Surgical Treatment of Diffuse Idiopathic Skeletal Hyperostosis (DISH) Involving the Cervical Spine: Technical Nuances and Outcome of a Multicenter Experience.

STUDY DESIGN: Retrospective multicenter. OBJECTIVES: diffuse idiopathic skeletal hyperostosis (DISH) involving the cervical spine is a rare condition determining disabling aero-digestive symptoms. We analyzed impact of preoperative settings and intraoperative techniques on outcome of patients undergoing surgery for DISH. METHODS: Patients with DISH needing for anterior cervical osteophytectomy were collected. Swallow studies and endoscopy supported imaging in targeting bone decompression. Patients characteristics, clinico-radiological presentation, outcome and surgical strategies were recorded. Impact on clinical outcome of duration and time to surgery and different surgical techniques was evaluated through ANOVA. RESULTS: 24 patients underwent surgery. No correlation was noted between specific spinal levels affected by DISH and severity of pre-operative dysphagia. A trend toward a full clinical improvement was noted preferring the chisel (P = 0.12) to the burr (P = 0.65), and whenever C2-C3 was decompressed, whether hyperostosis included that level (P = 0.15). Use of curved chisel reduced the surgical times (P = 0.02) and, together with the nasogastric tube, the risk of complications, while bone removal involving 3 levels or more (P = 0.04) and shorter waiting times for surgery (P < 0.001) positively influenced a complete swallowing recovery. Early decompressions were preferred, resulting in 66.6% of patients reporting disappearance of symptoms within 7 days. One and two recurrences respectively at clinical and radiological follow-up were registered 18-30 months after surgery. CONCLUSION: The "age of DISH" counts more than patients' age with timeliness of decompression being crucial in determining clinical outcome even with a preoperative mild dysphagia. Targeted bone resections could be reasonable in elderly patients, while in younger ones more extended decompressions should be preferred.

Use of the SpineJack direct reduction for treating type A2, A3 and A4 fractures of the thoracolumbar spine: a retrospective case series.

BACKGROUND: Compression injuries of the thoracolumbar spine without neurological impairment are usually treated with minimally invasive procedures. Intravertebral expandable implants represent an alternative strategy in fractures with low fragments' displacement. METHODS: Patients with A2, A3 and A4 fractures of the T10-L2 spinal segment without neurological impairment, fracture gap >2 mm, vertebra plana, pedicle rupture, pedicle diameter <6 mm, spinal canal encroachment ≥50%, and vertebral body spread >30% were treated with the SpineJack device. Patients with pathological/osteoporotic fractures were excluded. Demographic and fracture-related data were assessed together with vertebral kyphosis correction, vertebral height restoration/loss of correction and final kyphosis. The modified Rankin Scale (mRS), Oswestry Disability Index (ODI), Visual Analogue Scale (VAS), Smiley-Webster Pain Scale (SWPS) and EuroQol-5D (EQ-5D) were evaluated at 1 (-post), 6 and 12 months (-fup) after surgery. Statistical analysis was performed and p values ≤0.05 were considered significant. RESULTS: Fifty-seven patients were included in the study. Patients aged >60 years reported worse kyphosis correction (<4°) with more postoperative complications, while vertebral plasticity in younger patients, fragmentation-related greater remodeling in A3/A4 fractures, and treatments within 7 days of trauma determined superior wedging corrections, with better EQ-5D-post and mRS-fup. Cement leakages did not affect functional outcome, while female gender and American Society of Anesthesiologists (ASA) score of 3-4 were associated with worse ODI-fup and VAS-fup. Although fracture characteristics and radiological outcome did not negatively influence the clinical outcome, A2 fracture was a risk factor for complications, thus indirectly compromising both the functional and radiological outcome. CONCLUSION: With spread of <30%, the SpineJack is an alternative to minimally invasive fixations for treating A3/A4 thoracolumbar fractures, being able to preserve healthy motion segments in younger patients and provide an ultra-conservative procedure for elderly and fragile patients.

