Posterior fixation of thoracolumbar burst fractures: Is it possible to protect one segment in the lumbar region?

Background

The treatment for thoracolumbar burst fractures is controversial. The aim of this retrospective study was to compare intermediate-segment (IS) and long-segment (LS) instrumentation in the treatment for these fractures.

Methods

IS instrumentation was considered as pedicle fixation two levels above and one level below the fractured vertebra (infra-laminar hooks attached to lower vertebra with pedicle screws). LS instrumentation was done two levels above and two levels below the fractured vertebra. Among a total of 25 consecutive patients, Group 1 included ten patients treated by IS pedicle fixation, whereas Group 2 included fifteen patients treated by LS instrumentation.

Results

The measurements of local kyphosis (p = 0.955), sagittal index (p = 0.128), anterior vertebral height compression (p = 0.230) and canal diameter expansion (p = 0.839) demonstrated similar improvement at the final follow-up between the two groups. However, there was a significant difference (p < 0.05) between Group 1 and Group 2 regarding clinical outcome [Hannover scoring system, Oswestry disability questionnaire and the range of motion of the lumbar region compared to neutral (0°)].

Conclusions

The radiographic parameters were the same between the two groups. However, the clinical parameters demonstrated that IS instrumentation is a more effective management of thoracolumbar burst fractures.     

Is it possible to cure the symptoms of the overactive bladder in women?

Purpose

To evaluate the feasibility of discontinuing treatment with mirabegron once symptoms have subsided in patients with overactive bladder (OAB).

Methods

The present study evaluated a total of 159 female OAB patients (age 62.9 ± 12.36), each of which were prescribed 50 mg/day mirabegron (Time point 1—T1). Data obtained from voiding diaries and patient-reported outcome variables were assessed during follow-up visits at months 1, 3, 6, 12, 18 (T2), and 21 (T4). At the 18-month visit, patients with an Urgency Bother-Visual Analog Scale score of ≤ 50% were advised to stop treatment with mirabegron. Upon re-emergence or worsening of OAB symptoms, patients were allowed to start taking medication again at their discretion (T3). Statistical analysis was performed using a Chi-square test. An ANOVA analysis and a two-sample t test were used to evaluate differences between groups.

Results

A total of 56 out of 159 (35.3%) patients took 50 mg of mirabegron daily between T1 and T2. A total of 17 out of 56 patients (30.4%) did not meet the criteria for mirabegron discontinuation (Group A). A total of 24 out of 56 patients (42.9%) stopped taking the medication temporarily, but later returned to treatment (Group B). The average time span between T2 and T3 was 53.9 days. Fifteen of 56 patients (26.8%) ceased treatment with mirabegron without starting it again before T4 (Group C). The average time span between T2 and T4, in Group C, was 124.7 days.

Conclusion

A small percentage of OAB patients were able to discontinue mirabegron due to symptom cessation.

     

Fibula fixation in the treatment of tibial pilon fractures – Is it really necessary?

BackgroundThere is a lack of consensus about the role of fibula fixation in these complex fractures, with only two clinical studies in the literature. We hypothesize that the fibula fracture need not be fixed in the tibial pilon fractures if primary stability can be achieved with tibial fixation alone.MethodsWe reviewed 79 patients with operatively treated tibial pilon with associated fibula fractures from 2007 to 2017 and divided them into two groups; patients with fibula fracture fixation and those without fixation. The primary outcome measure was any mechanical complications. Secondary outcomes were wound complications and other morbidities.ResultsThere were 54 (68.4%) patients with fibula fixation and 25 (31.6%) patients without fixation. There were no statistically significant differences in mechanical complications between the two groups. However, patients without fibula fixation were noted to have more wound complications (44% vs 25.9%, p = 0.108) although this was not statistically significant. In terms of removal of implant (ROI), there were no differences noted in patients with or without fibula fixation (33.3% vs 28%, p = 0.796). There were also no significant differences in ROI for those fixed with plate and screws when compared to those fixed with Rush rod and K wire within the group with fibula fixation.ConclusionFibula fixation in the treatment of tibial pilon fractures is not routinely necessary and does not result in decreased mechanical complications such as malunion, delayed union, nonunion and implant failure. Fibula fracture fixation should be reserved for cases where it may aid reduction or provide additional stability.     

Is it possible to do without the study of myocardial perfusion in 2013?

The analysis of myocardial perfusion is a key step in the cardiac MRI examination. In routine work, this exploration carried out at rest is based on the qualitative first pass study of gadolinium with an ECG-triggered saturation recovery bFFE sequence. In view of recent knowledge, the analysis of the myocardial perfusion under vasodilator stress may be carried out by scintigraphy or MRI, the latter benefiting from the absence of exposure to ionizing rays and a lower cost. Besides coronary disease, the perfusion sequence provides a rich semiology to compare with the clinics and the data from other sequences. Arterial Spin Labeling (ASL) is an alternative technique used in the animal to quantify myocardial perfusion.     

