The impact of SARS-CoV-2 pandemic on Oncologic and Degenerative Spine Surgery Department activity: the experience of Rizzoli Orthopaedic Institute under COVID-19 lockdown

OBJECTIVE

Experience of Department of Oncologic and Degenerative Spine Surgery of Rizzoli Orthopaedic Institute during SARS-CoV-2 pandemic lockdown.

PATIENTS AND METHODS

Retrospective observational study of surgically treated patients from 09th March 2020 to 04th May 2020.

DATA COLLECTED

age, sex, type of disease, neurological status, days of hospitalization, complications and type of discharge. A comparison analysis with same period of the last year was performed in order to evaluate the impact of COVID-19 spreading on daily surgical activity.

RESULTS

A total of 107 surgical procedures in 102 patients were performed from 09th March 2020 to 04th May 2020. Analysis showed a statistically significant difference in age, sex, ASIA class and type of treated disease compared to the same period of the last year (p=0.042, 0.006, 0.022 and 0.007, respectively). No statistically significant differences were observed in type of discharge, length of hospitalization and complications (p= 0.447, 0.261 and 0.127, respectively). 3 COVID-19 infections have been identified in hospitalized patients. 1 COVID-19 patient wad admitted from Emergency Department and was managed according to a dedicated path.

CONCLUSIONS

Surgical activity was paradoxically increased during SARS-CoV-2 pandemic lockdown through the management of urgent and non-deferrable spinal disease with a low rate (3,9%) of COVID-19 infections.

Isthmic spondylolisthesis and interspinous process device. Hype, hope, or contraindication?

OBJECTIVE

The aim of this study is to investigate, through the analysis of a case report and the literature review, indications and contraindications of Interspinous Process Device (IPD) in the surgical treatment of Lumbar Isthmic Spondylolisthesis (LIS).

PATIENTS AND METHODS

A 37-years-old male with L5-S1 grade 2 LIS, treated with IPD at another center, referred to us eight months later with a worsening of back and leg pain. A revision surgery was performed with IPD removal and a L5-S1 TLIF.

RESULTS

Clinical evaluation highlighted an improvement of pain, functionality, and quality of life scores at six months (VAS 4; ODI 30; EQ-5D 70) and twelve months follow-up (VAS 1; ODI 20; EQ-5D 90). CT scan was performed at six months and one-year follow-up to evaluate the fusion rate and stability of the implant.

CONCLUSIONS

Given the pathologic anatomy and the biomechanics of LIS, IPD is ineffective in preventing further vertebral body slippage resulting in segmental kyphosis, because of the lack of connection between the posterior arch and the vertebral body due to the isthmic lesion.

Biomaterials as bone graft substitutes for spine surgery: from preclinical results to clinical study

