A systematic review: characteristics, complications and treatment of spondylodiscitis

OBJECTIVE

This systematic review focuses on 5 key elements that may improve the decision-making process in spondylodiscitis: the infective agent, segmental instability, abscess development, neurological compromise and focus of infection.

MATERIALS AND METHODS

We included 64 studies published between May 2012 and May 2017, that reported both a description of the discitis and comparative data regarding the disease and its complications.

RESULTS

The majority of cases were caused by Staphylococcus spp (40.3%) and involved the lumbosacral region (52.3%). 27.8% of cases were associated to neurological compromise, 30.4% developed an abscess, 6.6% were associated to instability, and 54.7% underwent surgery. The abscesses mostly involved the lumbosacral region (60.4%) with paravertebral localization; 32.6% of cases involved the thoracic region, showing mostly epidural localization; a small number of cases (7%) involved the cervical region, mostly with epidural localization. 95% of paravertebral abscesses were treated percutaneously, while 85.7% of epidural cases underwent "open" surgery. Spinal cord compression mainly occurred in the cervical region (55.9%), neurological deficit was observed in over half of cases (65%), and surgery was required in most of the cases (83.9%). The majority of cases of instability involved the lumbosacral region (53.3%) and underwent surgery (87%). The focus of infection was mostly lumbosacral (61%) and almost all cases (95%) were treated surgically.

CONCLUSIONS

Spondylodiscitis is a complex and multifactorial disease, whose diagnosis and management are still challenging. Due to its potential morbidity, it is extremely important to investigate the 5 key elements discussed in this paper in order to provide an early diagnosis and initiate the most effective treatment.

Carbon ions therapy as single treatment in chordoma of the sacrum. Histologic and metabolic outcome studies

OBJECTIVE

Even though carbon ions treatment (CIRT) of sacral chordoma (SC) substantially reduces tumor mass, tumor remnants are observed in most patients. Differentiating tumor remnants from necrosis is challenging, expensive in terms of imaging and time-consuming. So far, there has not been a systematic histological and metabolic analysis of post-CIRT lesions. We designed a prospective study aiming to histologically a metabolically differentiate between viable tumor and foci of necrosis and of fibrosclerosis after CIRT and correlate these findings to clinical outcome in patients with SC.

PATIENTS AND METHODS

Between January 2013 and December 2016 18 patients, 12 males and 6 females, with histological confirmation of sacral chordoma, underwent CIRT. The total dose was 70.4 GyE, with a daily fraction of 4.4 GyE, for 4 weeks. MRI was performed every three months after treatment. FDG PET-CT scan and CT-guided needle biopsy were performed 6-12 months after CIRT. The incidence of complications (intraoperative and postoperative), local control (LC), overall survival (OS) and progression-free survival (PFS), changes in neurological status, clinical outcomes and toxicity were considered.

RESULTS

All histological analysis but 2 reported signs of necrosis and of fibrosclerosis after CIRT. One of these 2 patients turned into a dedifferentiated chordoma. Radiological partial response (PR) was observed in 10 patients (56.3%) and stable disease (SD) in 5 patients (28.3). Two patients (11%) had a local relapse. The overall survival rate was 100% at 24 months. FDG PET CT after CIRT showed uptake decreasing compared with the baseline exam in all but one patient.

CONCLUSIONS

The histological presence of necrosis and of fibrosclerosis after CIRT at the histological analysis supports the previous clinical evidence on the efficacy of CIRT. Volumetric stability of the residual mass should be considered as a success of treatment. In cases of a volumetric increase of the mass, a CT needle biopsy should always be performed. In our series, during the follow-up, the FDG-PET was able to promptly detect an increased uptake in the case which later was histologically defined as dedifferentiated chordoma.

Soft Tissue Metastasis from Carcinoma. A Case Report

The authors report a case of a man who developed soft tissue metastasis to the thigh from pulmonary carcinoma. In the preoperative staging, computerized tomograms and magnetic resonance imaging allowed to identify and characterize the features of soft tissue masses; these studies, however, must be always completed with needle (tru-cut) or incisional biopsy.

