Parathyroid Surgery in the Elderly: Should Minimally Invasive Surgery Be Abandoned?

Background

Single adenoma is the cause of 80 % of primary hyperparathyroidism (PHPT) resulting in wide acceptance of minimally invasive parathyroidectomy (MIP). The incidence of PHPT increases with age. Little information is available regarding the prevalence of multiglandular disease (MGD) in older patients.

Methods

The records of 537 patients that underwent parathyroid surgery between January 2005 and October 2012 at two endocrine surgery referral centers were retrospectively reviewed. Comparison was performed between patients younger than 65 and older than 65 years of age. Clinical variables included preoperative laboratories and imaging, extent of neck exploration, number of glands excised, and intraoperative parathyroid hormone levels during surgery.

Results

There were 374 (70 %) patients in the younger age group (YG) and 163 (30 %) patients in the older age group (OG). The mean age was 50 ± 0.5 and 71 ± 0.4 years, respectively. There was no difference between the groups in terms of gender or laboratory results. MGD was significantly more common in the OG (24 % vs. 12 %; p = 0.001) and similarly MIP was less commonly completed in the OG (49 % vs. 68 %; p < 0.001). Cure rates were comparable between the OG and YG (93 % vs. 95 %; p = 0.27). In the OG, patients with MGD had significantly smaller glands as compared to patients with single adenomas in this group (331 ± 67 vs. 920 ± 97 mg; p = 0.006, respectively).

Conclusions

MGD in PHPT was found to be more prevalent in older patients. Planning a bilateral neck exploration should be considered in older patients, especially when a relatively small gland is suggested by imaging or encountered during surgery.     

Primary Hyperparathyroidism: An Analysis of Failure of Parathyroidectomy

Background

Preoperative imaging in patients undergoing surgery for primary hyperparathyroidism (PHPT) is used primarily to facilitate targeted parathyroidectomy. Failure of preoperative localisation mandates a bilateral exploration. It is thought that the results of imaging may also predict the success of surgery. The aims of this study were to assess whether the findings on preoperative localisation influenced outcomes following parathyroidectomy for PHPT and to explore factors underlying failure to cure at surgery.

Methods

We analysed outcomes of all patients who underwent first-time surgery for PHPT in two centres over a 5-year period to determine an association with demographic characteristics and findings on preoperative imaging. Records of patients not cured by initial surgery were reviewed to explore factors underlying failure to cure.

Results

The failure rate (persistent disease) in the entire cohort was 5 % (25/541) (bilateral neck explorations, 5 %; unilateral exploration, 7 %; targeted approach, 4 %), while two patients developed recurrent disease. In patients who had undergone dual imaging with an ultrasound scan and ^99mTc-sestamibi scintigraphy, failure rates with “lateralised and concordant” imaging, “nonconcordant” imaging, and “dual-negative” imaging were 2, 9, and 11 %, respectively (p = 0.01). Of the 25 patients with persistent disease, multigland disease (MGD) was present in 52 % (13/25) and ectopic adenoma in 24 % (6/12).

Conclusions

Patients with PHPT who do not have lateralised and concordant dual imaging are at higher risk of persistent disease. A significant proportion of failures are due to the inability to recognise the presence and/or extent of MGD.     

Individual site-specific bone mineral density gain in normocalcemic primary hyperparathyroidism

Summary

In this study, we show that successful parathyroidectomy is followed at 1 year by a significant individual bone mineral density (BMD) gain in nearly half of normocalcemic PHPT patients with reduced bone mass. Alkaline phosphatase levels above median were identified as an independent predictor of individual BMD gain in normocalcemic PHPT patients.

Introduction

The aims of this study were to assess bone mineral density (BMD) gains after parathyroidectomy (PTX) in normocalcemic primary hyperparathyroidism (PHPT) at the individual level and to identify predictors of BMD gain after PTX in this context.

Methods

Longitudinal cohort study of 55 PHPT patients referred for low bone mass and mild abnormalities of calcium/phosphorus metabolism, and successfully treated by PTX. BMD gain at 1 year was considered significant if ≥0.030 g/cm² at one site or more, without any equivalent BMD loss at another site. A logistic regression analysis was performed to identify predictive factors of individual BMD gain.

