Kyphoplasty for the treatment of malignant vertebral compression fractures caused by metastases

Despite the literature supporting the efficacy of kyphoplasty for treatment of osteoporotic vertebral compression fractures in multiple myeloma, few reports exist documenting its use in the treatment of malignant vertebral compression fractures (MVCF) caused by metastases. Accordingly, we sought to evaluate the feasibility, efficacy and safety of kyphoplasty in the treatment of MVCF without epidural involvement. We performed a retrospective review of clinical outcome data for 48 patients with multiple spinal metastases treated with kyphoplasty. Outcome data (vertebral body height variation, degree of kyphosis, visual analog scale score for pain, Oswestry Disability Index score, the Short Form-36 [SF-36] questionnaire score for function) were collected preoperatively, postoperatively, and at 1 month, 6 months, 1 year, and 2 years after treatment. Significant improvements in all of the outcome measures were observed postoperatively and throughout the duration of follow-up. The mean anterior vertebral body height variation improved from 52.7 ± 16.8% preoperatively to 85.3% ± 13.2% postoperatively (p < 0.001). Kyphotic angle improved from 16.4° ± 4.7° preoperatively to 8.4° ± 2.5° postoperatively (p < 0.001). The mean visual analog scale score decreased significantly from presurgery to postsurgery (7.4 ± 2.1 to 3.8 ± 1.6; p < 0.001), as did the Oswestry Disability Index score (71.5 ± 16.7 to 32.4 ± 9.6; p < 0.001). The SF-36 scores for bodily pain, physical function, vitality, and social functioning all also showed significant improvement (p < 0.05). Kyphoplasty is an effective, minimally invasive procedure for the stabilization of pathological vertebral fractures caused by metastatic disease, even in levels with vertebral wall deficiency, leading to a statistically significant reduction in pain, improvement in function and prevention of further kyphotic deformity of the spine.     

经皮椎体后凸成形治疗中骨水泥渗漏对椎体高度恢复的影响

摘要 背景：将经皮椎体后凸成形通过球囊加压扩张在椎体内形成周围有相对致密松质骨的空腔,可有效降低骨水泥渗漏率,同时扩张的球囊有助于塌陷椎体的复位,矫正脊柱后凸畸形。 目的：回顾性分析手法复位后将经皮椎体后凸成形注入骨水泥治疗骨质疏松性椎体压缩骨折渗漏情况及对椎体高度恢复的影响。 方法：选择2008-02/2010-06华北石油总医院骨科行经皮椎体后凸成形治疗骨质疏松性椎体压缩骨折患者31例,41椎体。平均年龄69(53~82)岁。并于术前手法按压使腰部过伸复位。观察患者术后疼痛缓解、椎体高度恢复以及骨水泥渗漏情况。 结果与结论: 所有患者术后随访8~13(11.0±1.6)个月。患者视觉模拟疼痛评分由术前6.7±1.9下降至术后1.3±1.2,差异有显著性意义(P < 0.05)。椎体高度由术前(15.7±5.2) mm恢复至(20.2±4.5) mm,椎体高度显著恢复(P < 0.05)。发生骨水泥渗漏3例,均无明显临床症状。说明术前手法复位后经皮椎体后凸成形将骨水泥注入骨质疏松性椎体压缩骨折可以显著恢复椎体高度,止痛效果良好且无严重渗漏发生。 关键词：经皮椎体后凸成形;骨质疏松;骨质疏松性椎体压缩骨折;骨水泥;生物材料 doi:10.3969/j.issn.1673-8225.2010.42.038     

Outcome of posterior lumbar interbody fusion versus posterolateral fusion in lumbar degenerative disease