Radio-induced Sarcomas in Survivors of Ewing's Sarcoma

Of 255 cases of Ewing's sarcoma recorded at the Bone Tumor Center of the Rizzoli Orthopaedic Institute, 78 patients (irradiated and with a follow-up of longer than 3 years) were considered « at risk » for the development of a second radio-induced sarcoma (RIS). Three of the 78 patients developed an RIS in the irradiated field. Theoretical and statistical analyses were carried out considering different modalities of local treatment. Statistically, the only significant factor was related to the irradiation dose. Surgical resection seems to prevent RIS.

Best practices for the management of local-regional recurrent chordoma: a position paper by the Chordoma Global Consensus Group

Chordomas are rare, malignant bone tumors of the skull-base and axial skeleton. Until recently, there was no consensus among experts regarding appropriate clinical management of chordoma, resulting in inconsistent care and suboptimal outcomes for many patients. To address this shortcoming, the European Society of Medical Oncology (ESMO) and the Chordoma Foundation, the global chordoma patient advocacy group, convened a multi-disciplinary group of chordoma specialists to define by consensus evidence-based best practices for the optimal approach to chordoma. In January 2015, the first recommendations of this group were published, covering the management of primary and metastatic chordomas. Additional evidence and further discussion were needed to develop recommendations about the management of local-regional failures. Thus, ESMO and CF convened a second consensus group meeting in November 2015 to address the treatment of locally relapsed chordoma. This meeting involved over 60 specialists from Europe, the United States and Japan with expertise in treatment of patients with chordoma. The consensus achieved during that meeting is the subject of the present publication and complements the recommendations of the first position paper.

Iliac crest bone graft: a 23-years hystory of infection at donor site in vertebral arthrodesis and a review of current bone substitutes

OBJECTIVE

This is an exemplary case report underlining a relevant morbidity which could be associated to the use of autologous iliac crest bone graft (ICBG) for spine fusion.

CASE REPORT

Starting from 1990, a 25-years-old woman underwent two subsequent surgical treatments for non-Hodgkin lymphoma vertebral localizations. In the second surgery, arthrodesis was obtained with autograft through right posterior iliac crest osteotomy. During the chemotherapy treatment following the surgery, the patient suffered from infection at posterior iliac crest scar, the site of previous graft, caused by methicillin-resistant Staphylococcus aureus. She was subjected to surgical debridement and specific antibiotic treatment with local healing and phlogosis index reduction. Chemotherapy protocol was concluded and the patient healed with definitive lymphoma remission. After 22 years the patient had a relapse of donor site infection, requiring a new antibiotic therapy and a new surgical debridement.

RESULTS

The relapsed infection at donor site lasted for a long period, more than one year, despite of specific care. It finally healed after another accurate surgical debridement and postoperative antibiotic therapy.

CONCLUSIONS

This case report underlines the possible consequences on the patient's quality of life of a long-term disease affecting the iliac crest bone graft donor site. Literature concerning alternatives to autograft for spine fusion is also reviewed.

Denosumab: non-surgical treatment option for selective arterial embolization resistant aneurysmal bone cyst of the spine and sacrum. Case report

OBJECTIVE

Aneurysmal Bone Cyst (ABC) is a cystic lesion of bone, occurring in 70% of cases as a primary lesion. Even if the metaphyseal region of long bones is more frequently involved, vertebral localization is not rare: ABC represents 15% of all primary spine and sacral tumours. Selective arterial embolization (SAE) represents the first treatment option for vertebral ABC. However, in few cases, multiple SAEs are not possible. The aim of this work is to report two cases of vertebral ABC unresponsive to SAE positively treated with Denosumab.

PATIENTS AND METHODS

Two patients affected by ABC of the lumbar spine were treated by SAE without any response. Thus, the patients were submitted to an off-label treatment with Denosumab, following the same protocol already used in case of Giant Cell Tumour (GCT): 120 mg once a week for 4 weeks consecutively, then once every 40 days.

RESULTS

In both cases, patients resulted to be pain-free after 11-13 Denosumab administrations and CT scan showed almost complete ossification of the lesions.

CONCLUSIONS

The two cases reported here are not conclusive but they may support the project of a prospective study to confirm the effectiveness of Denosumab in ABC treatment as an alternative to SAE.