Results

Among the 55 PHPT patients included, 29 patients with hypercalcemia, 36 patients with normocalcemic PHPT, defined by normal pre-PTX serum total (albumin-corrected) calcium (tCa), including 15 patients with normal ionized calcium (iCa), were identified. At 1 year of PTX, an individual BMD gain was observed in 73.7 % of hypercalcemic, 44.4 % of normocalcemic, and 46 % of PHPT patients with both normal tCa and iCa. Site-specific BMD gains were most important at the spine and hip in all subgroups including patients with normal iCa. Alkaline phosphatase activity above median, which reflects high bone turnover, was predictive of individual BMD gain, both in the overall cohort (OR?=?4.9, 95 % CI 1.3–18.9), and in the normocalcemic group: OR?=?8.4, 95 % CI 1.4–56.6.

Conclusions

Successful PTX is followed at 1 year by a significant individual BMD gain in nearly half of normocalcemic PHPT patients with osteoporosis. ALP levels above median could contribute to the therapeutic decision in this context.     

Presentation, Management, and Outcomes of Hyperparathyroidism in Octogenarians and Nonagenarians

Background

Various elective surgical procedures are routinely performed on patients ≥80 years of age. With primary hyperparathyroidism (PHPT), surgical management is the only treatment. The goal of this study was to compare presentation and outcome of patients ≥80 to that of those <80 years of age.

Methods

Retrospective review of a prospectively collected database of all parathyroidectomies for PHPT performed at a university hospital. Patients ≥80 years at the time of surgery compared with patients <80 years.

Results

Over 13 years, 1,826 patients underwent parathyroidectomy for PHPT. A total of 154 patients were ≥80 years at the time of surgery (8.4 %), ranging from 80 to 91 years. Patients ≥80 years had higher serum PTH, creatinine and vitamin D levels and lower T scores. Calcium levels were similar. Patients ≥80 years had a greater history of hypertension, coronary artery disease, congestive heart failure, and stroke. Psychiatric disease was less common. Patients ≥80 years had the procedure under local anesthesia only more often. Use of a unilateral approach was equivalent. Rates of adenoma, double adenoma, and hyperplasia were comparable. Patients ≥80 years were observed overnight more frequently. Stays >24 h and disease recurrence and persistence, as well as morbidity rates, were all equivalent.

Conclusion

Disease presentation of PHPT in patients ≥80 is similar to <80. Despite increased comorbidities, parathyroidectomy is a safe procedure in this patient population with a noted equivalent complication rate to younger patients. Operative management remains the only treatment. Patient age should not be a deterrent to offer curative surgical intervention.     

An analysis of genotype–phenotype correlations and survival outcomes in patients with primary hyperparathyroidism caused by multiple endocrine neoplasia type 1: the experience at a single institution

Purpose

To examine the clinical characteristics and survival outcomes of patients with primary hyperparathyroidism (PHPT) in multiple endocrine neoplasia type 1 (MEN1) in relation to the MEN1 gene mutation.

Methods

The study population included the patients, positive for the MEN1 gene mutation, who underwent parathyroidectomy between 1983 and 2009 at a single tertiary referral center. Manifestations of the syndrome, other tumors and causes of death were retrospectively correlated with the specific types and locations of MEN1 gene mutations.

Results

Thirty-two patients from 19 families were diagnosed as having MEN1 on genetic examinations. Mutations were most common in exons 2, 7 and 10. A phenotypic analysis of the main MEN1 tumor types among the 32 patients revealed that PHPT was the most common (100 %), followed in order by pancreatic neuroendocrine tumors (PNETs) (53 %) and pituitary tumors (38 %). Death due to MEN1-related disease occurred in five patients (16 %), including malignant PNET in three cases (exons 2, 3), pituitary crisis in one case (exon 2) and thymic cancer in one case (large deletion).

Conclusions

Premature deaths related to MEN1 are due to the development of malignant PNET, pituitary crisis or thymic tumors associated with mutations in exons 2, 3 and a large deletion.     

Minimal Benefit to Subsequent Intraoperative Parathyroid Hormone Testing After All Four Glands Have Been Identified

Background

Modern tools, such as intraoperative parathyroid hormone (IoPTH) assay, reduce operative time and extent of parathyroidectomy. However, the utility of a subsequent final set of IoPTH after all four glands are visualized remains questionable. This study was designed to determine the added value of IoPTH assay following parathyroidectomy with four-gland visualization in patients with primary hyperparathyroidism (PHPT).

