Pyogenic spondylodiscitis of the thoracic and lumbar spine : a new classification and guide for surgical decision-making

Despite modern diagnostic imaging options pyogenic infections of the spine are often detected tardily and therefore accompanied by a high mortality rate. To ensure an efficient and adequate therapy it is necessary to identify and treat the focus of inflammation. The recommendations for the operative strategy are still a highly controversial issue. On the other hand no classification and guidelines for surgical treatment and treatment strategies of pyogenic spinal infection have yet been published. Pyogenic spinal infections are often underestimated in frequency of occurrence and severity of symptoms. From 1994 until 2008, 269?patients suffering from an infection of the thoracic and lumbar spine were treated in the Department of Orthopedic Surgery Heidelberg and 221?patients underwent surgery. Within the scope of a clinical trial clinical aspects and therapeutic consequences of patients with pyogenic spinal infections were retrospectively investigated. Based on the study data a classification of pyogenic spinal infections of the thoracic and lumbar spine and a guide for surgical decision-making was developed.     

Fractures and fractures-dislocations of the lumbar spine a retrospective study of 70 patients

Summary A retrospective study was undertaken to analyse and compare the results of Harrington instrumentation with postural reduction and nursing in patients with fractures and fracture-dislocations of the lumbar spine.Thirty patients were treated by postural reduction and nursing, and 38 underwent early surgical reduction and internal fixation with Harrington instrumentation, together with a posterior fusion in three patients and an anterior fusion at the level of the fracture in another two patients. External splintage was used in only one patient in the series. At an average follow up of 5.9 years, bony deformity quantified by angulation, displacement and the vertebral wedge index was greater in the conservative group than in the group treated surgically. No significant difference was observed in comparing the rates of neurological recovery in the two groups. At follow up, patients with no symptoms had less severe bony deformity. Loss of fixation of Harrington instrumentation occurred in 46% of patients treated by this method. The incidence of other complications was not significantly different in the two groups.Despite the unacceptably high rate of local complications, Harrington instrumentation achieved better correction of bony deformity than postural reduction and nursing, prevented progression of deformity and decreased the incidence of symptoms at follow up.This study indicates that in these injuries bony deformity can be satisfactorily corrected by early Harrington instrumentation alone, without spinal fusion and bracing, provided an exacting surgical technique is employed.Read in part at the Annual Meeting of the Australian Orthopaedic Association, Hobart, Australia, October, 1984, and at the Annual Meeting of the International Society for the Study of the Lumbar Spine, Sydney, Australia, 19th April, 1985     

Association between MRI findings and clinical outcomes in a period of 5 years after lumbar spine microdiscectomy

European Journal of Orthopaedic Surgery & Traumatology - To evaluate the associations between magnetic resonance imaging (MRI) findings and pain, disability and quality of life before surgery...     

Outcome between surgical and non-surgical treatment of metastatic tumors of the spine: a retrospective study of 259 patients

AIM: The purpose of this study was to evaluate the clinical outcome of patients with metastatic tumors of the spine after surgical and non-surgical treatment. METHODS: The charts of 259 patients with metastatic tumors of the spine were reviewed retrospectively to define predictors of outcome. Our data included patient demographics, primary tumor, location of the metastatic tumor within the spine, indication for surgical or non-surgical treatment, type of surgical and non-surgical intervention, post-treatment outcome in terms of neurology, use of adjuvant radiation therapy or systemic therapy. RESULTS: The most frequent indication for surgical treatment was the combination of neurological deficit (ND), pathological vertebral fracture, and pain (50 %). Surgical intervention was performed by the posterior approach in 67 %, by the anterior approach in 13 %, and by an anterior/posterior approach in 10 %. The post-surgical outcome, depending on the type of surgical approach in terms of ND, was for the posterior approach 29 % improved, for the anterior approach 53 % improved, and for the anterior/posterior approach 15 % improved. DISCUSSION: Our data suggest that the indications for metastatic tumor surgery in the spine depend on the location of the metastatic tumor in the spine, clinical symptoms, and prognosis.     

