The Diagnostic Value of Magnetic Resonance Imaging in Identifying Unsuspected Malignancy in Patients Undergoing Percutaneous Vertebral Augmentation for Vertebral Compression Fractures.

BACKGROUND: The aim of this study was to identify the rate of unsuspected malignancy in vertebral compression fractures (VCFs) treated with percutaneous vertebral augmentation procedures (PVAPs). METHODS: From 2004-2015, 410 patients with VCFs underwent PVAPs with biopsy in a single tertiary hospital. All patients had preoperative magnetic resonance imaging (MRI) read by consultant radiologists and reviewed by the performing surgeon prior to PVAPs. All procedures were performed by fellowship-trained spine surgeons. A patient was considered to have an unsuspected malignancy if preoperative MRI was negative for malignancy but histology from the operative biopsy was positive. RESULTS: A total of 44 of 45 patients (97.8%) were identified to have malignancy on preoperative MRI. One patient had a negative MRI but positive biopsy (myeloma). This patient also had a positive myeloma panel. A total of 41 of 44 patients with suspicious MRI preoperatively had a history of malignancy with histology consistent with metastatic spread from the known primary. Two patients had a new diagnosis of malignancy (1 breast carcinoma, 1 metastatic cancer likely of breast or gastrointestinal origin). Younger patients were more likely to have a VCF due to malignancy (odds ratio, 28.33 in age < 60 years). CONCLUSIONS: Almost 98% of patients with malignancy (44 of 45 patients) could be successfully identified with a preoperative MRI. The addition of a myeloma panel to MRI identified all patients with malignancies prior to PVAP in our study. We recommend MRI and myeloma panel for all patients with VCFs to be treated with PVAPs. For patients who undergo a PVAP, routine biopsy should be performed.

Risk factors for recurrence of giant cell tumours of bone.

PURPOSE: To determine the risk factors for recurrence of giant cell tumours (GCTs) of bone. METHODS: Medical records of 29 men and 29 women (mean age, 34 years) treated for primary (n=53) or recurrent (n=5) GCTs of bone and followed up for a mean of 40.2 months were reviewed. The tumours were located in the distal femur (n=18), proximal tibia (n=10), proximal femur (n=8), distal radius (n=7), proximal fibula (n=4), distal ulna (n=3), calcaneum (n=3), sacrum (n=2), vertebra (n=1), metatarsal (n=1), and distal humerus (n=1). 26 patients had pathological fractures, 12 had cortical break, and 20 had neither. The Campanacci grades of the tumours were I (n=1), II (n=18), and III (n=33); the grades of the remaining 6 tumours were unknown because radiographs were unavailable. The Enneking stages of the tumours were 1 (n=51), 2 (n=6), and 3 (n=1). Treatment included curettage and cementation (n=29), curettage, cementation, and adjuvant treatment with distilled water or liquid nitrogen for bones without fracture (n=18), wide resection for extensive soft tissue involvement (n=9), and amputation (n=2) for a recurrent GCT of the distal femur and a primary GCT of the calcaneus. Reconstruction included cementation (n=27), bone grafting (n=7), cementation/bone grafting with internal fixation (n=14), reconstruction with endoprosthesis (n=3), and none (n=7). RESULTS: 19 patients had recurrence after a mean of 23.1 months. The overall recurrence-free survival at years 1, 2, and 3 were 86%, 79%, and 72%, respectively. Recurrence did not correlate with patient age (p=0.20), primary or recurrent tumour at presentation (p=0.12), Campanacci grade (p=0.10), Enneking stage (p=0.54), or presence of pathological fracture (p=0.28). Compared to GCTs at other locations, GCTs in the proximal tibia were more likely to recur (27% vs. 60%, p=0.04). CONCLUSION: GCTs of the proximal tibia are more likely to recur than those at other locations.

Five-year outcomes of minimally invasive versus open transforaminal lumbar interbody fusion: a matched-pair comparison study.

STUDY DESIGN: Retrospective analysis of prospectively collected data. OBJECTIVE: To compare midterm clinical and radiological outcomes of minimally invasive surgery (MIS) versus open transforaminal lumbar interbody fusion (TLIF). SUMMARY OF BACKGROUND DATA: Open TLIF is a proven technique to achieve fusion in symptomatic spinal deformities and instabilities. The possible advantages of MIS TLIF include reduced blood loss, less pain, and shorter hospitalization. To date, there is no published data comparing their midterm outcomes. METHODS: From 2004-2007, 40 cases of open TLIF were matched paired with 40 cases of MIS TLIF for age, sex, body mass index, and the levels on which the spine was operated. Oswestry Disability Index, neurogenic symptom score, the 36-Item Short Form Health Survey, and visual analogue scale scores for back and leg pain were obtained before surgery, 6 months, 2 years, and 5 years after surgery. Fusion rates were assessed using Bridwell classification. RESULTS: Fluoroscopic time (MIS: 55.2 s, open: 16.4 s, P < 0.001) was longer in MIS cases. Operative time (MIS: 185 min, open: 166 min, P = 0.085) was not significantly longer in MIS cases. MIS had less blood loss (127 mL) versus open (405 mL, P < 0.001) procedures. Morphine use for MIS cases (8.5 mg) was less compared with open (24.2 mg, P = 0.006). Patients who underwent MIS (1.5 d) ambulated earlier than those who underwent open fusion (3 d, P < 0.001). Patients who underwent MIS (3.6 d) had shorter hospitalization than those who underwent open fusion (5.9 d, P < 0.001). Both groups showed significant improvement in Oswestry Disability Index, neurogenic symptom score, back and leg pain, SF-36 scores at 6 months until 5 years with no significant differences between them. Grade 1 fusion was achieved in 97.5% of both groups at 5 years. The overall complication rate was 20% for the open group and 15% for MIS group (P = 0.774), including 4 cases of adjacent segment disease for each group. CONCLUSION: MIS TLIF is comparable with open TLIF in terms of midterm clinical outcomes and fusion rates with the additional benefits of less initial postoperative pain, less blood loss, earlier rehabilitation, and shorter hospitalization.