Methods

A retrospective review of patients who underwent parathyroidectomy for PHPT between July 2001 and February 2012 by two experienced endocrine surgeons was performed. Included were patients with operative reports indicating that all four parathyroid glands were identified. Following four-gland visualization a subsequent final set of IoPTH was measured to confirm cure. Cure was defined as at least 50 % fall by 5, 10, or 15 min postexcision compared with preincision levels.

Results

Of 1,838 patients that underwent parathyroidectomy, four glands were visualized in 238 cases (13 %). Of those patients meeting inclusion criteria with four glands visualized, the final set of IoPTH fell to cure criteria in 235 patients (98 %). An inadequate drop was documented in three (2 %) patients all of which were found to have multigland disease. Only in one patient (0.4 %) was a fifth parathyroid gland identified and resected. In all three cases, the subsequent final IoPTH did not affect the ultimate outcome or cure rate.

Conclusions

When experienced surgeons visualize all four parathyroid glands, drawing a subsequent final set of IoPTH rarely changes the operative course and therefore serves a limited role.     

Surgery for Primary Hyperparathyroidism with Normal Non-suppressed Parathyroid Hormone can be Both Challenging and Successful

Background

Criteria for diagnosing primary hyperparathyroidism (PHPT) include hypercalcemia in the presence of parathyroid hormone (PTH) levels that are either elevated (classic PHPT) or normal but non-suppressed. However, there is no standard definition of what constitutes normal non-suppressed levels, and data are lacking regarding the potential for surgical cure in these patients.

Methods

A retrospective review of patients undergoing parathyroidectomy for sporadic PHPT between 2012 and 2014 was performed. Patients with normal PTH were compared to classic PHPT patients to assess demographics, imaging, operative findings, and outcomes.

Results

In total, 332 patients met study criteria, and 60 (18%) had normal PTH levels. Negative sestamibi scans were seen more often with normal PTH levels (18.3 vs. 4.8%, p < 0.001). Patients with normal PTH were more likely to have ≥2 glands removed (26.7 vs. 14.3%, p = 0.02), and the specimens were more likely to be classified as only mildly hypercellular or normocellular (20 vs. 2.9%, p < 0.001). Average follow-up was 24 months (range 6–55). Cure rate was 88% in the normal PTH group, compared to 96% in classic PHPT (p = 0.02). Among patients with normal PTH, those with PTH ≤ 55 pg/mL had an 83% cure rate, whereas those with PTH 56–65 had a 96% cure rate (p = 0.12).

Conclusions

Parathyroidectomy can have a high cure rate in the context of normal PTH levels despite an increased likelihood of negative imaging and multigland resection. Operative success is equivalent to classic PHPT when PTH levels are > 55 pg/mL.

     

Bilateral Neck Exploration Decreases Operative Time Compared to Minimally Invasive Parathyroidectomy in Patients with Discordant Imaging

Background

Unilateral parathyroidectomy for primary hyperparathyroidism (PHPT) has a high success rate in patients with concordant imaging by sestamibi and ultrasound. However, the optimal procedure when imaging is discordant remains controversial; therefore we compared unilateral exploration with intraoperative parathyroid hormone (IOPTH) monitoring to bilateral neck exploration without IOPTH monitoring in patients with discordant localization studies.

Methods

We conducted a retrospective study of 324 consecutive patients with PHPT treated at our institution from October 2005 to September 2009. We collected information regarding imaging, localization site, procedure performed, operative time, and calcium/PTH measurements.

Results

Of the 324 patients in the study, 79 (24 %) had discordant imaging by sestamibi and ultrasound. Of these, 62 patients (78 %) underwent bilateral neck exploration without IOPTH monitoring, and 14 patients (18 %) had unilateral exploration with IOPTH monitoring. IOPTH monitoring during unilateral exploration correctly predicted removal of single adenomas in 10/14 patients (71 %) and altered operative management in 4/14 cases (29 %), resulting in conversion to bilateral neck exploration. Operative time for unilateral exploration with IOPTH [median time: 96 min (range: 51–153 min)] was significantly increased relative to bilateral exploration [median time: 52 min (range: 28–149 min)]; p = 0.0027. We identified single-gland disease in 53/76 patients (70 %), double adenomas in 13/76 patients (17 %), and multiglandular hyperplasia in 10/76 patients (13 %). There was no difference in cure rate between these two surgical approaches (p = 1.0)

Conclusions

In contrast with prior studies, we found that operative time for unilateral exploration with IOPTH was significantly increased compared to bilateral neck exploration. In patients with discordant imaging, IOPTH is a useful adjunct in limiting exploration to a single side despite a high false negative rate.     