Applicability of the Clavien-Dindo classification to emergency surgical procedures: a retrospective cohort study on 444 consecutive patients

Background

Patients undergoing emergency surgery have a high risk for surgical complications and death. The Clavien-Dindo classification has been developed and validated in elective general surgical patients, but has not been validated in emergency surgical patients. The aim of the current study was to evaluate the Clavien-Dindo classification of surgical complications in emergency surgical patients and to study preoperative factors for risk stratification that should be included into a database of surgical complications.

Methods

A cohort of 444 consecutive patients having emergency general surgery during a three-month period was retrospectively analyzed. Surgical complications were classified according to the Clavien-Dindo classification. Preoperative risk factors for complications were studied using logistic regression analysis.

Results

Preoperatively 37 (8.3%) patients had organ dysfunctions. Emergency surgical patients required a new definition for Grade IV complications (organ dysfunctions). Only new onset organ dysfunctions or complications that significantly contributed to worsening of pre-operative organ dysfunctions were classified as grade IV complications. Postoperative complications developed in 115 (25.9%) patients, and 14 (3.2%) patients developed grade IV complication. Charlson comorbidity index, preoperative organ dysfunction and the type of surgery predicted postoperative complications.

Conclusions

The Clavien-Dindo classification of surgical complications can be used in emergency surgical patients but preoperative organ dysfunctions should be taken into account when defining postoperative grade IV complications. For risk stratification patients’ comorbidities, preoperative organ dysfunctions and the type of surgery should be taken into consideration.

     

MRI and its role in the evaluation and surgical decision making in patients with challenging IPP presentations: descriptions of MRI findings and algorithm for patient management

Study Type – Diagnostic (case series) Level of Evidence 4 What's known on the subject? and What does the study add? It is known that magnetic resonance imaging (MRI) is safe and effective for imaging patients with inflatable penile prostheses (IPPs). Previous series have reported results of MRI for imaging series of patients with IPPs. The impact on management in particular with regard to salvage procedures is not well defined. This study represents the largest known experience with MRI evaluation of IPPs. This also provides an algorithm that assists with decisions regarding utilization of MRI and treatment planning based on results.

OBJECTIVE

• ? In some patients who undergo placement of an inflatable penile prosthesis (IPP) the device may function inadequately. We describe the use of magnetic resonance imaging (MRI) for anatomical localization and detection of prosthesis malrotation, angulation, displacement and erosion in IPPs with equivocal clinical examination.

PATIENTS AND METHODS

• ? We prospectively performed MRI by a defined protocol including T1‐weighted imaging, and transaxial, sagittal and coronal fat‐saturated fast spin‐echo T2‐weighted imaging in both deflated and inflated states to evaluate patients seen at our referral centre for IPP‐related complaints.
• ? We retrospectively reviewed 32 such MRI studies performed as a supplement to clinical examination between 2000 and 2008.

RESULTS

• ? Of 32 cases, 75% (24/32) underwent surgical intervention. Of these, 45% (11/24) underwent device salvage procedures including cylinder revision in 33% (8/24), cylinder replacement in 8% (2/24) and pump replacement in 4% (1/24).
• ? MRI was most useful for determination of surgical approach in those with abnormal physical examination, and for justification of either surgical or expectant management in those with indeterminate physical examination.

CONCLUSIONS

• ? MRI is safe and effective for imaging genitourinary prostheses.
• ? We found MRI to be a valuable adjunct for evaluation of IPP‐related complaints when clinical examination is equivocal as it detected a variety of prosthetic and corporal abnormalities and impacted management decisions regarding observation, replacement or device salvage procedures.
• ? We provide technique, results and an algorithm that can be beneficial in this complex subset of patients.

     

Correlation between disability and MRI findings in lumbar spinal stenosis: a prospective study of 109 patients operated on by decompression

Background and purpose

MRI is the modality of choice when diagnosing spinal stenosis but it also shows that stenosis is prevalent in asymptomatic subjects over 60. The relationship between preoperative health-related quality of life, functional status, leg and back pain, and the objectively measured dural sac area in single and multilevel stenosis is unknown. We assessed this relationship in a prospective study.

