were classified as unstable. There were no statistically significant changes in clinical and functional outcomes reported in our patient series between patients with complete radiological healing and patients who reported stable fibrous non-union. CONCLUSIONS: In a selected group of elderly patients with a high risk for surgery, the conservative treatment of odontoid Type II fractures can be considered a viable management strategy. The achievement of a stable non-union allows for clinical and functional results comparable to complete fracture healing.

Could serum procalcitonin play a role in an emergency setting for patients with pyogenic spondylodiscitis?

OBJECTIVE: Spinal infections, represent quite rare but often severe conditions. However, due to symptoms' non-specificity and the lack of specific laboratory tests, diagnosis is often delayed with serious consequences for the patient's outcomes. The present investigation aimed at evaluating the role of procalcitonin (PCT) and other clinical features on the risk stratification and the clinical outcomes in spondylodiscitis patients treated in our Emergency Department. PATIENTS AND METHODS: The present investigation represents a single-center retrospective study. Clinical records of consecutive patients admitted to our Emergency Department from 1 January 2015 to 31 March 2021 were evaluated and patients with spondylodiscitis diagnosis in this period were recruited. Our primary outcome was the degree of autonomy of patients following the acute event. Our secondary outcome was the resolution of the infection. RESULTS: In the study period, a total of 345 patients were evaluated. Among these, 165 met the inclusion criteria, and constituted the study cohort. Concerning the primary outcome, we observed that the most significant predictive factors for being non-autonomous were elevated serum creatinine (> 1.05 mg/dl), Blood Urea Nitrogen (BUN) > 23 mg/dl, Lactate dehydrogenase > 228 U/L, PCT > 0.11 ng/mL. Patients with higher PCT (PCT > 0.11 ng/mL) and higher BUN (BUN > 23 mg/dl) had higher odds of infection persistence (the Odd Ratio, OR, were respectively 3.78 for PCT and 3.14 for BUN). CONCLUSIONS: PCT assay may play a role in diagnosing spondylodiscitis in an emergency setting. A PCT value > 0.11 ng/mL should be considered as a red flag, a predictor of worse clinical outcomes and persistence of infection.

Reprint of: Thoracolumbar burst fractures associated with incomplete neurological deficit in patients under the age of 40: Is the posterior approach enough? Surgical treatment and results in a case series of 10 patients with a minimum follow-up of 2 years.

INTRODUCTION: Surgical management of thoracolumbar burst fractures is controversial. While the goals of surgical treatment are well accepted (i.e., fracture reduction and stabilization, neural elements decompression, and segmental angular deformity correction), the choice of the best surgical approach (i.e., posterior vs. anterior vs. combined approach) remains controversial. Several studies have debated the advantages of each surgical approach but there is no definitive evidence available to date, particularly in young adult patients. The aim of this study was to assess whether posterior approach alone can be a valid surgical treatment for patient under the age of 40 affected by thoracolumbar burst fractures and incomplete neurological deficits. MATERIAL AND METHODS: A total of 10 consecutive patients affected by thoracolumbar burst fractures associated with incomplete neurological deficits treated at our institution from January 2015 to February 2017 were included in our study. All patients were under the age of 40 at the time of injury and underwent decompression and stabilization using the posterior surgical approach alone. Demographics, clinical, and radiographic parameters were recorded preoperatively, postoperatively and at the latest available follow-up. The minimum follow-up was set at 2 years post-operatively. RESULTS: The mean operative time was 303.6 min (range, 138-486). Average blood loss was 756 mL (range, 440-2100). Nine out of ten patients returned to a normal neurological status after surgery while 1 patient showed some improvement but did not recover completely. Segmental kyphotic deformity improved from a mean of 21.8° before surgery to 14.8° at the time of the last follow-up. The anterior and posterior wall height of the fractured vertebra was restored with an average of 4 mm. The Visual Analogue Scale score reported an improvement from the mean preoperative value of 7.92 to 1.24 at the last follow-up; 8 out of 10 patients resumed physical activity while all of them returned to work. CONCLUSIONS: A single posterior surgical approach is an acceptable option in terms of clinical, radiological and functional outcomes at 2 years follow-up in patients under the age of 40 presenting with a thoracolumbar burst fracture and neurological deficit.