Multigland Disease and Slower Decline in Intraoperative PTH Characterize Mild Primary Hyperparathyroidism

Background

Many patients with primary hyperparathyroidism (PHPT) present with less severe biochemical parameters. The purpose of this study was to compare the presentation, operative findings, and outcomes of these patients with “mild” PHPT to patients with “overt” disease.

Methods

A retrospective review of a prospectively collected parathyroid database was performed to identify cases of PHPT undergoing an initial neck operation. Patients were classified as mild when either the preoperative calcium or PTH was within the normal limits. Comparisons were made with the Student’s t test, Chi-squared test, or Wilcoxon rank-sum test where appropriate. Kaplan–Meier estimates were plotted for disease-free survival and compared by the log-rank test.

Results

Of the 1,429 patients who met inclusion criteria, 1,049 were classified as overt and 388 (27.1 %) were mild. Within the mild group, 122 (31.4 %) presented with normocalcemic PHPT and 266 (68.6 %) had a normal PTH. The two groups had similar demographics and renal function. Interestingly, the mild group had more than double the rate of kidney stones (3.1 vs. 1.3 %, p = 0.02). The mild group was less likely to localize on sestamibi scan (62.4 vs. 78.7 %, p < 0.01). Intraoperatively, more mild patients exhibited multigland disease (34.3 vs. 14.1 %, p < 0.01). When examining intraoperative PTH (IoPTH) kinetics where single adenomas were excised, the IoPTH fell at a rate of 6.9 pg/min in mild patients compared with 11.5 pg/min in the overt group (p < 0.01). Accordingly, 62.2 % of patients in the overt group and 53.3 % in the mild group were cured at 5 min postexcision (p < 0.01). There was no difference in the rates of persistence or recurrence between the groups, and disease-free survival estimates were identical (p = 0.27).

Conclusions

Patients with mild PHPT were more likely to have multigland disease and a slower decline in IoPTH, but these patients can be successfully treated with surgery.     

Effect of continuous positive airway pressure on serum cystatin C among obstructive sleep apnea syndrome patients

Purpose

The purpose of the present study was to evaluate the influence of continuous positive airway pressure (CPAP) on serum cystatin C, a novel biomarker of early renal impairment, among obstructive sleep apnea (OSA) patients.

Materials and methods

Newly diagnosed severe OSA patients who treated with CPAP for 3 months were enrolled from two sleep laboratories. Serum biomarkers of renal impairment, cystatin C, creatinine and estimated glomerular filtration rate (eGFR), were detected before and after CPAP treatment.

Results

A total of 39 severe OSA patients were enrolled, 29 (74.4 %) were male, and mean age was 51.2 ± 12.2 years. After CPAP treatment, there were no changes of creatinine and eGFR (77.80 ± 20.00 vs. 75.3 ± 16.60 and 98.69 ± 31.74 vs. 100.20 ± 28.30, all p > 0.05), but cystatin C declined significantly (0.87 ± 0.18 vs. 0.77 ± 0.21, p = 0.000).

Conclusion

CPAP can decrease cystatin C levels among severe OSA patients and may prevent the latent renal impairment.     

The Influence of Parathyroidectomy on Restless Legs Syndrome in Patients with Renal Hyperparathyroidism

Background

Restless legs syndrome (RLS) is a common and poorly understood movement disorder that leads to unpleasant leg sensations. Although RLS can be idiopathic, secondary etiologies such as iron deficiency and renal failure are common. The aim of this prospective cohort study was to evaluate whether RLS is a common feature in patients undergoing parathyroidectomy for renal hyperparathyroidism (rHPT) and if RLS-related symptoms can be influenced by surgery.