Between March 2003 and September 2007, 170 consecutive patients with lumbar degenerative disease were studied retrospectively. Eighty patients underwent posterior lumbar interbody fusion (PLIF group) with pedicle screw (PS) fixation, and 82 patients underwent posterolateral fusion (PLF group) with PS fixation. Eight patients were lost to follow-up. The minimum follow-up period in each group was 2.0 years. The mean follow-up period for the PLIF group was 3.6 years, and for the PLF group, the mean follow-up was 3.4 years: there was no significant difference between the two groups for length of follow-up. The Pain Index (PI) improved from 66 to 27 in the PLF group (p < 0.001) and from 69 to 29 in the PLIF group (p < 0.001), but there was no significant difference between the two groups (p > 0.05). In the PLF group, the preoperative mean Oswestry Disability Index (ODI) score was 34.5, which reduced to 14.2 at the final follow-up. In the PLIF group, the mean preoperative ODI was 36.4, which reduced to 16.2 at the final follow-up. There was no significant statistical difference between the two groups for ODI (p > 0.05). Eighty-eight percent (n = 72) of patients in the PLF group and 91% (n = 73) in the PLIF group had radiologically confirmed union, with no significant difference in fusion percentage between the two groups (p > 0.05). Twenty-two of 162 patients (14%) underwent a second operation: 18 (22%) in the PLF group and four (5%) patients in the PLIF group (p < 0.001). The clinical and functional outcomes in both groups were similar, and no significant difference was found in the parameters tested. Both surgical procedures were effective, but patients in the PLF group showed more complications related to hardware biomechanics than patients in the PLIF group (p < 0.001).     

Optimal patient positioning for ligamentotaxis during balloon kyphoplasty of the thoracolumbar and lumbar spine

Percutaneous balloon kyphoplasty aims to restore vertebral height, correct angular deformity and stabilize the spine in the setting of vertebral compression fractures. The patient is positioned prone with supports under the iliac crests and upper thorax to allow gravity to extend the spine. In the treatment of lumbar fractures, we evaluated patient positioning with the contribution of hip extension to increase anterior ligamentotaxis, thus facilitating restoration of vertebral height. Our positioning technique created a mean anterior height increase from 72% to 78% of the average height of the cranial and caudal vertebrae (p = 0.037). Balloon inflation did not significantly further increase anterior or posterior vertebral height, or Cobb angle.     

Combination of skull traction with posterior C1-2 fusion for old C1-2 dislocations

Between January 2003 and December 2009, 23 patients who had suffered old C1-2 dislocations, were surgically treated in our orthopedics department. Fifteen patients underwent direct posterior C1-2 fusion following pre-operative reduction by skull traction. In eight patients, reduction was achieved only by skull traction under general anesthesia, facilitated by manual hyperextension of the cervical spine and maintained by simultaneous posterior C1-2 fusion. Intra-operative traction was monitored using C-arm fluoroscopy and cortical somatosensory-evoked potentials. Posterior C1-2 fixation was achieved in nine patients using C1-2 laminar hooks and in 14 patients using C1 laminar hooks with C2 pedicle screws. During the follow-up of 5 to 72 months (mean: 42.8 months), solid bony fusion was accomplished in all patients. Using Di Lorenzo’s grades and Japanese Orthopedics Association scores, there was significant improvement (p < 0.05). The cervical medullary angle exhibited a significant improvement of 31.7°, from 121.6° to 153.3° (p < 0.05). There were no complications, including dural tears, spinal cord damage, vertebral artery damage, or breakage or loosening of implants.     

The influence of correction loss in thoracolumbar fractures treated by posterior instrumentation: A minimum 7-year follow-up

We retrospectively studied patients who underwent posterior pedicle screw instrumentation for thoracolumbar fractures to explore the relationship between correction loss after the operation and clinical outcome. The study included 52 patients, with a minimum postoperative follow-up of 7 years (mean of 9.8 years). From the analysis of radiological and clinical outcomes, we found that the relevant factors related to functional outcome were: (i) preoperative anterior vertebral height (AVH; regression coefficient [B] = −0.075, p = 0.045); and (ii) the latest follow-up AVH (B = −0.100, p = 0.043). This indicates that function is likely to be worse if the anterior vertebral column is compressed more severely at the time of injury, and that function will also be worse if the AVH is decreased at the latest follow-up. However, loss of AVH was not correlated with functional outcome. Therefore, we recommend that the AVH should be restored as much as possible by posterior instrumentation during the treatment of thoracolumbar fractures. Reducing the loss of correction to maintain the postoperative AVH is also critical to maintain the AVH at latest follow-up.     

Segmental Deformity Correction after Balloon Kyphoplasty in the Osteoporotic Vertebral Compression Fracture

Objective

Balloon kyphoplasty can effectively relieve the symptomatic pain and correct the segmental deformity of osteoporotic vertebral compression fractures. While many articles have reported on the effectiveness of the procedure, there has not been any research on the factors affecting the deformity correction. Here, we evaluated both the relationship between postoperative pain relief and restoration of the vertebral height, and segmental kyphosis, as well as the various factors affecting segmental deformity correction after balloon kyphoplasty.