Posterior Osteotomy and Osteosynthesis for Malunited Atlas Fracture: A Surgical Technique.

Conservative treatment is commonly accepted and widely used for most atlas compression fractures. Malunion due to mismatching of the articular surfaces in C0-C1 and C1-C2 is therefore frequent even without associated instability. Such a result is considered acceptable in the elderly with low functional requests but should be avoided in young patients. Authors describe a new surgical technique to reduce and fix a nonunion and malunited fracture of the atlas through a posterior arch osteotomy followed by articular masses stabilization with polyaxial screws and precurved titanium rod. Rod prebending reduces lateral inclination of the screw heads during the reduction maneuver through compression applied between screw heads making it effective.

Management of a Lumbar Burst Fracture Occurring After a Sneeze in a Patient Affected by Systemic Mastocytosis: A Case Report.

CASE: We present a 36-year-old man with L1 burst fracture after a sneeze. He was in follow-up for indolent systemic mastocytosis (ISM), and osteoporosis was treated with bisphosphonate. Owing to neurologic impairment, posterior decompressive laminectomy and thoraco-lumbar fusion with cemented screws were performed. CONCLUSION: Vertebral fractures in young patients affected by ISM required a multidisciplinary approach and a careful preoperative planning to achieve acceptable results. These fractures are so rare that even an experienced spine surgeon may not come across them during his whole career. Nevertheless, diagnostic tool improvement makes its diagnosis more frequent, that is why every spine surgeon should know this disease.

Vertebral body spread in thoracolumbar burst fractures can predict posterior construct failure.

BACKGROUND CONTEXT: The load sharing classification (LSC) laid foundations for a scoring system able to indicate which thoracolumbar fractures, after short-segment posterior-only fixations, would need longer instrumentations or additional anterior supports. PURPOSE: We analyzed surgically treated thoracolumbar fractures, quantifying the vertebral body's fragment displacement with the aim of identifying a new parameter that could predict the posterior-only construct failure. STUDY DESIGN: This is a retrospective cohort study from a single institution. PATIENT SAMPLE: One hundred twenty-one consecutive patients were surgically treated for thoracolumbar burst fractures. OUTCOME MEASURES: Grade of kyphosis correction (GKC) expressed radiological outcome; Oswestry Disability Index and visual analog scale were considered. METHODS: One hundred twenty-one consecutive patients who underwent posterior fixation for unstable thoracolumbar burst fractures were retrospectively evaluated clinically and radiologically. Supplementary anterior fixations were performed in 34 cases with posterior instrumentation failure, determined on clinic-radiological evidence or symptomatic loss of kyphosis correction. Segmental kyphosis angle and GKC were calculated according to the Cobb method. The displacement of fracture fragments was obtained from the mean of the adjacent end plate areas subtracted from the area enclosed by the maximum contour of vertebral fragmentation. The "spread" was derived from the ratio between this subtraction and the mean of the adjacent end plate areas. Analysis of variance, Mann-Whitney, and receiver operating characteristic were performed for statistical analysis. The authors report no conflict of interest concerning the materials or methods used in the present study or the findings specified in this paper. No funds or grants have been received for the present study. RESULTS: The spread revealed to be a helpful quantitative measurement of vertebral body fragment displacement, easily reproducible with the current computed tomography (CT) imaging technologies. There were no failures of posterior fixations with preoperative spreads <42% and losses of correction (LOC)<10°, whereas spreads >62.7% required supplementary anterior supports whenever LOC>10° were recorded. Most of the patients in a "gray zone," with spreads between 42% and 62.7%, needed additional anterior supports because of clinical-radiological evidence of impending mechanical failures, which developed independently from the GKC. Preoperative kyphosis (p<.001), load sharing score (p=.002), and spread (p<.001) significantly affected the final surgical treatment (posterior or circumferential). CONCLUSIONS: Twenty-two years after the LSC, both improvements in spinal stabilization systems and software imaging innovations have modified surgical concepts and approach on spinal trauma care. Spread was found to be an additional tool that could help in predicting the posterior construct failure, providing an objective preoperative indicator, easily reproducible with the modern viewers for CT images.