Methods

After providing written consent, patients who underwent a parathyroidectomy for rHPT between January and November 2011 answered a validated RLS-screening-questionnaire (RLSSQ). If this was suggestive for RLS a confirming questionnaire (IRLS) was also completed on the day before surgery, on the fifth postoperative day, and again during follow-up (minimum 12 months). Perioperative parathyroid hormone and calcium levels, as well as the scores of the questionnaires were analyzed.

Results

Twenty-one patients (14 men, 7 women) with a mean age of 47.8 ± 3.2 years underwent total parathyroidectomy with bilateral cervical thymectomy and parathyroid autotransplantation for rHPT. The mean score of the RLSSQ of all 21 patients prior to operation was 6.1 ± 0.5. In 10 of 21 patients (47.6 %) the results of the RLSSQ were suggestive for RLS with a mean score of 8.0 ± 0.3. The consecutive scores of the IRLS in these latter patients significantly dropped from 26.6 ± 1.4 to 19.0 ± 2.2 between the preoperative and postoperative settings (p < 0.05). After a mean follow-up of 17.3 ± 3.7 months the mean scores of the RLSSQ and the IRLS were 6.1 ± 0.6 and 16.3 ± 1.8.

Conclusions

rHPT may play a major role in the severity of RLS-associated symptoms in patients with renal failure. Consequently, parathyroidectomy may prove to be a valuable tool to reduce RLS-associated morbidity in affected patients. However, larger prospective trials are required to confirm the possible relation between RLS and rHPT seen in the present study.     

Parathyroid Cryopreservation after Parathyroidectomy: A Worthwhile Practice?

Background

Parathyroid cryopreservation is often utilized for patients having parathyroidectomy. This allows for future autotransplantation if a patient becomes permanently hypocalcemic after surgery. However, the practice of cryopreservation is costly and time-consuming, while the success rate of delayed autotransplantation is highly variable. We sought to determine the rate and outcomes of parathyroid cryopreservation and delayed autotransplantation at our institution to further evaluate its utility.

Methods

At our institution, 2,083 parathyroidectomies for hyperparathyroidism (HPT) were performed from 2001 to 2010. Of these, parathyroid cryopreservation was utilized in 442 patients (21 %). Patient demographics, preoperative diagnoses, and other characteristics were analyzed, as well as the rate and success of delayed autotransplantation.

Results

Of the 442 patients with cryopreservation, the mean age was 55 ± 1 years and 313 (70.8 %) were female. A total of 308 (70 %) had primary HPT, 46 (10 %) had secondary HPT, and 88 (20 %) had tertiary HPT. Delayed autotransplantation of cryopreserved parathyroid tissue was used in 4 (1 %) patients at an average time of 9 ± 4 months after initial surgery. Three of the 4 patients remained hypoparathyroid after this procedure. The single cured patient underwent the procedure only 4 days after the initial parathyroidectomy.

Conclusions

Although cryopreservation was used in over one-fifth of patients undergoing parathyroidectomy, the need for parathyroid reimplantation was very low (1 %). Furthermore, the success rate of parathyroid autotransplantation was poor in these patients. Therefore, the continued practice of parathyroid cryopreservation is questionable.     

Aluminum Overload Hampers Symptom Improvement Following Parathyroidectomy for Secondary Hyperparathyroidism

Background

Aluminum overload and accumulation in tissues may lead to skeletal, hematological, and neurological toxicity. The aim of this study was to assess the effects of serum aluminum levels on presentations, postoperative recovery, and symptom improvement in patients undergoing parathyroidectomy for secondary hyperparathyroidism.

Methods

From 2008 to 2013, all patients with end-stage renal disease undergoing initial parathyroidectomy were included in the study. Serum aluminum level was measured preoperatively and/or within 1 week after surgery. Preoperative and postoperative biochemical profile and symptoms were compared between the low and high aluminum groups.

Results

A total of 176 patients were included in the study. Of these, 38 (22 %) patients had serum aluminum levels higher than 20 μg/L. A higher percentage of patients in the high aluminum group were on peritoneal dialysis than in the low aluminum group (24 vs. 4 %, p = 0.001). Both groups had similar bone mineral density and changes in biochemical profiles. The preoperative parathyroidectomy assessment of symptoms (PAS) score was not associated with serum aluminum levels (p = 0.349), whereas the postoperative PAS score showed positive association (p = 0.005). There was a negative association between serum aluminum levels and the improvement of total PAS scores (p = 0.001). The high aluminum group had more residual symptoms in three aspects: bone pain (p = 0.038), difficulty getting out of a chair or car (p = 0.045), and pruritus (p = 0.041).