Methods

Between January 2004 and December 2006, 137 patients (158 vertebral levels) underwent balloon kyphoplasty. We analyzed various factors such as the age and sex of the patient, preoperative compression ratio, kyphotic angle of compressed segment, injected PMMA volume, configuration of compression, preoperative bone mineral density (BMD) score, time interval between onset of symptom and the procedure, visual analogue scale (VAS) score for pain rating and surgery-related complications.

Results

The mean postoperative VAS score improvement was 4.93±0.17. The mean postoperative height restoration rate was 17.8±1.57% and the kyphotic angle reduction was 1.94±0.38°. However, there were no significant statistical correlations among VAS score improvement, height restoration rate, and kyphotic angle reduction. Among the various factors, the configuration of the compressed vertebral body (p=0.002) was related to the height restoration rate and the direction of the compression (p=0.006) was related with the kyphotic angle reduction. The preoperative compression ratio (p=0.023, p=0.006) and injected PMMA volume (p<0.001, p=0.035) affected both the height restoration and kyphotic angle reduction. Only the preoperative compression ratio was found to be as an independent affecting factor (95% CI : 1.064-5.068).

Conclusion

The two major benefits of balloon kyphoplasty are immediate pain relief and local deformity correction, but segmental deformity correction achieved by balloon kyphoplasty does not result in additional pain relief. Among the factors that were shown to affect the segmental deformity correction, configuration of the compressed vertebral body, direction of the most compressed area, and preoperative compression ratio were not modifiable. However, careful preoperative consideration about the modifiable factor, the PMMA volume to inject, may contribute to the dynamic correction of the segmental deformity.     

Rearrangement of motor centers and its relationship to the neurological status of low-grade glioma examined on pre- and postoperative fMRI

Objective

Well-developed compensatory mechanisms, based on the phenomenon of brain plasticity, exist in patients with neuroepithelial tumors, especially with highly differentiated gliomas (WHO grade II). We studied phenomenon of rearrangement of sensorimotor cortex using functional magnetic resonance imaging (fMRI), and verified relationship between observed changes and results of neurological and neuropsychological assessment.

Methods

Study group included 20 patients with WHO grade II gliomas located within motor or sensory cortex. fMRI examination, as well as clinical, neurological (Karnofsky performance score [KPS] and Lovett's scale [Lo]), and neuropsychological assessment (Digit Coding Symbol Test and Digit Span Test) were performed pre-operatively and 3 months post-surgery.

Results

There were no significant differences in pre- and postoperative performance status of patients. Although statistically insignificant, an increase in frequency of activation of primary and secondary cortical motor centers was observed postoperatively (p > 0.05). Prior to surgery, motor centers were characterized by lower values of t-statistics than in postoperative period (p > 0.05). In contrast, values of parameters describing the size of examined centers, i.e. mean number of clusters, were lower, but not statistically significant on postoperative examination (p > 0.05). Compared to individuals without motor deficit, patients with preoperative Lo3/Lo4 paralysis showed significantly higher mean values of t-statistics in the accessory motor area on postoperative examination (p < 0.05).

Conclusions

The processes of motor cortex rearrangement seemed to be associated with the pre- and postoperative neurological and neuropsychological status of patients. After contralateral primary motor cortex, accessory motor area was the second most frequently activated center, both pre- and postoperatively.     

The impact of repeated surgery and adjuvant therapy on survival for patients with recurrent glioblastoma

Objective

Treatment of glioblastoma recurrence can have a palliative aim, after considering risks and potential benefits. The aim of this study is to verify the impact of surgery and of palliative adjuvant treatments on survival after recurrence.

Methods

From January 2002 to June 2008, we treated 76 consecutive patients with recurrent glioblastoma. Treatment was: 1-surgery alone – 17 patients; 2-adjuvant-therapy alone – 24 patients; 3-surgery and adjuvant therapy – 16 patients; no treatment – 19 patients. The impact on median overall-survival (OS-time between recurrence and death/last follow-up) of age, Karnofsky performance scale (KPS), resection extent and adjuvant treatment scheme (Temozolomide alone vs low-dose fractionated radiotherapy vs others) was determined. Survival curves were obtained through the Kaplan–Meier method. Cox proportional-hazards was used for multivariate analyses. Significance was set at p < 0.05.