An uncommon case of irreducible ankle fracture-dislocation: the "Bosworth-like" tibio-fibular fracture.

An irreducible ankle-fracture dislocation characterized by the dislocation of the proximal fragment of the fibula posteriorly to the tibial tubercle is defined as "Bosworth injury". In the present report it is described, for the first time in literature, a complex case where the Bosworth injury was associated to a tibial plafond fracture: the proximal fibular fragment was entrapped between the tibial pilon and the fractured posterior tibial tubercle, which acted as a clamp, thus avoiding ankle reduction. Due to the presence of the tibial fracture, it was not possible to observe the typical radiological signs of Bosworth injury and therefore two unsuccessful reductions were attempted before performing a CT scan that revealed the complexity of the case, that required an immediate ORIF procedure to prevent the onset of complications.

Lumboiliac fixation in lumbosacral dislocation and associated injuries of the pelvis and lumbosacral junction: a long-term radiological and clinical follow-up.

INTRODUCTION: The goal of the study was to evaluate both clinical and radiological outcome of a consecutive series of 11 patients submitted to lumboiliac fixation after lumbopelvic disjunction or associated injuries of the pelvis and lumbosacral tract in mid- and long-term follow-up. MATERIAL AND METHODS: The following were evaluated from clinical charts: damage control preoperative procedures, surgery, and pre-, intra- and post-operative complications; imaging was also evaluated from the preoperative assessment to the final follow-up (4 to 13.2 years; average 7.2 years). RESULTS: One patient died a few days after surgery; therefore, long-term follow-up was possible in 10 patients. One of the 10 patients could be evaluated only radiologically because he was non-compliant due to severe mental illness. There were four early complications: one patient had a massive pulmonary embolism, which was fatal; one had wound dehiscence; one developed pulmonary infection and one had caecal fistula, which was repaired by the general surgeon. Late complications were as follows: three patients required hardware removal or substitution because of deep infection (after 1year), system breakage (after 9 years) and screws loosening (after 7 years). Clinical evaluation was available in nine patients and was assessed using Oswestry forms and a Visual Analogue Scale (VAS). All patients were able to walk at least 1 kilometre without external support, two patients were using pain medication regularly and three patients were classified with severe disability at final follow-up. Degenerative changes in the joints close to the fused area were observed in two patients more than 10 years after the operation, but the correlation with surgery is questionable. DISCUSSION: Lumbopelvic disjunctions generally follow high-energy trauma often involving internal thoracic and abdominal organs; therefore, a well-trained team approach is mandatory to preserve patient life and to provide adequate treatment of skeletal injuries. Mechanical complications may occur several years after surgery, thus a long-term follow-up is mandatory. CONCLUSIONS: Lumbopelvic fixation is an effective surgical technique for treatment of spinopelvic disjunction. The patient numbers in this series, and in the literature in general, are low; therefore, a multicentre study is advisable to give evidence and statistical importance to our findings.

Costotransverse screw fixation in a severe cervicothoracic deformity because of a type 1 neurofibromatosis: case report.