Aortic dissection in the second trimester of pregnancy: is it possible to save both lives?

Aortic dissection during pregnancy is a potentially catastrophic clinical condition and can be lethal to both mother and fetus. The treatment of aortic dissection in pregnancy is based on location, severity, and gestational age. We report a case of acute aortic dissection in a 30-year-old female patient in her 26th week of gestation. Ascending aorta resection and interposition of a 26-mm Dacron graft was carried out without circulatory arrest by means of a double-felt "sandwich" technique on both anastomoses. The patient was discharged from the hospital 10 days after her initial admission. At the 34th week of gestation, the patient delivered a healthy baby by cesarean section. Because our patient was hemodynamically unstable, our aim at the 26th week of gestation was to perform a simplified surgical procedure, to avoid circulatory arrest, and to maintain a high perfusion pressure, in order to save the patient's life and to decrease the potential risk of damage to the fetus.     

Does neurological recovery in thoracolumbar and lumbar burst fractures depend on the extent of canal compromise?

STUDY DESIGN: Prospective study. OBJECTIVES: Forty-five consecutive cases of thoracolumbar and lumbar burst fractures treated non-operatively were analyzed to correlate the extent of canal compromise at the time of injury with (i) the initial neurologic deficit and (ii) with the extent of neurological recovery at 1 year. The effect of spinal canal remodeling on neurological recovery was also analyzed. SETTING: University teaching hospital in south India. METHODS: The degree of spinal canal compromise and canal remodeling were assessed from computed tomography scans. The neurologic status was assessed by Frankel's grading. RESULTS: The mean canal compromise in patients with neurologic deficit was 46.2% while in patients with no neurological deficit it was 36.3%. The mean spinal canal compromise in patients with neurological recovery was 46.1% and 48.4% in those with no recovery. The amount of canal remodeling in patients who recovered was 51.7% and 46.1% in the patients who did not recover. None of these differences was statistically significant. CONCLUSION: This study shows that there is no correlation between the neurologic deficit and subsequent recovery with the extent of spinal canal compromise in thoracolumbar burst fractures.     

Is it useful to apply transpedicular intracorporeal bone grafting to unstable thoracolumbar fractures? A systematic review

Background

The debate over the use of intracorporeal bone graft in treating unstable thoracolumbar fractures continues. We compiled evidence for the effect of transpedicular intracorporeal bone grafting (TPG) on outcome in patients with traumatic thoracolumbar fractures.

Method

A systematic review was conducted to compare the outcomes of short segment fixation and posterolateral fusion (PLF) with or without TPG. We reviewed articles in PubMed, Ovid, and the Cochrane Database published between January 1995 and August 2011. The correction loss and hardware failure between TPG and TPG+PLF were compared. We assessed the methodological quality of the studies according to the inclusion criteria.

Result

We divided 19 papers, involving 22 series, into two groups: posterolateral fusion, and posterolateral fusion combined with intracorporeal bone graft. Meta-analysis regression revealed statistically significant differences in correction loss and hardware failure between the two groups. There were no statistically significant differences in average age, follow-up period, fracture levels, or application of orthosis rate between the two groups.

Conclusion

PLF+TPG reduces hardware failure and correction loss compared with PLF alone. It also minimizes the likelihood of severe correction loss. For serious spinal injury cases, PLF+TPG was recommended to improve the prognosis. Further studies would be useful in determining the benefits of applying this method to the treatment of unstable thoracolumbar fractures.     

Is it possible to intraoperatively modulate the extent of thyroidectomy in small papillary thyroid carcinoma?

BackgroundThyroid lobectomy is the preferred option for small, unifocal papillary thyroid carcinoma. Involvement of the central neck lymph nodes is an indication for total thyroidectomy plus central neck dissection. We aimed to verify if frozen section examination of ipsilateral central neck nodes can identify the subgroup of patients scheduled for thyroid lobectomy intraoperatively who could benefit of more extensive initial operative treatment.MethodsNinety-four consenting patients with clinically unifocal cN0 papillary thyroid carcinoma underwent thyroid lobectomy plus ipsilateral central neck dissection with frozen section examination. If the frozen section examination was positive for metastases, a completion thyroidectomy and a bilateral central neck dissection were accomplished during the same procedure.ResultsFrozen section examination identified occult nodal metastases in 25 of the 94 patients who then underwent immediate completion thyroidectomy and bilateral central neck dissection. Overall, central neck node metastases were found at final histology in 35 cases: occult micrometastases were observed in additional 9 patients and nodal metastases ≥2 mm in additional 1 patient.ConclusionIntraoperative assessment of nodal status obtained with ipsilateral central neck dissection and frozen section examination is able to change the extent of thyroidectomy in about one-fourth of patients scheduled for thyroid lobectomy. Frozen section examination appears a safe and effective strategy to decrease the need of a second-step completion procedure and, theoretically, the risk of recurrence.     