Results

Median OS was 7 months. At univariate analysis, patients with a KPS ≥ 70 had a longer OS (9 months vs 5 months – p < 0.0001). OS was 6 months for patients treated with surgery alone, 5 months for patients that received no treatment, 8 months for patients treated with chemotherapy alone, 14 months for patients treated with surgery and adjuvant therapy-p = 0.01. Patients with a KPS < 70 were significantly at risk for death – HR 2.8 – p = 0.001.Subgroup analysis showed no significant differences between patients receiving gross total or partial tumor resection and among patients receiving different adjuvant therapy schemes. Major surgical morbidity at tumor recurrence occurred in 16 out of 33 patients (48%).

Conclusion

It is fundamental, before deciding to operate patients for recurrence, to carefully consider the impact of surgical morbidity on outcome.     

The Effect of Postural Correction and Subsequent Balloon Inflation in Deformity Correction of Acute Osteoporotic Vertebral Fractures

Objective

To determine deformity correction by postural correction and subsequent balloon inflation in acute vertebral compression fractures (OVCFs) and to examine the effect of bone mineral density on deformity correction.

Methods

A totol of 50 acute OVCFs received balloon kyphoplasty. Lateral radiographs were taken and analyzed at five different time points : 1) preoperative, 2) after placing the patient in prone hyperextended position, 3) after balloon inflation, 4) after deposition of the cement, and 5) postoperative. All fractures were analyzed for height restoration of anterior (Ha), middle (Hm) and posterior (Hp) vertebra as well as Cobb angle and Kyphotic angle. The bone mineral density (BMD) of lumbar spine was measured by dual-energy X-ray absorptiometry. According to the T-score, the patients were divided into two groups which were osteoporosis group and osteopenia group.

Results

Postoperative measurements of Ha, Hm and the Cobb angle demonstrated significant reduction of 4.62 mm, 3.66 mm and 5.34° compared with the preoperative measurements, respectively (each p<0.05). Postural correction significantly increased Ha by 5.51 mm, Hm by 4.35 mm and improved the Cobb angle by 8.32° (each p<0.05). Balloon inflation did not demonstrate a significant improvement of Ha, Hm or the Cobb angle compared with baseline prone hyperextended. Postural correction led to greater improvements of Ha, Hm and Cobb angle in osteoporosis group than osteopenia group (each p<0.05).

Conclusion

In acute OVCFs, the height restoration was mainly attributed to postural correction rather than deformity correction by balloon inflation. BMD affected deformity correction in the process of postural correction.     

Comparative analysis of perinatal and postnatal factors, and general movement in extremely preterm infants

Study aim: To describe general movement in extremely premature infants and examine correlations with risk factors for antenatal, perinatal, and postnatal morbidity. Study type: Prospective, single-center study. Nineteen patients were followed up. Methodology: The infants’ general movement was analyzed using video recordings. Qualitative and quantitative assessments were performed during the writhing movement (WM) period and fidgety movement (FM) period. The quality of the general movements (GMs) and the scores achieved were then correlated with antenatal, perinatal, and postnatal factors. Results: Infants’ motor activity fluctuated during the WM period, especially in extremely premature infants where poor repertoire is often observed. No correlations were found between WMs and obstetric factors. Gestational age correlated with WMs’ quality (p = 0.023). WMs correlated with factors of postnatal morbidity such as chronic lung disease (CLD) (p = 0.034) and nosocomial infections (p = 0.05). At 3 months corrected age, the spontaneous movement quality are correlated with neurological explorations such as US brain (p = 0.032), MRI (p = 0.039), EEG (p = 0.036), and neurological follow-up assessments (p = 0.015). Conclusion: Prudence must be used when performing the analysis of general movement in extremely preterm infants. WMs may be influenced by perinatal morbidity, and possibly by the severe brain immaturity of these infants. WMs correlate with CLD and nosocomial infections. Analysis of general movement in infants of 3 months corrected age is a valuable means to detect neurological disorders.     

Alternative grafts in anterior cervical fusion

Objective

The present retrospective study was conducted to compare the clinical and radiographic outcomes in patients undergoing anterior cervical discectomy with fusion (ACDF) using carbon fiber reinforced polymer (CFRP) cages, or allograft.