Vertebral fusion is performed in order to stabilize the spine in the presence of degenerative, traumatic or oncological pathologies that alter its stability. The autologous bone, harvested from the patient’s iliac crest or from the lamina during surgery, is still considered the “gold standard” for spine fusion due to its osteogenic, osteoinductive and osteoconductive properties. However, several biological and synthetic bone substitutes have been introduced as alternatives for regenerating bone tissue. We have studied in particular the use of ceramic biomaterials prepared from hydroxypatite (HA), starting from in vitro analysis, through an in vivo study on ovine animal model and a post-market surveillance analysis, to finally design and perform a clinical study, which is ongoing in our Department. In the first step, HA-derived biomaterials were tested in vitro in the presence of bone marrow-derived human mesenchymal stem cells (hMSCs) and evaluated for their ability to activate precursor cells. In the second step, the biomimetic bone graft substitute SintLife® putty (MgHA) was evaluated in vivo. A posterolateral fusion procedure was applied on 18 sheep, where a fusion level was treated with MgHA, while the other level was treated with autologous bone. Microtomography and histological/histomorphometric analysis were performed six months of after surgery. In the third step, we reported the results of a post-market surveillance study conducted on 4 independent cohorts of patients (total 115 patients), in which HA-derived biomaterials were used as bone graft substitutes or extenders. Finally, a clinical study has been designed and approved by the Ethics Committee of our Institute and is currently ongoing. This study aims to evaluate the efficacy of the ceramic biomaterial SintLife® putty for bone replacement in patients treated by posterolateral fusion for degenerative spine disorders. HA biomaterials were effective in promoting the in vitro growth of hMSCs and their osteogenic differentiation. In the animal model, SintLife® putty has been effective in generating neo-formed bone tissue with morphological and structural features similar to those of the pre-existing bone. The post-market surveillance analysis has not reported any intra-operative nor early or late post-operative adverse events. Seven patients are currently recruited for the clinical trial designed to evaluate Sintlife efficacy for spine fusion (FU range: 1-7 months). No adverse events have been recorded. The first CT analysis performed at 6 months FU showed a good spine fusion. The study is ongoing. Our results, obtained from in vitro, preclinical and clinical studies, suggest that biomaterials derived from hydroxyapatite could be a valid alternative to autologous bone graft for vertebral fusion. This would potentially avoid or reduce the need of autologous bone harvesting and therefore, the risk of drawback-related side effects.

Is lumbar drainage of postoperative cerebrospinal fluid fistula after spine surgery effective?

AIM

This study is a retrospective consecutive case series analysis of 198 patients who underwent spine surgery between 2009 and 2010. The aim of this paper was to assess the efficacy and safeness of bed rest and lumbar drainage in treating postoperative CSF fistula. Postoperative cerebrospinal fluid (CSF) fistula is a well-known complication in spine surgery which lead to a significant change in length of hospitalization and possible postoperative complications. Management of CSF leaks has changed little over the past 20 years with no golden standard advocated from literature.

METHODS

Postoperative CSF fistulas were described in 16 of 198 patients (8%) who underwent spine surgery between 2009 and 2010. The choice of the therapeutic strategy was based on the clinical condition of the patients, taking into account the possibility to maintain the prone position continuously and the risk of morbidity due to prolonged bed rest. Six patients were treated conservatively (position prone for three weeks), ten patients were treated by positioning an external CSF lumbar drainage for ten days. The mean follow-up period was ten months.

RESULTS

All patients healed their wound properly and no adverse events were recorded. Patients treated conservatively were cured in a mean period of 30 days, while patients treated with CSF drainage were cured in a mean period of 10 days.

CONCLUSION

Lumbar drainage seems to be effective and safe both in preventing CSF fistula in cases of large dural tears and debilitated/irradiated patients and in treating CSF leaks.

Fueling the debate: Are outcomes better after posterior lumbar interbody fusion (PLIF) or after posterolateral fusion (PLF) in adult patients with low-grade adult isthmic spondylolisthesis?

Study design: Retrospective cohort study.

Clinical question: Do more adult patients affected by low grade isthmic spondylolisthesis have significant clinical and radiological improvement following posterior lumbar interbody fusion (PLIF) than those who receive posterolateral fusion (PLF)?

Methods: One hundred and fourteen patients affected by adult low grade isthmic spondylolisthesis, treated with posterior lumbar interbody fusion or posterolateral fusion, were reviewed. Clinical outcome was assessed by means of the questionnaires ODI, RMDQ and VAS. Radiographic evaluation included CT, MRI, and x-rays. The results were analyzed using the Student t-test.

Results: The two groups were similar with respect to demographic and surgical characteristics. At an average follow-up of 62.1 months, 71 patients were completely reviewed. Mean ODI, RMDQ and VAS scores didn't show statistically significant differences. Fusion rate was similar between the two groups (97% in PLIF group, 95% in PLF group). Major complications occurred in 5 of 71 patients reviewed (7%): one in the PLIF group (3.6%), four in the PLF group (9.3%). Pseudarthrosis occurred in one case in the PLIF group (3,6%) and in two cases in PLF group (4.6%).

