Results following surgical resection of recurrent chordoma of the spine: experience in a single institution.

BACKGROUND: Chordoma of the spine is a low-grade malignant tumor with vague and indolent symptoms; thus, large tumor mass is encountered at the time of diagnosis in almost cases and makes it difficult for en-bloc free-margin resection. Salvage therapy for recurrent chordoma is very challenging due to its relentless nature and refractory to adjuvant therapies. The aim of this present study was to report the oncologic outcome following surgical resection of chordoma of the spine. MATERIALS AND METHODS: Retrospective review of 10 consecutive cases of recurrent chordoma patients who underwent surgical treatment between 2003 and 2018 at one tertiary-care center was conducted. RESULTS: There were 10 patients; 4 females and 6 males were included in this study. Eight patients had local recurrence. The recurrence was encountered at the muscle, surrounding soft tissue, and remaining bony structure. Distant metastases were found in 2 patients. The median time to recurrence or metastasis was 30 months after first surgery. CONCLUSION: En-bloc free-margin resection is mandatory to prevent recurrence. The clinical vigilance and investigation to identify tumor recurrent should be performed every 3 to 6 months, especially in the first 30 months and annually thereafter. Detection of recurrent in early stage with a small mass may be the best chance to perform an en-bloc margin-free resection to prevent further recurrence.

The correlation between the sagittal lumbopelvic alignments in standing position and the risk factors influencing low back pain.

Low back pain (LBP) is the most common health problem. Many factors have been demonstrated to be fundamental risk factors of LBP such as body mass index (BMI), age and sex. However, so far there have been few studies demonstrating the association between lumbo-pelvic alignment (LPA) and these factors. This present study was aimed to clarify the correlation between the LPA and the risk factors contributing to LBP. Standing lateral X-rays were taken from 100 healthy volunteers (70 males and 30 females) with no history of low back pain before their participation. Average age of subjects was 33.3±6.8 years (rang 21-50). Mean body weight was 59.1±7.9kg (range 40-82), mean body height was 163.6±7.2 cm (range 145-178) and mean BMI was 22.1±2.4 kg/m(2) (range 18.0-29.3). The LPA was classified into 3 types according to the recently proposed pelvic orientation guidelines. No direct correlation was found between the pelvic orientation and age or BMI. Each LPA type was associated with sex but not BMI and age (P=0.00, 0.71, and 0.36, respectively). The results from this study demonstrated the differences in LPA between male and female, and also confirmed that the sagittal orientation of the pelvis remained constant in adults. The high prevalence of LPA type 1 in males may reduce the occurrence of LBP in obese male individuals.

Treatment of acute tuberculous spondylitis by the spinal shortening osteotomy: a technical notes and case illustrations.

Surgical treatment for spinal tuberculosis is necessary in particular cases that a large amount of necrotic tissue is encountered and there is spinal cord compression. A spinal shortening osteotomy procedure has previously been described for the correction of the sagittal balance in a late kyphotic deformity, but there have been no reports on this as a surgical treatment in the acute stage. Thus, the aim of this report is to present the surgical techniques and clinical results of 3 patients who were treated with this procedure. Three patients with tuberculous spondylitis at the thoracic spine were surgically treated with this procedure. All the patients presented with severe progressive back pain, kyphotic deformity and neurological deficit. The patients recovered uneventfully from surgery without further neurological deterioration. Their pain was improved and the patients remained free of pain during the follow-up period. In conclusion, posterior spinal shortening osteotomy is an alternative method for the management of tuberculous spondylitis.

Reliability and validity of an adapted Thai version of the Scoliosis Research Society-22 questionnaire.