BACKGROUND CONTEXT: Spinal implant placement may be challenging in cases of severe cervicothoracic spinal deformities and anatomical anomalies as in Type 1 neurofibromatosis. Intralaminar screwing of the thoracic spine has been described in few cases in which pedicles were hypoplasic. The costovertebral joints have never been used before as an anchorage point for screws. PURPOSE: The purpose of the study was to describe a new thoracic fixation technique to be used in severe deformities whenever the posterior arch (laminae and pedicles) is not available because of anatomic abnormalities. STUDY DESIGN: This is a case report. METHODS: An 18-year-old woman with progressive tetraparesis caused by increasing deformity of cervicothoracic spine underwent evaluation and surgical treatment: procedure and techniques were described. The clinical features, the radiological findings, and the outcomes were assessed. Complications and local recurrences were also recorded. RESULTS: Costotransverse joint screwing was successfully used in one case of severe cervicothoracic spine deformity with major hypoplasia of the pedicles. The posterior arch of one thoracic vertebra became mobile soon after periosteal stripping probably because of iatrogenic fracture of the only existent pedicle. The four-cortical trajectory of the screws resulted in a good bone purchase allowing the surgeon to complete the procedure. No local or general complications were recorded during 2 years of follow-up. CONCLUSIONS: The procedure was used as a salvage technique during a difficult surgery where a local complication forced a change of strategy. Although the implant remained stable long enough to achieve fusion, it still consists of placing a screw through a joint that remains slightly mobile. This could possibly result in a screw loosening in the long period if fusion is not achieved. We suggest the use of this technique when all the other options have been explored and excluded for anatomical reasons.

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.

Sitting imbalance cause and consequence of post-traumatic Charcot spine in paraplegic patients.

PURPOSE: To analyze the role of spine alignment in post-traumatic paraplegic patient as a potential cause of late Charcot spine disease (CSD). METHOD: A retrospective review of three cases in which the disease appeared more than 15 years after a spinal cord injury treated by posterior fusion. A review of the literature concerning spine balance in sitting position, especially referred to paraplegic patients, is done to validate this hypothesis. RESULTS: Lumbar kyphosis in paraplegic patients during the sitting position may increase the mechanical load on disks and ligament below the previously fused area. This phenomenon, in combination with lack of protective mechanism because of poor muscular support and lack of sensitivity can speed up and amplify the normal degenerative changes in the disk and ligaments. CONCLUSIONS: More investigations are required to fully understand all the mechanisms underlying CSD pathogenesis to prevent it. Until then, a systematic long-term clinical and radiological follow-up in all post-trauma paraplegic patients is suggested. Combined anterior and posterior fusion, when feasible, can restore the sagittal balance providing a better quality of life in these patients.

Traumatic expulsion of T4 vertebral body into the spinal canal treated by vertebrectomy and spine shortening.

STUDY DESIGN: A case report. OBJECTIVE: To describe an exceptional case of traumatic 2-level adjacent disk disruption with expulsion of the vertebral body into the spinal canal treated by vertebrectomy and spine shortening. SUMMARY OF BACKGROUND DATA: Traumatic spondyloptosis is a very rare injury caused by high-energy trauma. Vertebral body expulsion is mostly the result of tremendous flexion-extension shearing forces causing a double contiguous disk disruption. METHODS: A 49-year-old male was admitted to the emergency department of another hospital because of a high-speed car crash. He was conscious and collaborating and showed a complete paraplegia. Spinal computed tomographic scan showed a posterior expulsion of the T4 vertebral body and dislocation into the spinal canal. Magnetic resonance imaging of the spine confirmed the presence of a 2-level adjacent T3-T4 and T4-T5 disk disruption and severe compression of the spinal cord by the T4 vertebral body. We performed a posterior stabilization from T1 to T8 with T4 vertebrectomy and spine shortening. RESULTS: A postoperative computed tomographic scan showed a tolerable sagittal and frontal alignment and apposition of the endplates of T3 and T5. At present, 12 months after surgery, the patient is neurologically unchanged, but he can keep the sitting position without support. CONCLUSION: Total vertebrectomy and spinal shortening are safe and replicable procedures applicable in few patients with paraplegia. A surgical procedure after 3 weeks makes a complete reduction and a perfect sagittal alignment of the spine difficult to be obtained.

En bloc resections for primary spinal tumors in 20 years of experience: effectiveness and safety.