Conclusions: In our series, there does not appear to be a clear advantage of posterior lumbar interbody fusion (PLIF) over posterolateral fusion (PLF) in terms of clinical and radiological outcome for treatment of adult low grade isthmic spondylolisthesis.

Osteoporotic vertebral fractures: a disabling and expensive disease of our century. A minimally invasive surgical technique to reduce the pain, the hospitalization, and restore the function

BACKGROUND AND OBJECTIVES

Minimally invasive spine surgery has gained a great consent in the treatment of vertebral osteoporotic fractures. We perform a retrospective clinical and radiographic review on 32 consecutive patients (22 female and 10 male) surgically treated for a thoracolumbar osteoporotic fracture (type A) by a minimally invasive system. By this study, we propose to determine the safety and efficacy of an expandable, percutaneous, minimally invasive technique to reduce the disability caused by vertebral osteoporotic fractures.

MATERIAL AND METHODS

We retrospectively reviewed 32 patients who were operated on between 2003 and 2004 by means of an innovative technique which employs an expandable system inserted by a minimally invasive approach into the vertebral body. Average age at surgery was 64.8 years (range, 27-82). All patients were mobilized in first post-operative day with no external immobilization and discharged from the Hospital in the second post-operative day.

RESULTS AND CONCLUSIONS

This innovative technique which employs an expandable system inserted by a minimally-invasive approach into the vertebral body permits to obtain a double mechanical support for the vertebral plate, to partially reduce the fracture, to mobilize the patient immediately, reducing disability and costs related to the vertebral osteoporotic fractures.

[The surgical treatment of renal cell carcinoma metastases to the vertebrae: intra-operative anesthesia related problems]

AIMS

Analysis of the intra-operative anesthesia related problems were compared during intra-lesional or extra-lesional surgeries for patients with metastatic renal cell carcinoma to the spine.

MATERIALS AND METHODS

We retrospectively collected and analyzed the hemodynamic data on 30 patients who had undergone surgical intervention. Twenty patients had an intra-lesional excision of the metastatic lesion in the vertebra, whereas for the rest, an en-bloc wide or marginal margin resection was carried out.

RESULTS

The surgical time for the en-bloc resections was much longer, and thus also the exposure to the anesthesia, but lesser variability within the data on blood pressure and pulse as compared with intra-lesional curettage. There was also more blood loss with the intra-lesional surgeries.

CONCLUSIONS

En-bloc resections of the vertebral tumors not only give better oncological local control, but also have less compromising effects on the patient, especially with respect to the intra-operative hemodynamics. In selected cases, en-bloc resections present a good option of treatment in vertebral metastases, and especially in highly vascular tumors such as the renal cell carcinoma metastases.

Vertebroplasty in the treatment of vertebral metastases: clinical cases and review of the literature

Bone metastases are the most common tumours affecting the musculoskeletal system. The most frequently affected area of the skeleton is the spine. The vertebral bodies are reached largely via the bloodstream and neoplastic substitution of the bone tissue causes progressive structural destruction leading to loss of stability and compression of the intracanal nerve structures. The treatment of bone metastases in the spine is different and controversial, mostly because of the wide spectrum of clinical and radiographic pattern of the local and systemic disease. Percutaneous vertebroplasty is emerging as one of the most promising new interventional procedures for relieving (or reducing) pain and improve stability. In this article we review indications, contraindications, technique, and complications of percutaneous vertebroplasty in spine metastases.