PURPOSE: The Scoliosis Research Society-22 (SRS-22) questionnaire is a widely accepted questionnaire used to assess the health-related quality of life for scoliosis patients in the United States. However, its adaptation in other languages is necessary for its multinational use. A cross-sectional study was performed to evaluate the validity and reliability of an adapted Thai version of the SRS-22 questionnaire. METHODS: An expert committee performed translation/retranslation of the English version of the SRS-22 questionnaire, as well as a cross-cultural adaptation process. Later, SRS-22 questionnaires and previously validated Short Form-36 version 2 (SF-36v2) outcome instruments were given to patients treated for idiopathic scoliosis with a minimum of 1 year of follow-up. Internal consistency and reproducibility were determined by Cronbach's alpha statistics and the intraclass correlation coefficient, respectively. Concurrent validity was measured by comparing SRS-22 results with a previously validated questionnaire (SF-36v2). Measurement was made using the Pearson correlation coefficient (r). RESULTS: The study showed satisfactory internal consistency with Cronbach's alpha values for all of the corresponding domains (pain, 0.72; self-image/appearance, 0.87; mental health, 0.83; satisfaction with management, 0.63; and function/activity, 0.83). The test-retest reproducibility was also excellent or good for all domains (pain, 0.72; self-image/appearance, 0.85; mental health, 0.82; satisfaction, 0.62; and function/activity, 0.81). For concurrent validity, excellent correlation was found in two domains, good in six domains, moderate in five domains, and poor in five domains of the 18 relevant domains. CONCLUSIONS: The Thai version of the SRS-22 outcome instrument has satisfactory internal consistency, excellent reproducibility, and acceptable validity.

Recurrent epithelioid sarcoma in the thoracic spine successfully treated with multilevel total en bloc spondylectomy.

Epithelioid sarcoma (ES) is a rare type of soft tissue tumor. The common location of ES is at the extremities and rarely occurs in axial skeleton. Only two cases have been reported so far. Initial wide resection is recommended for the treatment of ES. However, the local recurrent rate is high and repeat surgical resection is still an option for the treatment of the recurrent. In the spine, however, the proper treatment of recurrent ES has not yet been published. Therefore, the objective of this case report is to illustrate the management strategies for the local recurrent ES after initial surgical resection in the thoracic spine. A 14-year-old boy was diagnosed for ES in the thoracic spine for 2 years. He was first treated by surgical resection followed by the chemotherapy and radiotherapy but the disease had progressed and the spine was gradually deformed. He was admitted to our facility with a large soft tissue mass, severe kyphotic deformity and neurological deficit. We removed the tumor en bloc by one-stage posterior only approach. The posterior transpedicular spinal instrumentation and fibular strut graft were used for the reconstruction. On the last follow-up, 2 year after the surgery, the patient remained in good condition. In conclusion, the recurrent ES of the spine can still archive a good oncological outcome with repeat radical resection, but the initial radical resection remains the best treatment option in order to retard the relentless course of this kind of malignancy.

Lumbopelvic alignment on standing lateral radiograph of adult volunteers and the classification in the sagittal alignment of lumbar spine.

The analysis of the sagittal balance is important for the understanding of the lumbopelvic biomechanics. Results from previous studies documented the correlation between sacro-pelvic orientation and lumbar lordosis and a uniqueness of spino-pelvic alignment in an individual person. This study was subjected to determine the lumbopelvic orientation using pelvic radius measurement technique. The standing lateral radiographs in a standardized standing position were taken from 100 healthy volunteers. The measurements which included hip axis (HA), pelvic radius (PR), pelvic angle (PA), pelvic morphology (PR-S1), sacral translation distance (HA-S1), total lumbosacral lordosis (T12-S1), total lumbopelvic lordosis (PR-T12) and regional lumbopelvic lordosis angles (PR-L2, PR-L4 and PR-L5) were carried out with two independent observers. The relationships between the parameters were as follows. PR-S1 demonstrated positive correlation to regional lumbopelvic lordosis and revealed negative correlation to T12-S1. PA showed negative correlation to PR-S1 and regional lumbopelvic lordosis, but revealed positive correlation to HA-S1. T12-S1 was significantly increased when PR-S1 was lesser than average (35°-45°) and was significantly decreased when PR-S1 was above the average. PR-L4 and PR-L5 were significantly reduced when PR-S1 was smaller than average and only PR-L5 was significantly increased when PR-S1 was above the average. In conclusion, this present study supports that lumbar spine and pelvis work together in order to maintain lumbopelvic balance.

