Single-level Bryan cervical disc arthroplasty: evaluation of radiological and clinical outcomes after 18 years of follow-up.

PURPOSE: Many studies reported mid-term clinical and radiological outcomes after cervical disc arthroplasty. Only a few studies analysed the long-term results. The aim of the study was to evaluate the clinical and radiological outcomes in patients treated with single-level Bryan cervical disc arthroplasty after 18 years of follow-up. METHODS: This study was a retrospective analysis of institutional databases concerning patients treated with Bryan cervical disc arthroplasty. SF36 PCS, NDI and VAS were used to evaluate clinical and functional outcomes. Standard, flexion-extension X-ray and MRI were used to evaluate the radiological results. RESULTS: Fifty-seven patients treated with single-level Bryan cervical disc arthroplasty completed the 18-year follow-up. At the final follow-up, a residual movement was observed in 32 patients (56%). The treated level range of motion decreased from 10.1° pre-operatively to 6.1° at the last follow-up (p = 0.0021). The range of motion of the adjacent segments and of the cervical spine had no significant change. Disc degeneration of the adjacent segment after 18-year follow-up was observed in 77.1% of treated patients. CONCLUSION: The clinical and radiographic outcomes 18 years after surgery are acceptable. The treated level range of motion reduction and the adjacent segment degeneration seems not to affect the clinical results after 18 years of follow-up.

Critical analysis of lumbar interspinous devices failures: a retrospective study.

Interspinous devices (IDs) were introduced in the 90s. Since then, they have rapidly become very popular for the minimally invasive treatment of lumbar pain disorders. They feature different shapes and biomechanical characteristics, and are used in the spine degenerative pathologies or as motion segment stabilizers (dynamic stabilization) or to obtain the decompression of neurological structures. The indications seem to be rather narrow and still to be verified in terms of their clinical efficacy. However, IDs are being extensively utilized beyond their classical indications with the inevitable risk of a clinical failure. The aim of the present work was to carry out a critical analysis of the causes of failure in a series of 19 patients. From January 2007 to March 2009, 19 patients with residual painful syndrome after the implantation of IDs were observed. The series includes 11 males and 8 females with a mean age of 53.6 years (range 38-84 years) who were operated on elsewhere and who underwent revision surgery at our hospital. The inclusion criteria were low back pain and/or radiculopathy after the device implantation without improvement of the painful symptomatology, radiculopathy with signs of sensory and motor deficit, intermittent neurogenic claudication, and infection. All patients were thoroughly re-assessed with new standard imaging examinations such as MRI and CT scans, considering the following image features: the position of the device with respect to the spinous processes (X-ray), the intervertebral disc disease of the level operated upon or of the adjacent levels (MRI), the segmental instability (dynamic X-rays), the severity of the canal stenosis (CT). The accurate evaluation of the clinical and imaging parameters revealed three main causes of failure: errors of indication, technical errors and the structural failure of the ID. The most frequent cause of failure was a wrong indication. The results of the study are presented and the causes of failure are discussed in detail.

Cauda equina syndrome and spine manipulation: case report and review of the literature.

Cauda equina syndrome seems to be a very rare complication of spinal manipulations. Only few cases, in fact, were referred in literature in the past decades. Most of them are very old and poorly documented evoking doubts about the pathogenetic relationship between the spinal maneuvers and the onset of the syndrome. We observed and treated a 42-year-old patient who complained a rapid onset of saddle hypoparesthesia and urine retention only a few hours after the spinal manipulation performed for L5-S1 herniated disc. The comparison of the two following MRIs performed before and after the manipulations seems to prove a close pathogenetic relationship. The patient was operated soon after the admission to our emergency department and 1 year later he referred an incomplete recovery of the syndrome. The case offered the opportunity to update the literature. The review revealed only three cases from the beginning of the current century that confirm the rarity of the syndrome. Based on the data emerging from the official literature, safety of the manipulations and its pathogenetic aspects in causing lumbar radiculopathies are discussed.

Quality of life in patients following percutaneous PMMA acetabuloplasty for acetabular metastasis due to carcinoma.

Pain is the main symptom of acetabular osteolysis from metastatic carcinoma, and it is frequently associated with pathologic fractures. Radiotherapy alone usually is not effective for pain control, and it does not allow weight bearing. Surgical procedures requiring an aggressive approach and consequently high morbidity are rarely indicated in patients with multiple metastases. Polymethylmethacrylate (PMMA) has been widely used in oncologic and spinal surgery as a bone filler. We evaluated the functional results of percutaneous injection of PMMA in 20 patients (24 acetabula) with acetabular osteolysis from metastatic carcinoma. Patients were assessed before and after percutaneous acetabuloplasty, evaluating pain, mobility of the hip joint, general condition, use of analgesics, using the SF-36, QLQ-C30, Eastern Cooperative Oncology Group (ECOG) Performance Scale and Harris Hip Score. There was a marked clinical improvement in all patients during the first six post-operative months, with gradual worsening thereafter from deterioration of their general condition over the 12-month follow-up period. Percutaneous acetabuloplasty is reliable and effective in the short term, with a statistically significant reduction of pain and improvement in quality of daily life.

Minimally invasive spine stabilisation with long implants.

Originally aimed at treating degenerative syndromes of the lumbar spine, percutaneous minimally invasive posterior fixation is nowadays even more frequently used to treat some thoracolumbar fractures. According to the modern principles of saving segment of motion, a short implant (one level above and one level below the injured vertebra) is generally used to stabilise the injured spine. Although the authors generally use a short percutaneous fixation in treating thoracolumbar fractures with good results, they observed some cases in which the high fragmentation of the vertebral body and the presence of other associated diseases (co-morbidities) did not recommend the use of a short construct. The authors identified nine cases, in which a long implant (two levels above and two levels below the injured vertebra) was performed by a percutaneous minimally invasive approach. Seven patients (five males/two females) were affected by thoracolumbar fractures. T12 vertebra was involved in three cases, L1 in two cases, T10 and L2 in one case, respectively. Two fractures were classified as type A 3.1, two as A 3.2, two as A 3.3 and one as B 2.3, according to Magerl. In the present series, there were also two patients affected by a severe osteolysis of the spine (T9 and T12) due to tumoral localisation. All patients operated on with long instrumentation had a good outcome with prompt and uneventful clinical recovery. At the 1-year follow-up, all patients except one, who died 11 months after the operation, did not show any radiologic signs of mobilisation or failure of the implant. Based on the results of the present series, the long percutaneous fixation seems to represent an effective and safe system to treat particular cases of vertebral lesions. In conclusion, the authors believe that a long implant might be an alternative surgical method compared to more aggressive or demanding procedures, which in a few patients could represent an overtreatment.