Conclusions

A high serum aluminum level was associated with reduced symptom improvement in patients undergoing parathyroidectomy for secondary hyperparathyroidism.     

Successful management of postoperative pain with pregabalin after thoracotomy

Purpose

There is no established treatment for intercostal neuralgia associated with thoracotomy. We investigated the administration of pregabalin as a new perioperative treatment, assessing its safety and efficacy for intercostal neuralgia after thoracotomy.

Methods

Thirty patients suffering pain after thoracotomy severe enough to cause insomnia were prospectively enrolled and treated with 150 mg of pregabalin. We evaluated pain scores (Numeric Rating Scale, NRS), severity of nocturnal insomnia, and adverse effects before and after pregabalin administration.

Results

We noted significant decreases in pain scores, before vs. after pregabalin administration, from 8.2 ± 1.3 to 3.4 ± 1.3 (p < 0.0001), with improvement in nocturnal insomnia in 29 out of 30 patients. Eight patients reported adverse effects, including dizziness and daytime drowsiness; however, by reducing the dose of pregabalin, these effects were minimized while pain was controlled well.

Conclusion

Pregabalin was highly effective for neuralgia associated with intercostal damage after thoracotomy.     

Durability of Focused Minimally Invasive Parathyroidectomy in Young Patients with Sporadic Primary Hyperparathyroidism

Background

Historically, multigland hyperplasia was believed to be the predominant cause of primary hyperparathyroidism (PHPT) in young patients, and hence a relative contraindication for minimally invasive parathyroidectomy. Recent studies, however, demonstrate that the most common aetiology across all age groups is a solitary functioning adenoma. The aim of this study was to compare long-term outcomes in young patients (≤45 years), especially those under 30 years of age, with their older counterparts (>45 years) following focused minimally invasive parathyroidectomy (FMIP).

Materials and Methods

Patients ≤45 years who underwent FMIP between January 1999 and December 2007 were identified from an endocrine surgery database and compared with a matched control group of patients >45 years old also undergoing FMIP within that time period. The patients’ most recent calcium levels (≥6 months postoperatively) were examined to establish recurrence rates. Recurrence was defined as an elevation of serum calcium more than 6 months after surgery following initial postsurgical normocalcemia.

Results

A total of 117 patients ≤45 years and 160 patients >45 years who underwent FMIP were examined. Follow-up calcium levels were available for 72% of patients. The median length of follow-up was 46 months. No recurrences were identified in both the younger and older cohort of patients; therefore, no statistically significant difference in rates of recurrence could be determined between age groups.

Conclusion

Recurrence of PHPT following FMIP is rare with no evidence of a higher incidence in younger patients. FMIP can be safely offered to young patients as a long-term durable treatment option.     

Muscle Function Is Impaired in Patients With “Asymptomatic” Primary Hyperparathyroidism

Background

Patients with “asymptomatic” primary hyperparathyroidism (PHPT) often describe improvement after surgery.

Methods

We evaluated muscle and balance function, quality of life (QoL), and well-being in 58 PHPT patients and 58 population-based matched controls in a cross-sectional study. We tested whether patients considered “asymptomatic” according to international guidelines have functional impairment.

Results

Mean age of the patients and controls was 59 years, and 47 (81 %) were women. Patients had higher levels of plasma PTH and ionized calcium. Creatinine and 25-hydroxyvitamin D levels did not differ between groups. Altogether, 16 (28 %) patients were “asymptomatic.” Compared with controls, PHPT was associated with significantly lower QoL in all eight domains of the short form-36 questionnaire, lower well-being (WHO Five Well-Being Index; p < 0.001), and impaired postural stability during normal standing with eyes open (p < 0.05) or closed (p < 0.001). Maximum isometric muscle strength was reduced in both upper (p < 0.01) and lower (p < 0.001) extremities. Physical performance was decreased during 10 repeated chair stands (p < 0.001) and time to walk 3 m forward and back (p < 0.05). Restricting analyses to “asymptomatic” patients showed significantly lower muscle strength at knee extension and flexion and impaired postural stability than in matched controls.