Functional outcome after decompression and instrumented arthrodesis in degenerative lumbar spinal stenosis: factors influencing unsuccessful outcome change.

OBJECTIVE: To determine functional outcome after decompressive laminectomy and instrumented arthrodesis in patients with degenerative lumbar spinal stenosis and identify predictors of failed clinical outcome in these patients. MATERIAL AND METHOD: A retrospective cohort data were collected from January 1999 to February 2004. Degenerative lumbar spinal stenosis patients who had decompressive laminectomy and instrumented fusion with pedicular screw system and completed at least 2 years follow-up were enrolled in the present study. Outcomes included Oswestry Disability Index (ODI), Roland Morris score and patient satisfaction. Factors evaluated as outcome variables were age, gender onset, patient income, associated diseases, smoking, diagnosis of spondylolisthesis or scoliosis, number of levels of instrumentation and presence of S1 fusion. Univariate analysis for factors influencing failed clinical outcome used Chi-square and Fisher exact test and multivariate analysis used the logistic regression. RESULTS: One-hundred and fifty-eight patients were included in the present study. Mean follow-up was 2.64 years (range, 2-5 years). The mean age of the patients at the time of surgery was 60.3 years (range, 34-87 years) and 129 cases (81.7%) were female. According to the US FDA, the criteria of significant successful clinical outcome change is reduction of ODI at least 15%, the proportion of patients reporting significant successful clinical outcome change was 63.9%. Multivariate analysis identified age > 65 years, onset > 24 months and number of levels of instrumentation > 4 as the factors of failed clinical outcome change (p < 0.05). CONCLUSION: Decompression and instrumented arthrodesis in degenerative lumbar spinal stenosis gained satisfactory functional outcome. Older age, prolonged onset and long level of instrumentation were the factors of failed clinical outcome change.

The evaluation of short fusion in idiopathic scoliosis.

BACKGROUND: Selective thoracic fusion in type II curve has been recommended by King et al. since 1983. They suggested that care must be taken to use the vertebra that is neutral and stable so that the lower level of fusion is centered over the sacrum. Since then there has been the trend to do shorter and selective fusion of the major curve. This study was conducted to find out whether short posterior pedicle instrumentation alone could provide efficient correction and maintain trunk balance comparing to the anterior instrumentation. MATERIALS AND METHODS: A prospective study was conducted during 2005-2007 on 39 consecutive cases with idiopathic scoliosis cases King 2 and 3 (Lenke 1A, 1B), 5C and miscellaneous. Only the major curve was instrumented unless both curves were equally rigid and of the same magnitude. The level of fusion was planned as the end vertebra (EVB) to EVB fusion, although minor adjustment was modified by the surgeons intraoperatively. The most common fusion levels in major thoracic curves were T6-T12, whereas the most common fusion levels in the thoraco-lumbar curves were T10-L3. Fusion was performed from the posterior only approach and the implants utilized were uniformly plate and pedicle screw system. All the patients were followed at least 2 years till skeletal maturity. The correction of the curve were assessed according to type of curve (lenke IA, IB and 5), severity of curve (less than 450, 450-890 and more than 900), age at surgery (14 or less and 15 or more) and number of the segment involved in instrumentation (fusion level less than curve, fusion level as of the curve and fusion more than the curve) RESULTS: The average long-term curve correction for the thoracic was 40.4% in Lenke 1A, 52.2% in Lenke 1B and 56.3% in Lenke 5. The factors associated with poorer outcome were younger age at surgery (<11 years or Risser 0), fusion at wrong levels (shorter than the measured end vertebra) and rigid curve identified by bending study. However, all patients had significant improved trunk balance and coronal hump at the final assessment at maturity. Two patients underwent late extension fusion because of junctional scoliosis. CONCLUSIONS: With modern instrumentations, the EVB of the major curve can be used at the end of the instrumentation in most cases of idiopathic scoliosis. In those cases with either severe trunk shift, younger than 11 years old, or extreme rigid curve, an extension of one or more levels might be safer. In particular situations, the concept of centering the lowest vertebra over the sacrum should be adopted.