BACKGROUND CONTEXT: Many studies have demonstrated that en bloc surgical resection of primary spinal tumors with adequate margins results in improved local disease control and survival compared with intralesional excision. Nevertheless, the use of this procedure is under debate because most of the current evidence is provided by small and heterogeneous series of cases. PURPOSE: To validate the application of en bloc resection for the treatment of aggressive benign and primary malignant spinal tumors. STUDY DESIGN: This is a prospective cohort study. PATIENT SAMPLE: From August 1990 to March 2010, 103 consecutive patients affected by primary spinal tumors were enrolled in the study. All patients were submitted to the same clinical and imaging workup. OUTCOME MEASURES: Analysis of local recurrence (LR) and tumor-related mortality, reliability of preoperative surgical planning, and morbidity and mortality. In addition, the effects of possible predictors of these events were studied. METHODS: The parameters for the effectiveness and safety of en bloc resections performed on primary spinal tumors were considered as primary end points of this study, and two research questions were formulated. The analysis of the procedure effectiveness considered the identification of possible predictors of LR and tumor-related mortality. Information about safety is collected so as to clarify the possibility to respect the preoperative planning and to identify possible predictors of morbidity and mortality. Data from clinical and imaging examination were collected in a database and were used to answer the proposed research questions. RESULTS: All patients were followed for a minimum of 24 months or until death. At the final assessment, 69 patients resulted with no evidence of disease with a mean follow-up of 100 months. Among the 103 patients, tumor recurred in 22 cases with a mean follow-up period of 39 months after surgery. A Cox regression multivariate analysis shows that marginal and intralesional resections are independent predictors of LR (hazard ratio [HR] 9.45, 95% confidence interval [CI] 1.06-84.47 and HR 38.62, 95% CI 4.67-319.21, respectively, compared with wide resection) and tumor-related mortality (in particular, HR 17.10, 95% CI 3.80-77.04 for intralesional resection compared with the wide one). The same analysis demonstrates that en bloc resection performed in recurrent cases or patients previously submitted to open biopsy (nonintact cases) have a LR risk higher than intact cases (HR 3.45, 95% CI 1.38-8.63). The success rate of en bloc resections in achieving adequate margins is 82.4%, and Weinstein-Boriani-Biagini surgical staging can also predict the margins in a high percentage of cases (75.7%). Complications occurred in 41.7% of patients with a higher rate observed in the nonintact group and for surgery with a double-approach or multisegmental resections. The mortality rate related to surgery complications was 1.9%, whereas tumor-related mortality was 15.5%. CONCLUSIONS: Statistical analysis of the long-term results referred to 103 patients affected by aggressive benign and malignant primary spine tumors indicates that an en bloc resection is associated with a high rate of complications. Nevertheless, it decreases the risk of LR and tumor-related mortality. En bloc resection is a highly demanding procedure but can be performed to an acceptable degree of safety.

Complications in minimally invasive percutaneous fixation of thoracic and lumbar spine fractures and tumors.

PURPOSE: We propose to evaluate the complication rate in minimally invasive stabilization (MIS) for spine fractures and tumors, as a common alternative to open fusion and conservative treatment. METHODS: From 2000 to 2010, 187 patients were treated by minimally invasive percutaneous fixation in 133 traumatic fractures and 54 primitive and/or secondary spine tumors. Complications were classified, according to the period of onset as intraoperative and postoperative, and according to the severity, as major and minor. RESULTS: A total of 15 complications (8 %) were recorded: 5 intraoperative (3 %), 6 early postoperative (3 %) and 4 late postoperative (2 %); 6 were minor complications (3 %) and 9 were major complications (5 %). CONCLUSIONS: Minimally invasive stabilization of selected spine pathologies appears to be a safe technique with low complication rate and high patient satisfaction. MIS reduces hospitalization and allows a fast functional recovery improving the quality of life.

Occipito-cervical fusion in post-traumatic instability of the upper cervical spine and cranio-cervical junction.