A post-market surveillance analysis of the safety of hydroxyapatite-derived products as bone graft extenders or substitutes for spine fusion

OBJECTIVE

Iliac crest bone graft (ICBG) is considered the gold standard for spine surgical procedures to achieve a successful fusion, because of its known osteoinductive and osteoconductive properties. Considering its autogenous origin, the use of ICBG has not been associated to an increase of intraoperative or postoperative complications directly related to the surgery. However, complications related to the harvesting procedure and to the donor site morbidity have been largely reported in the literature, favoring the development of a wide range of alternative products to be used as bone graft extenders or substitutes for spine fusion. The family of ceramic-based bone grafts has been widely used and studied during the last years for spine surgical procedures in order to reduce the need for iliac crest bone grafting and the consequent morbidity associated to the harvesting procedures.

PATIENTS AND METHODS

We report here the results of a post-market surveillance analysis performed on four independent cohorts of patients (115 patients) to evaluate the safety of three different formulations of hydroxyapatite-derived products used as bone graft extenders/substitutes for lumbar arthrodesis.

RESULTS

No intraoperative or post-operative complications related to the use of hydroxyapatite-derived products were detected, during medium and long follow up period (minimum 12 months-maximum 5 years).

CONCLUSIONS

This post-market surveillance analysis evidenced the safety of ceramic products as bone graft extenders or substitutes for spine fusion. Moreover, the evidence of the safety of hydroxyapatite-derived products allows to perform clinical studies aimed at evaluating the fusion rates and the clinical outcomes of these materials as bone graft extenders/substitutes, in order to support their use as an alternative to ICBG for spine fusion.

Polyetheretherketone (PEEK) rods: short-term results in lumbar spine degenerative disease

Pedicle screw and rod instrumentation has become the preferred technique for performing stabilization and fusion in the surgical treatment of lumbar spine degenerative disease. Rigid fixation leads to high fusion rates but may also contribute to stress shielding and adjacent segment degeneration. Thus, the use of semirigid rods made of polyetheretherketone (PEEK) has been proposed. Although the PEEK rods biomechanical properties, such as anterior load sharing properties, have been shown, there are few clinical studies evaluating their application in the lumbar spine surgical treatment. This study examined a retrospective cohort of patients who underwent posterior lumbar fusion for degenerative disease using PEEK rods, in order to evaluate the clinical and radiological outcomes and the incidence of complications.

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.

Less invasive surgery in idiopathic scoliosis: a case report

BACKGROUND

Minimally invasive spine surgery (MISS) has become popular during the last decade due to continuous evidence in favor of lesser soft tissue damage, faster recovery, higher patient satisfaction and reduced health costs. During the last years, surgical ambition for better results as well as most detailed knowledge of spinal anatomy, have resulted in the continuous and successful expansion of indications of MISS, covering already successfully a wide range of degenerative spinal pathologies as well as adult spinal deformities.

AIM

We describe here a case report of a patient with adolescent idiopathic scoliosis (AIS) treated by minimally invasive posterior pedicle screw instrumentation.

MATERIALS AND METHODS

We report the case of an 18 years old female patient affected by AIS, Lenke type 1AN, with a 65 degree right thoracic curve and severe rib hump. Posterior pedicle screw instrumentation as well as corrective manoeuvres were performed exclusively by minimally invasive procedure, through three small midline skin incisions.

RESULTS

We obtained a good clinical and radiographical correction of scoliosis, which was maintained during the follow-up period. We also observed a limited intra-operative blood loss, a limited operative time, limited pain, earlier mobilization and limited hospital stay.

CONCLUSIONS

A minimally invasive technique can be used for the surgical treatment of AIS, showing satisfying deformity correction and multiple perceived advantages, although long-term data are needed before this kind of surgery can be recommended for routine use.

Myoepithelioma of the spine: first case in the literature

Myoepithelioma is a very rare tumour. This tumor type has been reported in the soft tissue, ear, sinonasal cavity, breast and lung. Although rare, myoepithelioma can occur in bone. We present the first case of myoepithelioma in the spine, documenting the clinical, radiographic and pathological features.

Neuropathic pain following spinal cord injury: what we know about mechanisms, assessment and management

BACKGROUND

In biology, it is easy to understand how a damaged functional system may generate wrong signals, but why this should happen when the system is disconnected is less clear. For this reason, among other pain syndromes, neuropathic pain (NP) following spinal cord injury (SCI) leaves most questions unanswered.

AIMS AND METHODS

Our purpose is to review current knowledge on NP after SCI, focusing on the mechanisms, assessment and management of the syndrome.