Patients and methods

The cohort included 109 consecutive patients with central spinal stenosis operated on with decompressive laminectomy or laminotomy. Preoperatively, all patients completed the questionnaires for EQ-5D, SF-36, Oswestry disability index (ODI), estimated walking distance and leg and back pain (VAS). The cross-sectional area of the dural sac was measured at relevant disc levels in mm², and spondylolisthesis was measured in mm. For comparison, the area of the most narrow level, the number of levels with dural sac area < 70 mm², and spondylolisthesis were studied.

Results

Before surgery, patients with central spinal stenosis had low HRLQoL and functional status, and high pain levels. Patients with multilevel stenosis had better general health (p = 0.04) and less leg and back pain despite having smaller dural sac area than patients with single-level stenosis. There was a poor correlation between walking distance, ODI, the SF-36, EQ-5D, and leg and back pain levels on the one hand and dural sac area on the other. Women more often had multilevel spinal stenosis (p = 0.05) and spondylolisthesis (p < 0.001). Spondylolisthetic patients more often had small dural sac area (p = 0.04) and multilevel stenosis (p = 0.06).

Interpretation

Our findings indicate that HRQoL, function, and pain measured preoperatively correlate with morphological changes on MRI to a limited extent.MRI plays a central role in the diagnosis of spinal stenosis. Despite this, the correlation between MRI characteristics and clinical symptoms remains elusive as a considerable number of asymptomatic subjects have MRI-verified spinal stenosis (Boden et al. 1990). The relationship between the hard pathomorphological data as seen on MRI and the more subjective data from accepted outcome tools in terms of HRLQoL, functional status, and pain is unknown but is clinically relevant.The absolute reduced cross-sectional area that gives neurological symptoms of central spinal stenosis has been estimated to be around 75 mm² (critical size) (Schönström 1988) and some studies today use a value of 70–80 mm² as a definition of spinal stenosis (Malmivaara et al. 2007). Since MRI is used for the preoperative planning, any correlation between MRI findings and preoperative symptoms and disability would be of interestWe therefore investigated the relationship between the minimal dural sac area (mm²), number of levels with stenosis, and spondylolisthesis in relation to preoperative subjective measures of disease in terms of: self reported walking distance, the visual analog scale (VAS) for leg and back pain, Oswestry disability index, the 4 physical domains of the SF-36, and the EQ-5D.     

Single-stage posterolateral vertebrectomy for the management of metastatic disease of the thoracic and lumbar spine: a prospective study of an evolving surgical technique

Appropriate surgical management of spinal metastases combines maximal neural decompression with simultaneous immediate spinal column stabilization in the context of a paliative operation undertaken to improve patients' quality of life. We have used a single-stage posterolateral vertebrectomy (SPLV) for disease of the lumbar spine, combined with bilateral costotransversectomies in the thoracic spine, for these challenging cases. In this prospective cohort study of 96 consecutive patients with metastatic disease of the spinal column for we describe our surgical technique in detail, we examine our learning curve in its use and we analyze the long-term surgical and "quality of life" results in 42 patients who underwent SPLV. The mean and maximum operative blood loss was significantly lower for the SPLV group when compared with combined approaches. All patients either remained neurologically stable or had improved with surgery. Both the mean and the range visual analog scale scores were significantly improved after the SPLV. The SPLV was the only surgical approach to demonstrate a statistically significant improvement in Eastern Cooperative Oncology Group scores at 3 months after the surgery. Seventy-five percent of patients were alive at 6 months and 50% of patients survived for more than 12 months after the surgery. Eleven patients had a major complication (26%) with 9 (21%) patients required early reoperation, 7 of them for wound failure. Our data demonstrates that the SPLV represents a technically achievable improvement in surgical approach to spinal metastases when key parameters are examined. On the basis of these results, we recommend that the SPLV should be considered in all cases where resection of thoracic or lumbar spinal metastatic disease and reconstruction is contemplated.     