INTRODUCTION: Surgical management of upper cervical spine (UCS) unstable injuries may be challenging as the number of cases requiring this surgery collected in every single center is small. This retrospective study was conducted to analyze the radiographic and clinical results in 12 patients undergoing a posterior occipito-cervical fusion by a polyaxial screws-rod-plate system. METHODS: There were eight male and four female patients with a mean age of 73.7 years (range 32-89 years). Six patients presented neurologic deficits at admission. Six patients had sustained major trauma. The remaining six patients had suffered a minor trauma. RESULTS: Two patients died postoperatively in Intensive Care Unit. All surviving patients achieved solid fusion at 6 months. No surviving patient had neurological deterioration postoperatively. There were no instrumentation failures or revision required. Two patients suffered from superficial occipital wound infection. CONCLUSIONS: Although the indication to occipito-cervical fusion decreased since the new C1-C2 posterior fixation techniques were described, it remains a valid and reliable option in UCS post-traumatic instability to be applied even in emergency especially in the elderly.

Complications in minimally invasive percutaneous fixation of thoracic and lumbar spine fractures.

Minimally invasive stabilization of thoracic and lumbar fractures without neurologic involvement is becoming a more frequent alternative to open fusion and conservative treatment. The authors analyzed the complication rate and limits of this technique in a consecutive series of 99 patients (127 thoracolumbar vertebral fractures) who underwent this technique between May 2005 and November 2009. Eighty-three patients had only spine injuries, whereas 16 had polytrauma injuries (mean Injury Severity Score, 25.2). In these 16 patients, percutaneous fixation was performed as a damage control procedure. The most frequent construct was monosegmental: 1 level above and 1 level below the fractured vertebra. In the remaining 21 patients, multilevel construction was performed for multiple injuries. Complications were analyzed according to the period of onset (intra- and postoperative) and the severity (major and minor). Twelve (12%) complications were recorded: 4 (4%) were intraoperative, 6 (6%) were early postoperative, and 2 (2%) were late postoperative; 4 (4%) were minor and 8 (8%) were major. Mean follow-up was 52 months (range; 36-90 months). All patients except 1 were considered healed after 6-month follow-up. The failed patient had an initial kyphosis greater than 20°, and a posterior open reduction and fusion would have been more appropriate. Minimally invasive stabilization of selected spine injuries is a safe technique with a low complication rate. The main goal of this approach is a fast recovery time, so any complication leading to an extended length of stay should be considered severe. An adequate learning curve is important to minimize complications.

Endoscopic excision of C2 Osteoid Osteoma: a technical case report.

PURPOSE: The Authors illustrate the feasibility of an open biopsy and complete excision of Osteoid Osteoma involving the C2 vertebral body performed via endoscopic anterior cervical approach. METHODS: A 23-year-old male patient with history of delayed diagnosis of cervical Osteoid Osteoma underwent evaluation and surgical treatment: the minimally invasive procedure and techniques were described. The clinical features, the radiological findings and the outcome were assessed. Complications and local recurrences were also recorded. RESULTS: There were no intra- or post-operative complications. Immediately after surgery the typical Osteoid Osteoma related pain disappeared. At three years follow-up the patient was asymptomatic and considered disease-free: CT-scan and x-Ray showed no local recurrence and C2-C3 interbody fusion with cervical plate in site. CONCLUSIONS: The endoscopic transcervical surgery represents an interesting option for the treatment of these diseases in difficult areas of the upper cervical spine, also minimizing soft tissue trauma and collateral damage allows patients a faster and complete return to normal function. To our knowledge this is the first report of cervical spine tumor removal using this minimally invasive approach.

Minimal invasive percutaneous fixation of thoracic and lumbar spine fractures.

We studied 122 patients with 163 fractures of the thoracic and lumbar spine undergoing the surgical treatment by percutaneous transpedicular fixation and stabilization with minimally invasive technique. Patient followup ranged from 6 to 72 months (mean 38 months), and the patients were assessed by clinical and radiographic evaluation. The results show that percutaneous transpedicular 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.