RESULTS

The mechanisms responsible for NP following SCI are poorly understood: NP is classically considered a "central pain syndrome" but recent evidence from experimental models reveals a possible "peripheral sensitization". Assessment of NP following SCI is well-established: in addition to clinical evaluation and self-reported scales, many neurophysiological, radiological and microscopic investigations may be performed. The management of NP following SCI is very difficult: evidence of effective drugs is lacking and alternative new treatment approaches yield different outcomes.

CONCLUSIONS

Recently clinical and instrumental tools have increased our knowledge on NP, suggesting that the discovery of new treatment agents will depend on an explanation of what changes after SCI: future research must point in this direction.

The role of surgical treatment in the rehabilitation protocols of thoraco-lumbar spine injuries

BACKGROUND

Rehabilitation is a crucial issue in the management of spinal cord injuries (SCI) but, in these patients, the primary treatment can bias the outcome of recovery protocols.

AIM

Purpose of this paper is to review our case load in the treatment of surgical failures and to define the role of surgery in thoraco-lumbar injuries rehabilitation.

PATIENTS AND METHODS

Between 2000 and 2009 seventy patients with post-traumatic paraplegia were referred to Surgical Department as rehabilitation was unfeasible due to inadequate spine injury treatment. Forty-six had had surgery, 24 were treated conservatively Twenty-five patients had a thoracic lesion, 9 a lumbar lesion and 36 a lesion of the thoraco-lumbar junction. A total of 44 surgical procedures were performed (by anterior, posterior or anterior-posterior).

RESULTS

On postoperative imaging sagittal alignment was found good in 93% of cases and acceptable in 7%. All patients regained the sitting position within 5 days after surgery. Wound healing problems requiring revision were observed in 4 cases. Major complications were a cerebro spinal fluid (CSF) leakage and a massive pulmonary embolism case in the early post-op.

CONCLUSIONS

Wrong primary treatment frequently leads to demanding revision procedures with increased risks for the patient and more than double costs for the health care system. Whatever the technique a stable spine is the target in surgery of SCI allowing a quick and effective rehabilitation without external orthosis.

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.

Aneurysmal bone cyst of the mobile spine: the therapeutic role of embolization

PURPOSE

Our aim is to define the role of embolization in the treatment of aneurysmal bone cyst of the spine in order to include this option in the decision making process.

METHODS

From April 2004 to November 2009, seven patients with primary aneurysmal bone cyst of the mobile spine treated by embolization have been prospectively followed-up. All clinical presentations and imagings were recorded. There are many options of embolic agent and techniques used, but all aim to devascularize the tumor. The therapeutic protocol includes: embolization repeated every 8 weeks until the appearance of radiographic signs of healing. Complications, rate of healing and clinical outcome were analyzed.

RESULTS

The number of embolizations varied from one to a maximum of seven without related intra- or post-operative complications. One patient, after four selective arterial embolizations, underwent direct percutaneous injection of embolic agents into the cyst. A clinical and radiographical response was achieved in all patients who were found alive and completely free of disease at mean follow-up of 46 months after last treatment and nobody crossed to surgical option.

CONCLUSION

Embolization seems to be the first option for spinal aneurysmal bone cyst treatment because of the best cost-to-benefit ratio. It is indicated in intact aneurysmal bone cyst, when diagnosis is certain, when technically feasible and safe and when no pathologic fracture or neurologic involvements are found. If embolization fails, other options for treatment would still be available.

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.

Ewing's sarcoma of the mobile spine

OBJECTIVES

To evaluate the role of enbloc resection on the oncological outcome of patients with Ewing's sarcoma of the mobile spine treated with systemic multiagent chemotherapy combined with radiation therapy. While the role of chemotherapy and radiation therapy is well known and accepted in the treatment of Ewing sarcoma, there is no consensus on the role of enbloc resection in those tumors occurring in the mobile spine and, therefore, it can be difficult to conclude the decision making process, particularly if to achieve a tumor-free margin resection functionally relevant structures should be sacrificed. The study design of this work was the retrospective analysis of a series of 27 cases of Ewing sarcoma of the mobile spine homogeneously treated.

METHODS

Twenty-seven patients with primary ES of the mobile spine were treated from 1979 to 2008 by the same multidisciplinary team. All the patients presented with pain. Motor deficits were present in 6 patients. All the patients were submitted to multiagent protocols of chemotherapy (always) and radiotherapy (alternative to surgery or associated to). Surgery was performed in 17 cases both for functional purpose (7 cases: intralesional piecemeal excision) both for curative purpose (10 cases: enbloc resection, resulting characterized by marginal/wide or intralesional margins). Patients were observed for a minimum of 2 years or until death. The mean follow-up time was 65 months (median 28 months; ranging 2 to 218 months). Neurological function, local recurrence, distant relapse, and treatment-related complications were evaluated.