Recurrence factors in patients with Keratinizing squamous metaplasia of the bladder after surgical management: a single-center retrospective study

BackgroundKeratinizing squamous metaplasia (KSM) is a clinically heterogeneous disease that lacks research that provide definitive recurrent risk factors. Therefore, we identified the recurrence factors in patients with KSM of the bladder after transurethral resection (TUR). We also attempted to investigate the association between KSM and bladder cancer.MethodsClinical information of 257 patients diagnosed with KSM who underwent TUR in Xiangya Hospital from January 2010 to November 2018 were retrospectively collected. Clinical information was available for follow-up of 223 patients. To determine the risk factors for recurrence, we conducted univariate and multivariate cox regression analysis respectively. To explore the association between KSM and bladder cancer, we used clinical follow-up data.ResultsThe median follow-up time is 49 (IQR, 12–121) months. Five-year recurrence-free rate (RFR) and 1-year RFR were 86.1% and 91.9%, respectively. Thirty-one patients (13.9%) relapsed of KSM after a median follow-up of 49 months (range, 12–121 months), and none of them developed subsequent bladder cancer. Univariate Cox analysis indicated that urinary tract infection [hazard ratio (HR) =2.111; 95% confidence interval (CI): 1.043–4.271; P=0.038], and atypical urothelial hyperplasia of the bladder (HR =4.191; 95% CI: 2.006–8.756; P<0.001) were significant recurrence factors. Multivariate Cox analysis suggested that atypical urothelial hyperplasia of the bladder (HR =3.506; 95% CI: 1.663–7.392; P=0.001) was the independent risk factor for postoperative recurrence of KSM.ConclusionsThe recurrence rate in patients with KSM was about 13.9%, and atypical urothelial hyperplasia of the bladder was the independent risk factor in patients with KSM recurrence. In cases with bladder atypical urothelial hyperplasia, close follow-ups are necessary. Also, we demonstrated that KSM did not increase the subsequent risk of bladder cancer.     

Far lateral lumbar disc herniations and associated structural abnormalities. An evaluation in 60 patients of the comparative value of CT, MRI, and myelo-CT in diagnosis and management

The management of 60 patients with far lateral lumbar disc herniations operated on over a 5-year period are presented. These lesions were located superiorly within the neural foramens beneath or distal to the facet joints. The type of surgery performed in 43 of 60 (72%) of these patients was significantly altered by the presence of diffuse and lateral recess stenosis. This was better appreciated on the myelogram and myelo-CT (M-CT) studies than with the noncontrast CT and MRI examinations alone. Myelo-CT findings were particularly valuable in assessing patients who had previous surgical procedures.     

Impact of a multidisciplinary pain program for the management of chronic low back pain in patients undergoing spine surgery and primary total hip replacement: a retrospective cohort study

Background

Low back pain is a very common disorder. In this field chronic low back pain represents a special challenge. The management of chronic low back pain consists of a range of different intervention strategies. Usually operative intervention should be avoided if possible. However, there are constellations were surgical therapy in patients with chronic low back pain seems to be meaningful.The aim of this study was to investigate the clinical outcomes after spine surgery and hip replacement in patients with chronic low back pain after undergoing a structured rehabilitation program including cognitive – behavioral therapy.

Methods

From January 1, 2007 to January 1, 2010 patients were indicated for total hip replacement (THA) or spine surgery after receiving inpatient multidisciplinary pain programs including cognitive – behavioral therapy at our orthopedic institute with a specialized unit for the rehabilitation of chronic pain patients. Indications for surgery were based on the synopsis of clinical and imaging findings and on positive effects after local injections during the multidisciplinary pain program. The tools for assessment included follow-up at 6 and 12 months and analyses of pain, chronicity, physical functioning and depression.

Results

Of the 256 patients admitted for multidisciplinary pain program, fifteen were indicated to benefit from a surgical intervention during multidisciplinary pain program. Ten patients received spine surgery. THA was indicated in five patients. In all cases, the peri- and postoperative clinical courses were uneventful. Only two of the patients subjected to spine surgery and three patients who had THA were improved after 12 months. One patient reported a worsened condition. All patients presented with good functional outcomes and normal radiological findings.