Clinical features, diagnostic and therapeutic approaches to haematogenous vertebral osteomyelitis

This article review the clinical features and the diagnostic approach to haematogenous vertebral osteomyelitis in order to optimise treatment strategies and follow-up assessment. Haematogenous spread is considered to be the most important route: the lumbar spine is the most common site of involvement for pyogenic infection and the thoracic spine for tuberculosis infection. The risk factors for developing haematogenous vertebral osteomyelitis are different among old people, adults and children: the literature reports that the incidence seems to be increasing in older patients. The source of infection in the elderly has been related to the use of intravenous access devices and the asymptomatic urinary infections. In young patients the increase has been correlated with the growing number of intravenous drug abusers, with endocarditis and with immigrants from areas where tuberculosis is still endemic. The onset of symptoms is typically insidious with neck or back pain often underestimated by the patient. Fever is present in 10-45% of patients. Spinal infections may cause severe neurological compromise in few cases, but mild neurological deficit, limited to one or two nerve roots, was detected in 28-35% of patients. The diagnosis of haematogenous vertebral osteomyelitis may be very difficult, as the symptoms can be sometimes not specific, vague or almost absent. The usual delay in diagnosis has been reported to be two to four months, despite the use of imaging techniques: in the early diagnosis of vertebral ostemyelitis is important the role of bone scintigraphy. The general principles for the management of spine infections are non operative, consisting of external immobilization and intravenous antibiotics, followed by oral antibiotics. Indications for surgery should be given in case of absence of clinical improvement after 2-3 weeks of intravenous antibiotics, persistent back pain and systemic effects of chronic infection and with presence or progression of neurological deficit in elderly or in cervical infection. Chronic ostemyelitis may require surgery in case of a development of biomechanical instability and/or a vertebral collapse with progressive deformity.

Spinal metastases: treatment evaluation algorithm

Spinal metastases are only apparently similar lesions, considering the large varieties of istotypes and the spread of the primary tumor. These metastases develop early and are not terminal events, they have to be considered as severe complications because, when possible, surgical treatment can improve the history of the patient in terms of life expectancy and quality of life. The approach to these lesions should be multidisciplinary in collaboration with oncologists and radiotherapists, in fact the average of survival of these patients has increased in recent years. The evolution of anesthaesiological techniques that permit surgical treatments that were once considered prohibitive. The application of new adjuvant therapy increases the effectiveness for surgical treatment. Controversy exist over the most appropriate treatment for patients with metastatic disease of the vertebral column. The purpose of this article was to determine the best sequential process to arrive at the most appropriate treatment considering the individual general conditions and the parameters of the metastases. We review 269 cases in 182 patients suffering from spinal metastases from a solid tumour treated between 1996 and 2002. As the number of treatment options for metastatic spinal disease has grown, it has become clear that effective implementation of these treatments can only be achieved by multidisciplinary approach.

Giant cell tumor of the upper cervical spine: transmandibular-translingual access. Clinical case

The authors describe the clinical case of a patient aged 18 years affected with giant cell tumor (GCT) at C3 who came to the surgical unit of Orthopaedics and Traumatology at the Ospedale Maggiore in Bologna after being treated by surgery elsewhere. Particular attention is paid to surgical access by means of median transmandibuloglossotomy used in order to obtain a sufficiently wide surgical field that can adequately expose the vertebral segment affected by neoplastic disease. In particular, possible complications that may be observed postsurgery can be compared to other surgical approaches to the upper cervical spine and above all that there are no permanent clinical sequelae.

Posterior lumbar interbody fusion a mid-term review of 60 cases

It is the purpose of this study to evaluate the clinical and radiographic medium-term results of a series of 60 patients submitted to intersomatic lumbar fusion by posterior approach, using a system constituted by carbon wedges to be associated with bone grafts for intersomatic fusion, and by steel or titanium plates or bars used for posterior pedicle osteosynthesis. Satisfactory clinical results were obtained in 88.2% of cases and complete radiographic fusion in 91.4% of cases. Complications were generally observed in 8.3% of cases. In light of these results, we may consider intersomatic lumbar fusion by posterior approach a method that is perhaps aggressive, but effective in the treatment of severe lumbar spondylolysis. The use of carbon wedges brings several advantages that favor intersomatic fusion, its progressive control, and the restoration of normal lordosis of the lumbar spine.