Cervical neurofibromatosis with quadriparesis: Management by fibular strut graft.

This is a case report of an eight-year old boy with neurofibromatosis and a 120 degrees dystrophic kyphosis of the cervical spine. He presented with progressive quadriparesis caused by spondyloptosis of the C2/C3, and was successfully treated by skull traction and one-stage anterior fibular strut graft lying between the tubercle of the atlas through the C2 body slot and lower vertebrae. At seven years follow-up there was, loosening of lower vertebral screws which allowed growth and residual mobility of lower vertebral joints while the fusion of upper cervical spines was still solid.

Floor activities and degenerative spinal diseases.

BACKGROUND: The typical oriental life style in Thailand involves significant time spent on activities on the floor. This introduces an abnormal load against the spine and can cause the low back pain leading to the degenerative change of the lumbosacral region. OBJECTIVE: To determine whether various floor activities in the early adult life could result in late degenerative lumbar stenosis in the elderly patients. A case-controlled study was conducted. The patients having undergone spinal surgery according to the degenerative spinal stenosis were the case subjects. The control group consisted of the subjects having no significant back pain. The cases and the controls were matched by age, gender, and residence location. The data were collected from their medical records, roentgenograms and the standardized questionnaire. A variety of floor activities categorized by common behaviors in the Thai life style was recorded. RESULTS: There were 65 matches of cases and controls. Fifty-four patients were female performing floor activities for more than 28 times/week or more than 2 hours/week for longer than 10 years significantly increased the risk of degenerative spinal diseases by more than 15 times when being compared to the control. The most predictable activities related to the degenerative spinal diseases were occupational, cooking, and latrine use. CONCLUSION: Floor activities increased the risk of symptomatic degenerative spinal diseases in the Thai population. The question whether the prolonged postures of these routine activities could result in lumbar spinal stenosis needs more investigation in further studies.

A comparison between the Cotrel-Dubousset and the pedicle screw-plate instrumentations in the adolescent idiopathic scoliosis.

BACKGROUND: The Cotrel-Dubousset instrumentation (CD) is one of the standard instrumentations in the scoliosis surgery. Since the pedicle screw-plate system (PSP) was developed, it has resulted in the three-planar and three-dimensional correction with the minimal neurological complications. However, the correction effectiveness between these two methods is still open to question. OBJECTIVE: To compare the results of using the CD and the PSP in the treatment of adolescent idiopathic scoliosis. MATERIAL AND METHOD: A retrospective cohort study was conducted in all patients having an adolescent idiopathic scoliosis who underwent the surgery with either the CD or the PSP instrumentation at the Department of Orthopedics, Ramathibodi Hospital, during 1991 to 1998. The data of the Cobb angle, kyphotic angle, plumb line, rib hump difference and vertebral rotation were collected pre-operatively, post-operatively, and at the last follow-up. RESULTS: Forty-three patients having an adolescent idiopathic scoliosis were included. Eighteen patients: 16 females and 2 males were operated by the CD multiple hooks, and 25 patients: 23 females and 2 males were operated by the PSP instrumentation. The PSP system significantly reduced the Cobb angle and de-rotated the vertebrae in comparison with the CD group (p-value < or = 0.05). The percentage of the correction in King Type III, IV and T-L curve was higher than the other types. Both instrumentations could restore thoracic kyphosis without any major complications. CONCLUSION: The PSP system was more effective in the sagital correction, vertebral derotation and rib hump compared to the CD instrumentation. Although the PSD is a technically demanded operation, the PSP system is currently one of the most appropriate instrumentation for the adolescent idiopathic scoliosis treatment.

Spinal and bilateral breast metastases of embryonal rhabdomyosarcoma.

A case of spinal and bilateral breast metastasis was reported The primary tumor was an embryonal rhabdomyosarcoma of the left hand. Intralesional resection of metastatic spinal sarcoma was done with concurrence chemotherapy and radiotherapy. The literatures of these rare conditions were reviewed.