Conclusions

The indication for surgical intervention in patients with chronic low back pain and degenerative diseases must be critically assessed. THA in this cohort should focus on functional aspects, such as the improvement of range of motion, rather than the reduction of pain. Spine surgery in chronic low back pain patients after multidisciplinary pain program including cognitive – behavioral therapy cannot be recommended due to its questionable success.

     

Factors associated with lumbar disc high-intensity zone (HIZ) on T2-weighted magnetic resonance image: a retrospective study of 3185 discs in 637 patients

Background

It is well known that internal disc disruption (IDD) is accelerated by factors such as aging and injury. High- intensity zone (HIZ) on lumbar MRI is usually considered a marker of painful IDD. However, many painful IDD show no HIZ. This suggests that the risk factors of HIZ may be different to these of IDD. The purpose was to clarify the correlation between the HIZ on lumbar MR and the factors, including gender, age, body weight, and low back pain (LBP).

Methods

Characteristics were obtained from the medical record. The MR images, biplanar post-discography radiographs, and post-discography CT images were reviewed and rated by two experienced radiologists in a blinded fashion.

Results

Annular HIZ correlated significantly with age (OR?=?1.011), body weight (OR?=?1.022), and LBP symptom (OR?=?1.527). The lowest two HIZ prevalence rates were in the second and the third decades (11.54% and 7.84%). The highest prevalence was in the sixth decade (38.03%). The body weight was positively associated with the HIZ prevalence. There was a significant difference in HIZ prevalence between symptomatic and asymptomatic patients (36.16% vs. 26.96%, P?<?0.05). All the HIZ discs exhibited grade 3 or grade 4 disruptions, but only 9 discs (9/16, 8 exhibited grade 4 annular tears) were detected with exact pain reproduction.

Conclusions

It is demonstrated that the presence of HIZ on lumbar MR image was associated with aging, high body weight, and low back pain symptom. HIZ sign indicated a part of the natural history of disc degeneration but was not an actual source of low back pain.

     

Effects of surgical treatment for cervical spondylotic myelopathy in patients > or = 70 years of age: a retrospective comparative study

The objective of this study was to compare efficacy of cervical surgery for myelopathy in patients > or = 70 and < or = 60 years of age. Forty patients > or = 70 years and 50 patients < or = 60 years of age with MRI and CT proven myelopathy were neurologically assessed using the JOA score. Three operative procedures were performed: anterior spinal fusion, laminoplasty, and laminectomy. Postoperatively, patients exhibited comparable outcomes irrespective of age or operative procedure performed. The only exception was the increase in postoperative neurologic complications noted for the older individuals with greater comorbidities.     

Type 1 Modic changes was a significant risk factor for 1-year outcome in sick-listed low back pain patients: a nested cohort study using magnetic resonance imaging of the lumbar spine

Background contextIt is not clear whether Modic changes (MC) is associated with low back pain (LBP) outcome.PurposeTo study associations between baseline degenerative manifestations and outcome in sick-listed LBP patients.Study designProspective nested cohort study based on a randomized controlled trial.Patient sampleOut of 325 sick-listed LBP patients, 141 were consecutively examined by magnetic resonance imaging (MRI) and included and 140 completed the study.Outcome measuresDegenerative manifestations of the lumbar spine were quantified; associations were studied in relation to the three primary outcomes: change of back+leg pain, change of function as measured by Roland-Morris questionnaire, and 1-year unsuccessful return to work (U-RTW).MethodsBy using a previously validated MRI protocol, a specialist in radiology, who had no access to clinical data, described the images. Associations were studied by linear and logistic regression with adjustment for previously identified prognostic factors for 1-year pain and function and for U-RTW.ResultsClinically, 43% of the patients had radiculopathy. Degenerative changes were prevalent with altered disc contours in 84%, high-intensity zones in 70%, and nerve root touch or impingement in 63% of the patients. MC was identified in 60% of the patients, 18% with Type 1 changes and 42% with Type 2 changes, Type 1 including both Type 1 and Type 1 in combination with Type 2. Patients with Type 1 changes reported more back pain and did not improve in pain or disability. They increased to include 30% of the patients with U-RTW at 1 year. Patients with Type 2 changes did not differ significantly from patients without MC but differed significantly from patients with Type 1 changes in all three outcomes. Other degenerative manifestations were not significantly associated with any of the three outcomes.ConclusionsThe only degenerative manifestation negatively associated with outcome was Type 1 MC that affected 18% of the cohort at baseline and implied an increased risk for no improvement in pain and function and for U-RTW, even after adjustment for other prognostic factors.     