Surgically treated cervical myelopathy: a functional outcome comparison study between multilevel anterior cervical decompression fusion with instrumentation and posterior laminoplasty.

BACKGROUND CONTEXT: Multilevel cervical myelopathy can be treated with anterior cervical discectomy and fusion (ACDF) or corpectomy via the anterior approach and laminoplasty via the posterior approach. Till date, there is no proven superior approach. PURPOSE: To elucidate any potential advantage of one approach over the other with regard to clinical midterm outcomes in this study. STUDY DESIGN: A prospective, 2-year follow-up of patients with cervical myelopathy treated with multilevel anterior cervical decompression fusion and plating and posterior laminoplasty. PATIENT SAMPLE: In total, 116 patients were studied. Sixty-four patients underwent ACDF two levels and above or anterior cervical corpectomy and fusion one level and above. Fifty-two patients underwent posterior cervical surgery (laminoplasty C3-C6 and C3-C7). OUTCOME MEASURES: Self-report measures: Japan Orthopedic Association (JOA) score, JOA recovery rate, visual analog scale for neck pain (VASNP), neck disability index (NDI), and American Academy of Orthopaedic Surgeons (AAOS) neurogenic symptom score (AAOS-NSS). Physiologic measures: range of motion (ROM) flexion and extension of neck. Functional measures: short-form 36 (SF-36) score comprising physical functioning, physical role function, bodily pain, general health, vitality, social role function, emotional role function, and mental health scales. METHODS: Comparison of the JOA scores, JOA recovery rates, NDI scores, SF-36 scores, VASNP, and ROM preoperatively to 2 years. Chi-square and two-sided Student t tests were used to analyze the variables. RESULTS: Posterior surgery took an hour shorter (p<.05) and had better improvement in JOA scores at early follow-up of 6 months (p=.025). Anterior surgery group had better improvement of NDI scores at early follow-up of 6 months (p=.024) and was associated with less blood loss intraoperatively compared with posterior surgery. There was no statistical difference between the two groups for JOA scores, JOA recovery rates, SF-36 quality-of-life scores, NDI, AAOS-NSS, VAS neck pain, and ROM at 2 years. Complications were higher for anterior surgery group: two hematoma postoperation, one vocal cord paresis, and one new onset C6/C7 dermatome numbness versus one dura leak in posterior surgery group. CONCLUSIONS: Our study showed that patients with multilevel disease treated with laminoplasty do well and compare favorably with patients treated with an anterior approach. Notably, posterior surgery was associated with shorter operating time, better improvement in JOA scores at 6 months, and a tendency toward lesser complications. Posterior surgery was not associated with increased neck disability and neck pain at 2 years. Anterior surgery had better NDI improvement at early follow-up. There is a need for a larger study that is prospectively randomized with long-term follow-up before we can confidently advocate one approach over the other in the management of cervical myelopathy.

Two-year outcome of erectile dysfunction in patients younger than 50 years with fracture-unrelated lumbar spine disease requiring surgical decompression: a prospective study.

STUDY DESIGN: This is a prospective study. OBJECTIVE: A 2-year outcome of erectile dysfunction (ED) in patients younger than 50 years with fracture-unrelated lumbar spine disease requiring surgical decompression for ED is evaluated. Risk factors for ED were also evaluated. SUMMARY OF BACKGROUND DATA: There is no literature documenting 2-year follow-up of ED status in young patients with atraumatic lumbar spine disease. METHODS: All male patients younger than 50 years who underwent lumbar spine surgery between June 2006 and November 2007 without risk factors for ED were included. Patient demographics, neurological dysfunction, visual analogue scale (VAS) for back and leg pain, Oswestry Disability Index, North American Spine Society score for neurogenic symptoms, and the international index of erectile function-5 scores were recorded preoperatively and at 2 years. Patients who did not complete a 2-year follow-up were excluded. RESULTS.: A total of 75 patients were eligible for the study. Nineteen patients did not complete a 2-year follow-up giving a response rate of 75%. There were 56 patients in the study with a mean age of 38.4 (SD, 7.2; range, 20-49). The most common diagnosis was prolapsed intervertebral disc (77%) for which patients underwent discectomy. Preoperatively, 21 of 56 (37.5%) patients had ED. Despite significant improvement in mean VAS scores for back pain and leg pain, Oswestry Disability Index, and North American Spine Society score for neurogenic symptoms at 2 years (P < 0.01), the mean international index of erectile function-5 scores remained stable. Patients with ED at 2 years had greater back pain (mean VAS score 3.4) compared with patients without back pain (mean VAS score, 1.6; P ≤ 0.01). CONCLUSION: Despite excellent outcome in most spine scores postoperatively after lumbar spine surgery, one has to be less optimistic about any improvement in the ED status of patients after surgery. ED is still a problem 2 years after surgery. Back pain reduction may have a significant role in dealing with ED at 2 years postoperatively. LEVEL OF EVIDENCE: 2.