Thoracolumbar burst fractures associated with incomplete neurological deficit in patients under the age of 40: Is the posterior approach enough? Surgical treatment and results in a case series of 10 patients with a minimum follow-up of 2 years.

INTRODUCTION: Surgical management of thoracolumbar burst fractures is controversial. While the goals of surgical treatment are well accepted (i.e., fracture reduction and stabilization, neural elements decompression, and segmental angular deformity correction), the choice of the best surgical approach (i.e., posterior vs. anterior vs. combined approach) remains controversial. Several studies have debated the advantages of each surgical approach but there is no definitive evidence available to date, particularly in young adult patients. The aim of this study was to assess whether posterior approach alone can be a valid surgical treatment for patient under the age of 40 affected by thoracolumbar burst fractures and incomplete neurological deficits. MATERIAL AND METHODS: A total of 10 consecutive patients affected by thoracolumbar burst fractures associated with incomplete neurological deficits treated at our institution from January 2015 to February 2017 were included in our study. All patients were under the age of 40 at the time of injury and underwent decompression and stabilization using the posterior surgical approach alone. Demographics, clinical, and radiographic parameters were recorded preoperatively, postoperatively and at the latest available follow-up. The minimum follow-up was set at 2 years post-operatively. RESULTS: The mean operative time was 303.6 min (range, 138-486). Average blood loss was 756 mL (range, 440-2100). Nine out of ten patients returned to a normal neurological status after surgery while 1 patient showed some improvement but did not recover completely. Segmental kyphotic deformity improved from a mean of 21.8° before surgery to 14.8° at the time of the last follow-up. The anterior and posterior wall height of the fractured vertebra was restored with an average of 4 mm. The Visual Analogue Scale score reported an improvement from the mean preoperative value of 7.92 to 1.24 at the last follow-up; 8 out of 10 patients resumed physical activity while all of them returned to work. CONCLUSIONS: A single posterior surgical approach is an acceptable option in terms of clinical, radiological and functional outcomes at 2 years follow-up in patients under the age of 40 presenting with a thoracolumbar burst fracture and neurological deficit.

Residual mobility after removal of instrumentation in patient, with type a2-a3 vertebral fractures, treated with percutaneous pedicle screw fixation.

Percutaneous techniques for treatment of thoraco-lumbar fractures type A2 and A3 are widely used. These techniques are considered temporary fixations and instrumentation must be removed with fracture healing. The aim of the study is to analyze clinical results, motility of treated segments and any loss of correction after the removal of instrumentation. We evaluated 36 patients who underwent surgery for removal of the instrumentation. Standard and dynamics x-ray before surgery and at 1 and 12 months after surgery were obtained. Radiographic evaluation was performed by comparing loss of correction after removal of the instrumentation, residual mobility of fractured vertebra, upper and lower level with values defined by Dvorak. For clinical assessment were used SF-12, Oswestry Disability Index (ODI) and Visual Analog Scale (VAS), administered before surgery and at 1 and 12 months after the removal. We analyzed a total of 108 levels in 36 patients. After removal of the instrumentation a normal range of motion was restored in the proximal and distal segment of the fracture, while at level of fractured segment we noticed a decrease in motility. Clinically, patients had a significant decrease in VAS and ODI at 1 month after removal. Our study shows that percutaneous fixation for treatment of thoraco-lumbar fractures type A2 and A3, allows to preserve motility of the treated segments after the removal of the instrumentation until 12 months. The removal of instrumentation is associated with good clinical results without of loss of correction in treated segment.

A thoracic pain of difficult diagnosis. Unusual localization of osteoid osteoma.

Osteoid Osteoma (OO) is a benign tumor that can affect any age, but it occurs mostly in adolescents. Only few cases are reported in early infancy but very rare in advanced age. From our series of OO of the spine, we selected a rare case that combines many unusual features that makes diagnosis very difficult. A case of a painful thoracic syndrome in an old female patient due to an OO localized in the inferior edge of the left pedicle of T11 with engagement of the foramen was reported. The age of the patient, the absence of any typical clinical and diagnostic signs, such as nocturnal pain or side effects to NSAIDs administration, are unusual at presentation of OO. She presented instead, a type of pain to the chest that was stabbing, fulminating and radiating. The interest of the case is due to the association of a variety of clinical aspects that stimulate discussion as well as to the role of the modern investigative diagnostic process.