Age‐related changes in prostate zonal volumes as measured by high‐resolution magnetic resonance imaging (MRI): a cross‐sectional study in over 500 patients

Study Type – Diagnosis (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Benign prostatic hyperplasia is the most common symptomatic disorder of the prostate and its severity varies greatly in the population. Various methods have been used to estimate prostate volumes in the past including the digital rectal examination and ultrasound measurements. High‐resolution T2 weighted MRI can provide accurate measurements of zonal volumes and total volumes, which can be used to better understand the etiology of lower urinary tract symptoms of men.

OBJECTIVE

• ? To use ability of magnetic resonance imaging (MRI) to investigate age‐related changes in zonal prostate volumes.

PATIENTS AND METHODS

• ? This Institutional Review Board approved, Health Insurance Portability and Accountability Act‐compliant study consisted of 503 patients who underwent 3 T prostate MRI before any treatment for prostate cancer.
• ? Whole prostate (WP) and central gland (CG) volumes were manually contoured on T2‐weighted MRI using a semi‐automated segmentation tool. WP, CG, peripheral zone (PZ) volumes were measured for each patient.
• ? WP, CG, PZ volumes were correlated with age, serum prostate‐specific antigen (PSA) level, International Prostate Symptom Score (IPSS), Sexual Health Inventory for Men (SHIM) scores.

RESULTS

• ? Linear regression analysis showed positive correlations between WP, CG volumes and patient age (P < 0.001); there was no correlation between age and PZ volume (P= 0.173).
• ? There was a positive correlation between WP, CG volumes and serum PSA level (P < 0.001), as well as between PZ volume and serum PSA level (P= 0.002).
• ? At logistic regression analysis, IPSS positively correlated with WP, CG volumes (P < 0.001).
• ? SHIM positively correlated with WP (P= 0.015) and CG (P= 0.023) volumes.
• ? As expected, the IPSS of patients with prostate volumes (WP, CG) in first decile for age were significantly lower than those in tenth decile.

CONCLUSIONS

• ? Prostate MRI is able to document age‐related changes in prostate zonal volumes.
• ? Changes in WP and CG volumes correlated inversely with changes in lower urinary tract symptoms.
• ? These findings suggest a role for MRI in measuring accurate prostate zonal volumes; have interesting implications for study of age‐related changes in the prostate.

     

Significance of atypical urinary cytology in the evaluation of patients with end‐stage renal disease for kidney transplantation – a retrospective study

To determine what percentage of renal transplant candidates have atypical urinary cytology, what proportion have urothelial carcinoma and whether cystoscopy is necessary with atypical cytology. All end‐stage renal disease (ESRD) patients (703) presenting for renal transplantation at our institution were retrospectively reviewed. Individuals producing sufficient urine were screened with urine cytology and those with atypical cytology or risk factors for bladder cancer underwent cystoscopy. Four hundred and thirty patients had available urinary cytology and, of these, 151 (35%) had atypical cytology. Of patients with atypical cytology, three were identified to have urothelial carcinoma. However, three additional patients with urothelial carcinoma did not present with atypical cytology. In total, 6 of 703 (0.85%) patients had bladder cancer. All were treated with transurethral resection and eventually underwent renal transplant. One patient has had disease progression post‐transplant to distant metastases. This is the largest study to date evaluating the incidence of urothelial carcinoma in ESRD patients presenting for transplant workup. We found the incidence of bladder cancer to be higher than in the general Canadian population, however, most lesions were low grade. We found atypical cytology in transplant candidates to be a poor predictor for these low‐grade lesions and do not recommend routine cystoscopy for atypical cytology.