Floor activity score.

OBJECTIVE: To propose an instrument to measure the amount of floor activities performed by an individual. MATERIAL AND METHOD: A list of 12 questionnaires relating to floor activities is proposed. A cross-sectional survey of the response to the questionnaires was tried on 3 communities representing rural, urban and metropolitan areas. The total number of enrolled people was 733. The scores of the questionnaires were tested for statistical difference (p< 0.05) among the communities by Chi-square and ANOVA nonparametric tests. RESULTS: The total scores among the three communities were significantly different. The rural civilians achieved the highest score, whereas the metropolitan area had the lowest score. CONCLUSION: The proposed instrument measuring floor activities is able to discriminate the activities of civilians in rural, urban and metropolitan areas.

Apical derotation in the treatment of idiopathic scoliosis.

STUDY DESIGN: A prospective study of the pedicular screw plate system in the treatment of idiopathic scoliosis. OBJECTIVES: To study the efficacy of apical derotation of pedicular screw plate system in idiopathic scoliosis correction and evaluate the feasibility of the technique. SUMMARY OF BACKGROUND DATA: In the surgical treatment of idiopathic scoliosis, the standard technique of fixation currently utilized the linkage of the pedicle screws via rods. Alternatively the technique of apical correction of the deformity by sagittally contoured plates found to be a convenient and effective mean of deformity correction and rigid fixation. MATERIAL AND METHOD: Twenty-five patients who were diagnosed as idiopathic scoliosis and underwent posterior spinal fusion and fixation with pedicle screws and plates were prospectively analysed. The parameters were compared between preoperative and postoperative by paired t-test. These parameters included Cobb angles, body height, shoulder height difference, coronal trunk balance, hump difference and vertebral rotation. RESULTS: There was statistically significant difference between the pre-op and post-op parameters studied. CONCLUSION: The instrument can effectively correct the scoliosis of moderately severed deformity in 3 dimensions especially regarding the vertebral derotation and restoration of thoracic kyphosis.

The clinical efficacy of piroxicam fast-dissolving dosage form for postoperative pain control after simple lumbar spine surgery: a double-blinded randomized study.

STUDY DESIGN: A prospective, randomized, double-blinded clinical trial was conducted. OBJECTIVE: To study the efficacy of piroxicam fast-dissolving dosage form in reducing postoperative pain after simple lumbar spine surgery. SUMMARY OF BACKGROUND DATA: Many reports mention the use of nonsteroidal antiinflammatory drug for relieving postoperative pain, but study still is lacking on their use in spine surgery. METHODS: For this study, 50 patients who underwent discectomy or one-level laminectomy were randomly sampled into two groups: 21 patients in the placebo control group and 29 patients in the study group. In addition to a normal postoperative analgesic regimen, each patient received placebo or piroxicam fast-dissolving dosage form (2 tablets administered sublingually 1 to 3 hours before surgery). This regimen was repeated with 2 tablets after 24 hours, then 1 tablet after 48 hours. Postoperative pain was evaluated every 6 hours by a visual analog scale for 3 days. The amount of morphine usage was measured on postoperative days 1, 2, and 3. Postoperative variables such as blood loss, length of wound, and time of operation also were recorded. RESULTS: There was no difference between the groups with respect to age, weight, height, gender, and type of operation. The postoperative pain of the study group, as measured by visual analog scale, showed significant improvement (P < 0.05) during the postoperative period 12 to 42 hours after surgery. The study group used less morphine, but their usage showed no significant difference on postoperative days 1, 2, and 3. When the visual analog scale between the types of operation was compared, the scale for the discectomy group was better than that for the laminectomy group. The results of the postoperative variables showed no difference between the groups in terms of postoperative blood loss, length of wound, and time of operation. CONCLUSIONS: Sublingual administration of piroxicam fast-dissolving dosage form after simple spine surgery is effective and efficient in relief of postoperative pain. Because of its low side effects and high toleration, piroxicam fast-dissolving dosage form may be considered as an alternative for postoperative pain control during the early postoperative period.