Methods

We retrospectively reviewed cases of ACDF using allograft in 20 patients, and CFRP in 19 who had sequential radiographs before and after surgery, and at 1 year.

Results

There were no apparent significant differences between the 2 groups in age (p = 0.057), gender (p = 0.635), or complications (p = 0.648). At 12 months, there were no cases of construct failure, and fusion appeared to have been achieved in patients of both groups. Lordosis was increased significantly in both groups after surgery (p < 0.001 in allograft and p = 0.025 in CFRP), and was maintained up until 1 year (p < 0.018 in allograft and p = 0.05 in CFRP) without a difference between groups (p = 0.721). Anterior interbody height was significantly increased (p < 0.001 in both groups at each time points) after surgery, without a significant difference between groups (p > 0.21). This increase in height was greatest in magnitude immediately after surgery, and declined with the passage of time. There was no detectable health-related quality of life difference between allograft and CFRP group after surgery (p > 0.05).

Conclusion

The present study demonstrates that CFRP cages appear to have comparable fusion rates, restoration of lordosis and disc space height, and complication rates to patients who undergo ACDF with allograft.     

Learning curve for percutaneous endoscopic lumbar discectomy depending on the surgeon's training level of minimally invasive spine surgery

Purpose

To evaluate the differences of learning curve for PELD depending on the surgeon’ s training level of minimally invasive spine surgery.

Methods

We retrospectively reviewed the medical records of 120 patients (surgeon A with his first 60 patients, surgeon B with his first 60 patients) with sciatica and single-level L4/5 disk herniation who underwent PELD by the two surgeons with different training level of minimally invasive spine surgery (Group A: surgeon with little professional training of PELD; Group B: surgeon with 2 years of demonstration teaching of PELD).

Results

Significant differences were observed in the operation time (p = 0.000), postoperative hospital stay (p = 0.026) and reoperation rate (p = 0.050) between the two groups. In the operation time, significant differences were observed between the 1–20 patients group and 41–60 patients group in Group B (p = 0.041), but there were no significant differences among the 1–20 patients group, 21–40 patients group and 41–60 patients group in Group A. In the postoperative hospital stay, the significant differences were observed in the 1–20 patients group between Group A and Group B (p = 0.011). Significant differences were observed between preoperative and postoperative VAS back score, VAS leg score and JOA score. Higher improvement in the VAS leg score was observed in Group B than Group A (p = 0.031). In the rate of reoperation, the significant difference was observed between the 1–20 patients group and 41–60 patients group in Group A (p = 0.028) but there were no significant differences among the 1–20 patients group, 21–40 patients group and 41–60 patients group in Group B.

Conclusions

The surgeons’ training level of minimally invasive spine surgery was an important factor for the success of PELD, especially the demonstration teaching of PELD for the new minimally invasive spine surgeons.     

Survival outcomes for radiotherapy treatment of epidermoid tumors with malignant transformation

Epidermoid tumors are intracranial lesions that may occasionally undergo malignant transformation. Although surgical resection is the first-line treatment for malignant epidermoids, postoperative radiotherapy has been intermittently reported with favorable findings. Our analysis identified all previously reported patients with malignant epidermoids treated with surgical resection alone or surgery plus radiotherapy to examine the potential role for this adjuvant therapy. Whereas patients treated with surgery only had an overall survival of 6.6 months, those treated with postoperative radiotherapy demonstrated a statistically significant increase in survival to 12.7 months (log-rank test, p < 0.003). Furthermore, the mean dosage of radiation given to this patient population was 52.2 Gy, with no appreciable survival benefit for the utilization of levels of radiation greater than 50 Gy. When determining the management for malignant transformation of epidermoid tumors, the combination of surgical resection and radiotherapy may be associated with improved short-term survival.     