The Feasibility of Long-Segment Fluoroscopy-guided Percutaneous Thoracic Spine Pedicle Screw Fixation, and the Outcome at Two-year Follow-up.

Introduction: Posterior percutaneous instrumentation may represent a challenge when multiple levels need to be instrumentated, especially when including the upper thoracic spine. The aim of the present study was to evaluate the technical feasibility and the long-term outcome of such long constructs in different surgical conditions. Materials and Methods: This investigation was a retrospective cohort study which included patients who underwent thoraco-lumbar percutaneous fixations. We collected clinical, surgical and radiological data, with a minimum follow-up of 24 months. Health-related quality-of-life, residual pain, instrumentation placement, and complications were studied. Results: A total of 18 procedures were enrolled, in which 182 screws were implanted, (170 positioned in thoracic and 12 in lumbar pedicles, respectively). No surgical complications or hardware failure occurred in our series, 6 out of 182 (3,2%) screws had a partial pedicle breach, without neurological impairment or need for surgical revision. Conclusion: According to our results, a fully posterior percutaneous approach for long thoraco-lumbar spine instrumentation can be considered safe and reproducible, although an adequate training is strictly required.

Unusual Posterior Epidural Migration of Intervertebral Herniated Disc: A Report of Two Cases.

Disc herniation is one of most common causes of spine surgery. Because of the presence of posterior longitudinal ligaments, disc fragments often migrate into the ventral epidural space. A posterior epidural herniation of a disc fragment is a rare occurrence. We report two cases of posterior migrated disc fragments, with, radiological and clinical findings. Because of the rarity of a posterior migration of the intervertebral disc fragments, a differential diagnosis can be challenging. This painful syndrome associated with neurological lower limb deficits can be confused initially, with other posterior epidural space-occupying lesions such as tumours, abscess or hematomas. A gadolinium-enhanced MRI scan is the gold standard for a correct diagnosis. Early surgical decompression of the spine with a posterior approach remains the optimal technique in ensuring the best possible outcome for the patient.

Medical management of acute non-specific low back pain: comparison of different medical treatments, one center's retrospective analysis.

Within the developed countries, low back pain and related ailments represent one of the most relevant conditions, affecting both health and socio-economic systems. Non-specific acute low back pain (nsALBP) could represent either an isolated event or the presenting symptom of an underlying condition. Its management is usually medical and radiological investigations should be avoided. However, a general agreement on the best pharmacological treatment is still missing. In the present study, we retrospectively collected patients' data from the institutional database. Two different medical treatments were recognized and groups consequently set. Outcomes were the clinical status, measured using the visual analogue scale (VAS) score for back pain, the use rate of rescue drugs, side effects related to medical treatment, compliance to the treatment, and global satisfaction. The pharma blending of Tramadol 75 mg and Dexketoprofen 25 mg (available blended in a single tablet), resulted effective in the nsALBP management, with less side effects and rescue-drug use along with a higher compliance. Furthermore, patient satisfaction in this treatment group was significatively higher. Many different medical treatments have been investigated and reported in nsALBP management during the last decades. Associations of different drugs are the most common protocols, even though there is no general agreement. Tramadol and Dexketoprofen provide a good clinical result, fewer side effects and a long-lasting and more effective painkiller action, reducing the use of rescue drugs. Moreover, our results suggest that a single tab may provide a higher compliance rate.

Kyphoplasty vs conservative treatment: a case-control study in 110 post-menopausal women population. Is kyphoplasty better than conservative treatment?