RESULTS

Three periods were considered according to the evolution of therapeutic strategies. Four patients were treated in the period 1979 to 1982. All were submitted to chemotherapy (REA-2) and radiation therapy (RT). Two of them were submitted to intralesional excision. All these patients died 2 to 29 months later without significant difference in the two groups. In the period 1983 to 1990 all patients were treated with chemotherapy (REN-1/2) and RT. Two were submitted to intralesional excision and had a worse evolution as died of the disease at 2 and 11 months follow up, while the patients who did not received surgery evolved more favourably: 1 died of the disease 57 months after the end of the treatment, 3 are continuously disease free at 130, 190, 290 months. The sixteen patients treated in the period 1991 to 2008 received chemotherapy (REN-3 and ISG-SSG) and RT, combined with intralesional excision in 3, with enbloc with intralesional margins in 4, enbloc with tumor-free margins (wide or marginal) in 6. Only one patient submitted to tumor-free margin enbloc resection had local recurrence and died 29 months after the treatment (biopsy was performed by open approach), the other surviving continuously disease free at 17 to 193 months follow-up (av. 76 months). All the patients submitted to intralesional excision and to enbloc resection resulting in margin violation had the same prognosis, as died of the disease 10 to 63 months after the treatment. Only one of the 3 patients who had no surgery died of the disease 8 months after the treatment, the other surviving 9 and 49 months follow-up. Among the seven patients who had neurological symptoms at the occurrence, just those with no metastasis and who underwent enbloc resection are alive.

CONCLUSIONS

The current study seems to demonstrate that tumor-free margin enbloc resection provides better local control and longer survival, while the results after intralesional margin resection or piecemeal excision combined with chemotherapy and RT is less effective than chemotherapy and RT alone.

Spinal Infection Multidisciplinary Management Project (SIMP): From Diagnosis to Treatment Guideline

Spine infections require a multidisciplinary approach to be treated and solved. A guide line to drive physicians in the deep complexity of such a disease is extremely helpful. SIMP suggests a flow-chart built up on clear concepts such as right and well managed antibiotic therapy, sound stability of the spine, correct and smart use of the standard and functional imaging techniques, such as f18 FDG PET/CT. In 16 months a total of 41 patients have been treated for spondylodiscitis, discitis and vertebral osteomyelitis by our team of physicians and 25 patients have been enrolled in a prospective study whose target is the assessment of the SIMP flow-chart and of every single aspect that characterize it.

The surgical management of metastatic epidural compression of the spinal cord

Metastatic epidural compression of the spinal cord is a significant source of morbidity in patients with systemic cancer. With improved oncological treatment, survival in these patients is improving and metastatic cord compression is encountered increasingly often. The treatment is mostly palliative. Surgical management involves early circumferential decompression of the cord with concomitant stabilisation of the spine. Patients with radiosensitive tumours without cord compression benefit from radiotherapy. Spinal stereotactic radiosurgery and minimally invasive techniques, such as vertebroplasty and kyphoplasty, with or without radiofrequency ablation, are promising options for treatment and are beginning to be used in selected patients with spinal metastases. In this paper we review the surgical management of patients with metastatic epidural spinal cord compression.

A Little Talk on Adamkiewicz's Artery. Some Practical Considerations on the Pre-Operative Identification of this Artery Starting from a Single Team Experience in Pre-Surgical Selective Embolization of Vascularized Spinal Lesions