Conclusions

PHPT is associated with deleterious effects on muscles and QoL. Impairments also apply to patients with mild disease, normally considered “asymptomatic.” This may explain why “asymptomatic” patients report improvements following surgery. The impaired muscle function may contribute to increased fracture risk independent of bone mineral density.     

Predictors of Bone Mineral Density Improvement in Patients Undergoing Parathyroidectomy for Primary Hyperparathyroidism

Introduction

Primary hyperparathyroidism (PHPT) results in increased bone turnover, resulting in bone mineral density (BMD) reduction and a predisposition towards fractures. Parathyroidectomy (PTX) is the only definitive cure.

Objective

The primary goals of this study were to investigate the impact of PTX on BMD in patients with PHPT and to identify factors associated with post-operative BMD improvement using a multivariate model.

Methods

Between 1999 and 2010, a total of 757 patients underwent PTX for treatment of PHPT; 123 patients had both a pre- and a post-operative dual-energy X-ray absorptiometry (DEXA) scan. A prospective database was queried to obtain information about patient demographics, medications, comorbidities, and pre- and post-operative laboratory values. A Cox regression model was used to stratify patients and to identify factors that independently predict BMD response following PTX in this patient population.

Results

Overall, mean percent change in BMD was +12.31 % at the spine, +8.9 % at the femoral neck (FN), and +8.5 % at the hip, with a mean follow-up of 2.3 ± 1.5 years. A total of 101 (82.1 %) patients had BMD improvement at their worst pre-operative site. In patients who improved, 69.9 % (n = 86) had >5 % increase. Factors associated with BMD improvement at the worst pre-operative site were as follows: male gender (hazard ratio [HR] 2.29; 95 % confidence interval [CI] 1.54–4.21); pre-operative BMD with T-score less than ?2.0 (HR 1.89; 95 % CI 1.11–2.39); age <55 years (HR 1.74; 95 % CI 1.14–2.25); BMD DEXA scan at >2.5 years post-operatively (HR 1.71; 95 % CI 1.09–2.17); history of previous fracture (HR 1.24; 95 % CI 1.05–1.92); and private insurance (HR 1.18; 95 % CI 1.06–2.1). The use of bisphosphonates, estrogens, vitamin D supplementation, or tobacco; obesity; history of previous PTX, serum calcium or parathyroid hormone levels were not independently associated with post-operative BMD improvement.

Conclusion

Osteoporosis is one of the established National Institutes of Health criteria for PTX in asymptomatic patients with PHPT, but BMD improvement is not consistently seen during the post-operative period. Gender, age, more severe pre-operative bone disease, and insurance status were all predictors for greater BMD improvement following PTX. Further studies with a rigorous post-operative BMD regimen are needed in order to validate these results.     

Retropharyngeal Parathyroid Glands: Important Differences

Introduction

In primary hyperparathyroidism (PHPT), parathyroid ectopia is seen in up to 22% leading to more difficult surgery. We aimed to determine the rate and characteristics of retropharyngeal (RP) parathyroid glands.

Methods

A prospective database was queried for patients with sporadic PHPT who had surgery from 1997 to 2016. The data of RP patients were compared to those who had surgery for sporadic PHPT over the same time period with hyperfunctioning parathyroids in anatomically normal positions (N).

Results

RP glands occurred in 47/3006 (1.6%) patients and were more common at reoperative than initial surgery (5.5 vs 1.4%, p < 0.01). RP patients had prior failed surgery more often than N patients (17 vs 3.1%, p < 0.01). Preoperative calcium levels (p = 0.06), PTH levels (p = 0.15), and mean gland weights (p = 0.07) were similar among groups. For RP glands, ultrasound imaging was negative in all but one patient, while 99mTc-sestamibi accurately indicated a posterior midline position in only 13/47 (28%) and was negative in 21%. All RP glands were anatomically superior. RP patients more often required > 1 post-resection intraoperative PTH level (36 vs 21%, p = 0.02). Failure due to persistent PHPT was more likely in RP patients (4.7 vs 2.1%, p = 0.2).

Conclusion

In PHPT, hyperfunctioning RP glands are seen in 1.6% of cases and often associated with initial failure (17%). At reoperation, RP ectopia is 4X more common. RP glands are associated with a high rate of negative imaging, but imaging results suggestive of a midline abnormality can guide exploration. The RP space should be evaluated prior to ending an otherwise unfruitful surgery.