OBJECTIVE: Osteoporosis is a highly prevalent disease worldwide. Consequences of vertebral osteoporotic fractures include pain and progressive vertebral collapse resulting in spinal kyphosis, decreased quality of life, disability and mortality. Minimally invasive procedures represent an advance to the treatment of osteoporotic VCFs. Despite encouraging results reported by many authors, surgical intervention in an osteoporotic spine is fraught with difficulties. Advanced patients age and comorbidities are of great concern. PATIENTS AND METHODS: We designed a retrospective case-control study on 110 post-menopausal women consecutively visited at our institution. Study population was split in a surgical and a conservative cohort, according to the provided treatment. RESULTS: Kyphoplasty treated patients had lower back pain VAS scores at 1 month as compared with conservatively treated patients (p < 0.05). EQ5D validated questionnaire also showed a better quality of life at 1 month for surgically treated patients (p < 0.05). SF-12 scores showed greater improvements at 1 month and 3 months with statistically significant difference between the two groups just at 3 months (p < 0.05). At 12 months, scores from all scales were not statistically different between the two cohorts, although surgically treated patients showed better trends than conservatively treated patients in pain and quality of life. Kyphoplasty was able to restore more than 54.55% of the original segmental kyphosis, whereas patients in conservative cohort lost 6.67% of the original segmental kyphosis on average. CONCLUSIONS: Kyphoplasty is a modern minimal invasive surgery, allowing faster recovery than bracing treatment. It can avoid the deformity in kyphosis due to VCF. In fact, the risk to develop a new vertebral fracture after the first one is very high.

Degenerative facet joint changes in lumbar percutaneous pedicle screw fixation without fusion.

BACKGROUND: Aim of the study was to evaluate degenerative lumbar facet-joints changes after percutaneous pedicle screw fixation (PPSF) in the treatment of lumbar fractures. MATERIALS AND METHODS: Thirty patients underwent short PPSF without fusion. CT-scan was performed in the pre- and post-operative time at four, eight and 12 months. The six zygapophyseal joints adjacent the fracture's level were evaluated. RESULTS: At four months patients showed no differences between pre- and post-operative joint radiographic aspect. At eight and 12 months, CT-scan demonstrated a progressive degeneration only in the middle joints respectively in 21.42% and in 76.92% of the cases. All 10 disrupted facet joints showed progressive degenerative changes at eight and 12 months. CONCLUSION: Lumbar percutaneous fixation without fusion induces little degenerations essentially collocated in the middle joints close to fracture level at eight and 12 months. In the proximal and distal joints adjacent the screws degenerative changes can be seen only when associated to pedicle-screw encroachment.

Posterior percutaneous reduction and fixation of thoraco-lumbar burst fractures.

BACKGROUND: Treatment of A3 thoraco-lumbar and lumbar spinal fractures nowadays remains a controversial issue. Percutaneous techniques are becoming very popular in the last few years to reduce the approach-related morbidity associated with conventional techniques. HYPOTHESIS: Purpose of the study was to analyze the clinical and radiological outcome of patients who underwent percutaneous posterior fixation without fusion for the treatment of thoraco-lumbar and lumbar A3 fractures. MATERIALS AND METHODS: Sixty-three patients, having sustained a single-level thoraco-lumbar fracture, underwent short segment percutaneous instrumentation and were retrospectively analyzed. sagittal index (SI) was calculated in all patients. Clinical and functional outcome were evaluated by Visual Analog Scale (VAS), Oswestry Disability Index (ODI) and Short Form General Health Status (SF-36). RESULTS: Average operative blood loss was 82 mL (50-320). Mean pre-operative SI in the thoraco-lumbar segment was 13.3° decreased to 5.8° in the immediate postoperative with a mean deformity correction of 7.5. Mean pre-operative SI in the lumbar segment was 16.5° decreased to 11.3° in the immediate postoperative with a mean deformity correction of 5.2. Not statistically significant correction loss was registered at 1-year minimum follow-up. Constant clinical conditions improvement in the examined patients was observed. CONCLUSION: Percutaneous pedicle screw fixation for A3 thoraco-lumbar and lumbar spinal fractures is a reliable and safe procedure. LEVEL OF EVIDENCE: Level IV. Retrospective study.

Comparison of plasma antioxidant levels in middle-aged and old male with idiopatic osteoporosis: preliminary data.