The major radicular artery eponymically named "Adamkiewicz's artery" (AKA) is an important vessel supplying the spinal cord, especially the lumbar enlargement. This report emphasizes the importance of anatomical knowledge of this artery and highlights the concept of the potential risk of neurological complications during different procedures: spine orthopedic/neurosurgery, aortic repair (vascular surgery) and endovascular selective embolizations performed by interventional neuro/radiologists. Anatomical considerations are made on the spinal cord arterial circulation with a special focus on the AKA. Our review of the literature considered this anatomical element essential to compare the potential risk of spinal cord ischemic damage during orthopedic/neurosurgical spine procedures, aortic vascular surgery repair procedures and endovascular selective arterial embolizations. Evaluation of the endovascular selective arterial spine embolization risk was based on our series of 410 embolization procedures. Spinal cord infarction and transient or permanent paraplegia may result from inadvertent interruption of the AKA. The presence of intersegmental collaterals may decrease the risk of spinal cord ischemia: this is an important element to bear in mind that may help in spine surgery or aortic repair procedures performed by vascular surgeons. Nevertheless, during aortic repair (open surgery or stent-graft procedures) interruption of bilateral segmental arteries at multiple consecutive levels including that of the AKA may occur thereby increasing the ischemic spinal cord risk, annulling the benefit of intersegmental collaterals. Accidental embolizations of the AKA during endovascular spine procedures (i.e. selective arterial embolizations) performed by interventional neuro/radiologists will cause an almost certain spinal cord infarction due to the consequent embolizations of the anterior spinal artery (ASA).

Outcomes of C1 and C2 posterior screw fixation for upper cervical spine fusion

To achieve stable fixation of the upper cervical spine in posterior fusions, the occiput is often included. With the newer techniques, excluding fixation to the occiput will retain the occiput-cervical motion, while still allowing a stable fixation. Harms's technique has been adapted at our institution and its effectiveness for indications such as C2 complex fractures and tumors using C1 or C2 as endpoints of a posterior fixation are reviewed. Fourteen cases were identified, consisting of one os odontoideum; four acute fractures and four non-unions of the odontoid; three tumors and two complex fractures of C2 vertebral body, and one C2-C3 post-traumatic instability. One misplaced screw without clinical consequences was the only complication recorded. Screw loosening or migration was not observed at follow-up, showing a stable fixation.

Spinal metastasis: a retrospective study validating the treatment algorithm

A retrospective clinical study was conducted to validating the treatment algorithm in patients with spinal metastasis. The study participants were 43 patients with spinal metastasis from carcinoma. Since most interventions are palliative we had to seek for clear definitions to describe the results, aiming to increase the quality of life. To this purpose, we would introduce the concept of "target achievement". We presume that the target is achieved when all the following findings are present: a survival rate which is not inferior to the average, improvement or the maintenance of the neurological condition and achievement of local control. The results of this study demonstrate that performing the treatment suggested by the algorithm, the majority of the patients have a good residual quality of life. Worse results are obtained when a more aggressive treatment is selected.

[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.

Solitary plasmacytoma of the spine: a 22 years follow-up case report

BACKGROUND AND OBJECTIVES

Plasmacytoma is a systemic malignancy and it is the most frequent primary tumor affecting the skeleton. Progression from solitary plasmacytoma to systemic diffusion is reported to be 65-100% in 15 years. A case report of a rare 22-year follow-up of a thoracic solitary plasmacytoma is here presented.

MATERIAL AND METHODS

Clinical case analysis, radiographs, magnetic resonance images and histological sections of the lesion are discussed. Repeated surgical interventions were required due to progression and local recurrence of disease.

RESULTS

Although the inadequate surgical treatment, low response to chemotherapy and radiation therapy, and many local recurrences, no systemic diffusion of the disease was observed in 22 years.

DISCUSSION

Aggressive surgery may be indicated in young patients with isolated lesion and good prognostic factors. Palliative surgery remains necessary in order to decompress the cord and to stabilize the spine.

Acute paraplegia by epidural abscess: full neurological recovery following surgical decompression

Authors report a case of acute paraplegia due to an epidural spinal abscess caused by a heroin injection that happened four months before. A complete neurological recovery is obtained by surgical decompression and antibiotic therapy despite the preoperative neurological status. The need for a surgical stabilization following extensive laminectomy is discussed.

Interlocking nail for femoral shaft fractures: is dynamization always necessary?

A series of 179 closed femoral fractures treated by static interlocking nailing (Grosse-Kempf nail) was reviewed to evaluate the effect of dynamization on the time to bony union. In 75 patients, dynamization was performed whereas in 104 the implant was left static. Union occurred in 178 patients. We observed one infection. Time to union was significantly shorter in the static group (103 days) compared to the dynamized group (126 days).

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.