     

Relationship between total testosterone, cognitive function, depressive behavior, and sleep quality in chronic kidney disease patients not on dialysis

Background

Studies show that testosterone levels are associated with cognitive function, depression, and sleep quality in the general population. However, these relationships in chronic kidney disease (CKD) patients not on dialysis have not yet been evaluated before.

Methods

All patients underwent history taking, physical examination, blood pressure measurement, routine urine and biochemical analysis, 24-h urine collection to measure urinary protein excretion and creatinine clearance, and evaluation of cognitive function, depressive behavior, and sleep quality.

Results

In total, 109 CKD patients were enrolled. Total testosterone levels in stage 3, 4, and 5 CKD patients were 8.32 ± 4.35, 6.71 ± 3.12, and 4.22 ± 1.28 ng/ml, respectively (p < 0.0001). Post hoc analysis revealed that total testosterone levels were different between stages 3 and 5 (p < 0.0001) and stages 4 and 5 CKD patients (p < 0.0001) but not between stages 3 and 4 CKD patients (p 0.094). Standardized Mini Mental State Examination (SMMSE) score, Pittsburgh Sleep Quality Index (PSQI) score, and Beck Depression Inventory (BDI) score were 26.2 ± 1.9, 7.1 ± 3.4, and 8.6 ± 6.4, respectively. In linear regression analysis, total testosterone levels were independently associated with SMMSE score [b 0.170, confidence interval (CI) 0.047–0.293, p 0.008] and BDI score (b ?0.750, CI ?1.283 to ?0.216, p 0.006) but not with sleep quality.

Conclusion

Total serum testosterone levels were independently associated with cognitive function and depressive behavior but not with sleep disorders in stage 3–5 CKD patients not on dialysis.     

Effectiveness of pedicle screw-based ligamentotaxis in reducing preoperative kyphosis in thoracolumbar spinal fractures: a retrospective analytical study based on injury surgery interval

Objectives

Although there is an agreement of using long-level construct than short-level construct to correct the kyphosis, no literature mentioned the success of this treatment based on timing of surgery after the injury. Objective of this paper was to study the effect of ligamentotaxis on preventing the development of postoperative kyphosis in unstable thoracolumbar burst fractures based on injury surgery interval (ISI).

Study design

This is a retrospective analysis in 67 patients with unstable thoracolumbar burst fractures operated with posterior-only pedicle screw fixation.

Methods

A retrospective analytical study was conducted in 67 patients who had unstable thoracolumbar fracture and operated with posterior-only pedicle screw construct two levels above and one level below the fractured vertebra. Results were analyzed based on ISI: group 1 (34 patients) was operated within 7 days; group 2 (19 patients) operated between 7 and 14 days; and group 3(14 patients) operated after 14 days of injury. Immediate postoperative and final follow-up kyphotic angles were analyzed among all three groups using Kruskal–Wallis test. Complications regarding implant failure were also noted at final follow-up.

Results

Average follow-up was 37 ± 8.1 months. Average preoperative kyphosis at thoracolumbar junction was 26.3° ± 3.9°, 26.3° ± 2.9° and 26.3° ± 2.8° in groups 1, 2 and 3, respectively, which did not show any difference (P = 0.98). Immediate postoperatively kyphotic angle was improved to 4.3° ± 1.9°, 5.4° ± 1.7° and 10.1° ± 3.0° in groups 1, 2 and 3, respectively, which exhibited statistically significant difference (P < 0.001); and at final follow-up kyphotic angles were 5.4° ± 1.9°, 7.2° ± 1.7° and 15.0° ± 1.6° in groups 1, 2 and 3, respectively showing 1.1°, 1.7° and 4.9° loss in correction at final follow-up. Comparison of kyphotic angles and loss of kyphotic angles amongst the three groups showed statistically significant difference (P < 0.001). Two patients from group 3 had implant failure that required implant extraction.

Conclusion

Posterior-only pedicle screw fixation in unstable thoracolumbar fractures would correct and maintain the postoperative correction in kyphosis, at least at 3-year follow-up, without increasing implant failure if ISI is less than 2 weeks. While patients operated after 2 weeks of injury would require additional anterior procedure.