Cost-effectiveness of the treatment of traumatic thoracolumbar spine fractures: Nonsurgical or surgical therapy?

Background:

Spinal fractures can be an important cause for disabling back pain. Therefore, in judging the cost-effectiveness of nonsurgical or surgical therapy, not only direct costs but also the indirect costs should be calculated. In this prospective randomized study, the costs incurred by nonsurgically and surgically treated patients with a traumatic thoracolumbar spine fracture without neurological involvement were analysed.

Materials and Methods:

32 patients with a traumatic thoracolumbar spine fracture were prospectively randomized for operative or nonsurgical treatment. Patients were sent a questionnaire every three months to inquire about work-status, additional health costs and doctor visits. The patients who have minimum followup of two years were included.

Results:

Of thirty-two patients, 30 met the criterion of the followup period of at least two years. Fourteen patients received nonsurgical therapy, while 16 received surgical treatment. Direct costs of the treatment of nonsurgically treated patients were €10,608 ($12,730). For the operatively treated group, these costs were €18,769 ($22,523). Indirect costs resulted in a total of €219,187 ($263,025) per nonoperatively treated patient. In the operatively treated group, these costs were €66,004 ($79,206).

Conclusion:

In the treatment of traumatic thoracolumbar spine fractures, the indirect costs exceed the direct costs by far and make up 95.4% of the total costs for treatment in nonsurgically treated patients and 71.6% of the total costs in the operative group. In view of cost-effectiveness, the operative therapy of traumatic thoracolumbar spine fractures is to be preferred.     

Is it possible to preserve lumbar lordosis after hybrid stabilization? Preliminary results of a novel rigid–dynamic stabilization system in degenerative lumbar pathologies

Purpose of the study

To evaluate the results of a novel rigid–dynamic stabilization technique in lumbar degenerative segment diseases (DSD), expressly pointing out the preservation of postoperative lumbar lordosis (LL).

Materials and methods

Forty-one patients with one level lumbar DSD and initial disc degeneration at the adjacent level were treated. Circumferential lumbar arthrodesis and posterior hybrid instrumentation were performed to preserve an initial disc degeneration above the segment that has to be fused. Clinical and spino-pelvic parameters were evaluated pre- and postoperatively.

Results

At 2-year follow-up, a significant improvement of clinical outcomes was reported. No statistically significant difference was noted between postoperative and 2-year follow-up in LL and in disc/vertebral body height ratio at the upper adjacent fusion level.

Conclusions

When properly selected, this technique leads to good results. A proper LL should be achieved after any hybrid stabilization to preserve the segment above the fusion.

     

Is it possible to reduce the number of endomyocardial biopsies with new immunosuppressive drugs?

INTRODUCTION: Using previous immunosuppressive regimens the considerable number of rejections of heart transplantations required routine surveillance myocardial biopsies, particularly during the early months. More effective immunosuppressive regimens would probably allow routine biopsies to be reduced. Our objectives were to assess the incidence of and the time to rejection with a new immunosuppressive protocol, considering the possibility of reducing the number of routine biopsies. MATERIALS AND METHODS: We undertook a retrospective study of patients who had undergone heart transplantation from January 2002 to August 2005 and who received induction therapy with Daclizumab (two doses) and maintenance therapy with tacrolimus + mycophenolate + low doses of steroids. RESULTS: Among 42 patients, 13 (31%) showed myocardial rejection in the first 3 months. All episodes were grade 3A and none had hemodynamic consequences. After 3 months, three patients (7.1%) experienced 3A rejection and 1 (2.4%), grade 4 acute rejection after ceasing medical treatment. Each episode of rejection was predictable, either owing to reduction in immunosuppression therapy or to a previous history of rejection. CONCLUSIONS: The majority of rejection episodes occur in the first 3 months posttransplantation. After that time, the incidence of rejection is less and clinically predictable. Therefore, surveillance biopsies should be limited to the first 3 months, and performed later either in symptomatic patients (with a history of previous rejection) or in those whose immunosuppressive therapy needs to be reduced.     

Is there a need for lumbar orthosis in mild compression fractures of the thoracolumbar spine?: A retrospective study comparing the radiographic results between early ambulation with and without lumbar orthosis

Compression fractures of the thoracolumbar spine are common in spinal trauma. Most patients are treated with early ambulation. Bracing is an option not always recommended by the treating team. There are no definite recommendations so far regarding the need for lumbar orthosis in this type of injury. The authors retrospectively compared two methods for treating patients with compression as great as 30%: early ambulation with and without lumbar orthosis. The results show that although demographic variables, type of injury, and cause of injury were similar between the groups, neither treatment emerged as superior. Thoracolumbar fractures with compression as much as 30% can be treated with early ambulation and no external support. Close clinical and radiographic follow-up is essential.