Posterior interbody fusion using a diagonal cage with unilateral transpedicular screw fixation for lumbar stenosis

Few reports have described the combined use of unilateral pedicle screw fixation and interbody fusion for lumbar stenosis. We retrospectively reviewed 79 patients with lumbar stenosis. The rationale and effectiveness of unilateral pedicle screw fixation were studied from biomechanical and clinical perspectives, aiming to reduce stiffness of the implant. All patients were operated with posterior interbody fusion using a diagonal cage in combination with unilateral transpedicular screw fixation and had reached the 3-year follow-up interval after operation. The mean operating time was 115 minutes (range = 95-150 min) and the mean estimated blood loss was 150 mL (range = 100-200 mL). The mean duration of hospital stay was 10 days (range = 7-15 days). Clinical outcomes were assessed prior to surgery and reassessed at intervals using Denis’ pain and work scales. Fusion status was determined from X-rays and CT scans. At the final follow-up, the clinical results were satisfactory and patients showed significantly improved scores (p < 0.01) either on the pain or the work scale. Successful fusion was achieved in all patients. There were no new postoperative radiculopathies, or instances of malpositioned or fractured hardware. Posterior interbody fusion using a diagonal cage with unilateral transpedicular fixation is an effective treatment for decompressive surgery for lumbar stenosis.     

球囊扩张椎体后凸成形注入骨水泥治疗骨质疏松性脊柱骨折58例

背景：探讨球囊扩张椎体后凸成形注入骨水泥治疗骨质疏松性脊柱骨折的疗效。 方法：采用球囊扩张椎体后凸成形治疗老年人骨质疏松性单节段椎体压缩性骨折58例,58个椎体。病变位于T6~L4椎体,以T10~L2胸腰段发生多见。所有患者均采用局麻方法,患者俯卧于脊柱外科手术架上,在C臂透视下行单侧或双侧椎弓根穿刺,注入骨水泥。 结果：发生骨水泥渗漏8例,骨水泥沿后纵韧带渗漏至邻近椎体后缘1例,椎体外边缘6例,皮下1例,但患者没有临床症状。治疗后脊柱 X射线片显示椎体高度有所恢复,脊柱后凸畸形改善。所有患者疼痛明显缓解,疼痛缓解率100%,视觉模拟评分、后凸角度、活动能力评分治疗前与治疗后6个月比较,差异有显著性意义(P < 0. 05),治疗后6个月与随访结束时比较差异无显著性意义(P > 0. 05)。 结论：球囊扩张椎体后凸成形注入骨水泥治疗能够明显缓解骨质疏松性脊柱骨折导致的疼痛,并可以部分恢复椎体高度和脊柱后凸畸形,有利于改善脊柱的功能,提高患者的生活质量。 关键词：球囊扩张椎体后凸成形术;骨质疏松;胸腰椎骨折 doi:10.3969/j.issn.1673-8225.2009.47.040     

单侧穿刺经皮椎体注入骨水泥后凸成形治疗多椎体骨质疏松性压缩骨折

背景：经皮椎体成形和经皮椎体后凸成形是一种治疗骨质疏松症所致椎体压缩性骨折的新方法,目前已经在各大医院广泛开展,但是在临床上很多病例有多个椎体的骨折,采用经典的手术方法操作次数多,增加手术风险,射线暴露量大,医疗费用高。 目的：观察单侧穿刺经皮椎体后凸成形治疗老年多椎体骨质疏松压缩骨折的疗效。 方法：选择2007-06/2009-06巢湖市第一人民医院骨二科和皖南医学院附属弋矶山医院骨一科收治的多椎体骨质疏松压缩骨折患者12例(29椎),根据治疗前MRI信号改变判断疼痛性椎体并进行选择性单侧穿刺球囊扩张后凸成形的治疗。根据目测类比评分评价手术前后疼痛变化,观察治疗后症状改善、骨折复位情况及有无并发症发生。 结果与结论：12例穿刺均顺利完成,48 h内疼痛缓解,平均随访14个月。治疗后目测类比评分较治疗前降低(P < 0.01)。椎体前缘、中部、后缘平均高度治疗前低于治疗后,至末次随访椎体复位后前缘、中部、后缘平均高度未见明显丢失(P > 0.05)。治疗前穿刺侧与对侧椎体高度差距有显著性意义(P < 0.01),治疗后两侧差距无显著性意义(P > 0.05)。治疗前后同侧相比差异均有显著性意义(P < 0.01)。提示对多椎体压缩骨折采用选择性单侧穿刺后凸成形治疗,临床效果满意,能够缩短治疗时间、减少并发症、射线暴露和治疗费用,适于老年多椎体骨质疏松压缩骨折的治疗。 关键词：骨质疏松;脊柱;压缩骨折;后凸成形;骨水泥 doi:10.3969/j.issn.1673-8225.2010.25.025     

Prediction of outcomes for brainstem cavernous malformation

Objective

Brainstem cavernous malformation (CM) poses a challenge to neurosurgeons in terms of operability, postoperative complications and unpredictable outcomes. The present study was conducted to analyze the clinical parameters that might predict the outcomes and to summarize our center experience in treatment of brainstem CM.