Erectile dysfunction in young surgically treated patients with lumbar spine disease: a prospective follow-up study.

STUDY DESIGN: This is a prospective study. OBJECTIVE: The prevalence of erectile dysfunction (ED) in patients younger than 50 years with fracture-unrelated lumbar spine disease requiring surgical decompression without other risk factors for ED is evaluated. SUMMARY OF BACKGROUND DATA: There is little literature documenting ED in young patients with atraumatic lumbar spine disease. METHODS: All male patients younger than 50 years who underwent lumbar spine surgery during June 2006 to November 2007 without risk factors for ED were included. Patient demographics, neurological dysfunction, visual analogue scale (VAS) for back and leg pain, Oswestry Disability Index (ODI), North American Spine Society score for neurogenic symptoms (NS), and the International Index of Erectile function (IIEF-5) scores were recorded preoperatively, at 1, 3, and 6 months. RESULTS: There were 61 patients with mean age 38.4 years (SD = 7.0; range, 20-49). Most of patients had (43 or 70.5%) prolapsed intervertebral disc with discectomy being the commonest operation. Mean VAS scores, ODI, and NS improved significantly postoperatively. However, the mean IIEF-5 scores did not. Preoperatively, there was no correlation between ED and VAS scores on back pain (P = 0.70), leg pain (P = 0.91), ODI (P = 0.93), or NS (P = 0.51). At 6 months, patients with NS > 70 had an increased risk of ED (P = 0.03). Eighty percent of patients with NS > 70 had ED compared with 30% of patients with NS ≤ 70. There was, however, no correlation between ED with ODI (P = 0.38) and VAS scores on back pain (P = 0.20) or leg pain (P = 0.08) at 6 months. CONCLUSION: The incidence of ED in patients younger than 50 years with nonfracture-related lumbar spine disease undergoing surgery without risk factors was 34.3%. Despite improvement in VAS, ODI, and NS scores postoperatively, ED did not improve. Patients with NS > 70 postoperatively were more likely to have ED reflecting possible permanent nerve damage from lumbar spine pathology.

Locked knee from superior dislocation of the patella-diagnosis and management of a rare injury.

Knee locking is often caused by a torn meniscus or loose body. A rare cause of knee locking is a superior dislocation of the patella following trauma with less than 20 reported cases in the English literature. An unusual case of a locked knee secondary to interlocking osteophytes between the medial femoral condyle and the inferior pole of the patella without any history of trauma is presented.

Subtalar arthroscopy using a 2.4-mm zero-degree arthroscope: indication, technical experience, and results.

The subtalar joint is complex. With the advent of smaller diameter arthroscopes, subtalar arthroscopy has become an important diagnostic and therapeutic tool for subtalar joint disorders. The objective of this study was to evaluate the outcome of patients who underwent arthroscopy for subtalar joint disorders using a 2.4-mm zero-degree arthroscope. In this prospective study, 6 patients who underwent subtalar arthroscopy from September 2008 to January 2009 in the authors' institution were included. The American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot scores were recorded preoperatively and at 3 and 6 months postoperatively. Mean +/- SD age was 45.5 +/- 16.2 years (range, 27.5-63.2). Postoperative diagnosis included arthrofibrosis, osteoarthritis, and osteochondral disease of the subtalar joint. Mean +/- SD AOFAS scores improved from 49.67 +/- 18.83 (range, 22-76) to 67.33 +/- 14.92 (range, 53-91) at 3 months (P = .03) and 75 +/- 19.74 (range, 54-100) at 6 months (P = .004). Subtalar arthroscopy using the 2.4-mm zero-degree arthroscope shows promising results in the diagnosis and treatment of subtalar pathologies. Patients have a significant improvement in their AOFAS hindfoot scores as early as 3 months and continue to improve subsequently. Usage of the zero-degree arthroscope allows the "instrumentation hand" to maneuver more easily in space and perform the operative procedure without getting in the way of the "camera hand." It can also save on inventory costs for centers that already have the zero-degree arthroscope. The role of specialized imaging is still unclear. Diagnosis of sinus tarsi syndrome should be historical with direct visualization of the joint revealing exact etiology.