OBJECTIVES: With the purpose of evaluating the role of oxidative stress (OS) in male idiopatic osteoporosis, we have evaluated plasma total antioxidant capacity (TAC) in patients classified according to age (< 65 or ≥ 65 yrs), with normal hormone values and in age-matched healthy control subjects. PATIENTS AND METHODS: TAC was evaluated with a colorimetric method, using the system metamyoglobin-H2O2 and the chromogen ABTS; the latency time (LAG, sec) in the appearance of ABTS radical species is proportional to antioxidant content of the system. RESULTS: We found slightly increased LAG values in middle-aged patients, compared with age-matched controls, probably expression of a compensatory mechanism to OS; on the contrary aged patients showed significantly lower LAG values in comparison with age-matched controls, suggesting a defective compensatory mechanism and, therefore, a risk for oxidative damage. CONCLUSIONS: OS could be a possible mechanism underlying male osteoporosis, both in middle-aged and aged patients, but compensatory mechanisms seem to be defective in the last group.

Cauda equina syndrome: evaluation of the clinical outcome.

AIM: Cauda equina syndrome is a rare but highly impairing syndrome involving lower limbs as well as urinary, defecatory and sexual function. In the literature the most investigated sphincter dysfunction is the urinary. Bowel and sexual function are often overlooked since they become more relevant after the acute phase. PATIENTS AND METHODS: Eight consecutive male patients affected by cauda equina syndrome with sphincter dysfunction due to herniated disc disease of lumbar spine were treated between 2007 and 2009. Five patients were followed-up for at least two years. Sexual function was evaluated by IIEF-5 questionnaire; bowel function was investigated by means of clinical and instrumental investigation and manometry. RESULTS: Although little clinical improved, patients still complained severe symptoms at first year follow-up while all but one improved significantly in the following year. At two years follow-up only the patient whose cauda equina syndrome was misdiagnosed and surgically treated late respect to the onset of the syndrome, complained a persistent severe sexual and bowel dysfunction. CONCLUSIONS: Our results show that a long-term follow-up is mandatory to evaluate the real outcome of surgical managed cauda equine syndrome because short-term evaluation could be misleading about the residual capacity of late neurologic improving. Despite the relatively low number of cases evaluated, our results confirm that early diagnosing and treating the syndrome are relevant for the final outcome.

Percutaneous pedicle screw fixation in polytrauma patients.

PURPOSE: The clinical outcome of polytrauma patients underwent spine fixation was analyzed and correlated both to surgical time (early versus delayed) and to fixation type (open versus percutaneous). METHODS: Twenty-four polytrauma patients were retrospectively evaluated. Patients were evaluated according to age, accident dynamic, mechanical ventilation need, blood transfusion need, SAPS II score, type of vertebral injury, time of fixation (within or after 72 h) and type of fixation. RESULTS: Nine patients underwent percutaneous pedicle screw fixation and 12 open fusion. An early fixation allows better clinical outcome considering ICU stay (13.7 versus 21.71 days), H-LOS (25.8 versus 69.5 days), mechanical ventilation need (7 versus 16.2), blood transfusion need (250 versus 592 cc). CONCLUSIONS: In polytrauma patients an early spine fixation improves clinical outcome. Patients underwent percutaneous screw fixation showed a better outcome compared to open surgery group obtained despite worst clinical conditions.

Transdiscal L5-S1 screws for the treatment of adult spondylolisthesis.

PURPOSE: The aim of the study was to evaluate clinical and radiographic outcome of patients treated with a modified Grob technique analysing the advantages related to increased mechanical stability. METHODS: 30 patients that underwent "in situ" fusion for L5-S1 spondylolisthesis were evaluated. All patients presented a low-dysplastic developmental L5-S1 spondylolisthesis. Patients were divided into two groups: A, in which L5-S1 pedicle instrumentation associated with transsacral screw fixation was performed, and B, in which L5-S1 pedicle instrumentation associated with a posterolateral interbody fusion (PLIF) was performed. RESULTS: Patients treated with transdiscal L5-S1 fixation observed a faster resolution of the symptoms and a more rapid return to daily activities, especially at 3-6 months' follow-up. The technique is reliable in giving an optimal mechanical stability to obtain a solid fusion. CONCLUSIONS: The advantages of this technique are lower incidence of neurologic complications, speed of execution and faster return to normal life.