Presurgical embolization of spinal tumours using glubran 2 acrylic glue

SUMMARY

This study aimed to define the indications, technique and results of presurgical embolization of spinal tumours using Glubran 2 acrylic glue. Embolization was performed prior to surgery in eight patients with benign tumours and 11 patients with malignant lesions. The main embolization agent used was Glubran 2, a new acrylic glue with the EC mark, suitable for permanent embolization of the pathological circulation of primary and secondary spinal tumours. All the procedures were technically feasible and achieved partial or complete embolization of the vascularized lesion without periprocedural complications. Glubran 2 proved easy to use with excellent intravascular penetration achieving permanent embolization. The degree of presurgical embolization in terms of surgical field haemostasis was correlated with the degree of vascular occlusion achieved.

Vertebral hemi-resection for bone tumor with wide invasion of the vertebral canal: modified surgical method

The authors describe a variation in the method of vertebral hemi-resection used for the treatment of neoplasms that present a wide invasion of the vertebral canal. This is followed by a review of the literature on the subject.

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.

Retrograde intramedullary osteosynthesis of femoral fracture: preliminary results of Maggiore Hospital

The Distal Femoral Nail (DFN), Mathys Medical Ltd. Switzerland) was used in our division for the treatment of fractures of the distal metaepiphysis, and in some cases of the diaphysis, of the femur. A total of 16 cases treated over 30 months, between October 2000 and March 2003 (minimum 6, maximum 61 months), were analyzed retrospectively. A total of 11 metaepiphyseal fractures (65%) and 6 diaphyseal fractures (35%) were treated. Consolidation of the fracture was observed in 15 cases out of 16 (equal to 93.8%) with a mean time of 140 days (minimum 120 days, maximum 240 days) after surgery. Mean flexion of the knee equal to 90 degrees and 3 cases of stiffness with lower mobility at 45 degrees were observed: in 2 cases stiffness was of extra-articular origin caused by exuberant bone callus. There were no iatrogenic complications of the vascular type, nor were there infections, or cases of implant loosening. Shortening (1 cm) in a type B2 fracture (based on the AO classification) was observed. The results we obtained suggest that DFN represents a valid alternative to the open treatment of fractures of the distal metaphysis of the femur; in cases of patients with multiple trauma or in elderly patients where invasiveness is reduced, importance is awarded to less blood loss, a shorter amount of time required for surgery, and early mobilization and weight-bearing.

Allogeneic gene-modified tumour cells in metastatic kidney cancer. Preliminary report

An allogeneic irradiated RCC cell line, engineered to produce IL-2 (ACHN-IL-2), admixed with autologous metastatic formalin-treated tumour cells, was used to vaccinate ten MRCC patients in progression of disease in spite of IL-2 immunotherapy. The cells were administered subcutaneously and/or intra-tumourally. Sixty-four MRCC patients in progressive disease, not treated by vaccination but receiving similar IL-2 immunotherapy, were considered as the control group. Patients received 4-16 injections (mean 9 +/- 4), containing an average of 10.6 x 10(7) +/- 7.7 x 10(7) ACHN-IL-2-transfected cells (a minimum of 4 x 10(7), and a maximum of 31 x 10(7)). Four patients also received intra-tumour injections. Vaccination was administered during 30-418 days, and the follow-up continued for 649 +/- 353 days (190-1342). Throughout this period, the patients continued receiving the previously set immunotherapy treatment. No adverse side effects related to the treatment were observed. One complete and one partial tumour response were observed, as well as two stable and one no-relapse disease. All but one patient died. Responding patients resumed progression in 4-11 months and died 18 and 36 months after beginning the vaccine therapy. In spite of the small number of treated patients, Wilcoxon's test showed a significant (P < 0.05) improvement of the survival in the vaccinated group compared to that of the control. The described vaccination protocol seems safe, devoid of adverse side effects and promising. It warrants further investigation.

Distal diaphyseal fractures of the tibia treated by modified Grosse-Kempf nail

Fractures of the distal fourth of tibia are difficult to treat because of the possible involvement of the joint, the comminution of the fragments, the local skin conditions and the surgical method required. There are many methods of osteosynthesis, and these range from external fixation to use of a plate to combined methods. Intramedullary nailing is generally not indicated in the treatment of such fractures, but if the correct technical procedure is used, indications may be widened, and the method may even be used in cases such as these. It is necessary to saw the tip of the nail so that the distal holes go beyond the fracture line. A total of 30 cases of fracture of the distal fourth of the tibia treated by Grosse-Kempf nailing sawed distally are reported.