Methods

A total 59 patients with radiological and histologically confirmed brainstem CM diagnosed between 2000 and 2012 were retrospectively reviewed. All but five patients were deemed amenable to surgical resection. Complete resection was attempted in all CM and was achieved in 58/59 patients. Modified Rankin scale (mRS) score dichotomized as mRS 0–2 (favorable outcome) or mRS 3–6 (unfavorable outcome) was employed for neurological status assessment. The association of various clinical parameters to the different brainstem location was evaluated. Predictors of the surgical outcomes were analyzed using the univariate and multivaraite regression statistics.

Results

Mean age of 32 female and 27 male patients was 34.3 years. The differences in size of cavernoma, conservative treatment and complications were significantly associated with various location of the CM in the brainstem. Clinical parameters including age at presentation (p = 0.029, OR = 0.061, CI = 0.009–0.414), favorable preoperative mRS (p = 0.004, OR = 0.058, CI = 0.009–0.343), pontine location of CM (p = 0.018, OR = 0.017, CI = 0.001–0.495), and early surgical treatment (p = 0.05, OR = 0.087, CI = 0.07–1.03) were independent predictors of favorable surgical outcomes. Mean long-term follow up of 42.9 months was available in 31/59 (52.5%). The mean size of CM was 22.5 mm; small size (<10 mm) at presentation was associated with favorable outcomes at long-term follow-up (univariate analysis, p = 0.041, adjusted R² = 0.471). Preoperative mRS (p = 0.039) and location of the CM (p = 0.034) in the brainstem were predictors of good surgical outcomes at long term follow-up.

Conclusion

Favorable surgical outcomes can be predicted in brainstem CM patients with early age at presentation, pontine location of the cavernoma, favorable preoperative mRS and those undergoing early surgery. The outcomes at long-term follow-up were associated with location of the CM in the brainstem, size of the CM and the preoperative mRS.     

Significance of increased signal intensity on MRI in prognosis after surgical intervention for cervical spondylotic myelopathy

We aimed to examine whether increased signal intensity (ISI) on T2-weighted MRI can be used to predict the surgical outcome of patients with cervical spondylotic myelopathy (CSM). ISI on T2-weighted MRI are frequently observed but the relevance of this finding remains controversial in patients with CSM. Between September 2007 and February 2009, 52 patients with CSM who underwent surgery were studied prospectively. Preoperative and postoperative functional status was evaluated using the modified Japanese Orthopaedic Association (JOA) scoring system, and the recovery rate was calculated using the Hirabayashi method. An MRI was performed on all patients. For those with ISI on T2-weighted MRI, the ratio of the signal intensity on T2-weighted to T1-weighted MRI (T2:T1 ratio) at the same spinal cord level and of similar area was calculated. Although the clinical outcome of all patients had improved at final follow-up, there was a significant difference between patients with ISI and those without ISI in age, duration of symptoms, preoperative and postoperative JOA scores, and recovery rate. The preoperative and postoperative JOA scores and the recovery rate differed significantly (p < 0.05) between the three groups: patients without a T2-weighted ISI, and those with different levels of a T2:T1 ratio. Patients with an ISI usually had a low preoperative JOA score and experienced less improvement in neurologic function after surgery. The T2:T1 ratio can be used to help predict surgical outcomes.     

Outcome of surgical decompression of spinal mass lesions in non-Hodgkin's lymphoma and plasmacytoma

Objective

Surgical treatment for spinal mass lesions due to non-Hodgkin's lymphoma (NHL) or plasmacytoma is necessary only in rare instances. The purpose of this study was to investigate long-term outcome and quality of life of surgery combined with postoperative chemotherapy or radiochemotherapy.

Methods

The data of patients, who underwent spinal surgery for mass lesions in a 10-year periods were reviewed, identifying 10 patients with a histopathological diagnosis of NHL or plasmacytoma. Functional outcome were assessed by the Karnofsky Performance Score (KPS), quality of life by the Short Form-36 (SF-36) Health Survey Questionnaire, and pain by the Visual Analog Scale (VAS).

Results

Clinical presentations included pain (n = 10), paresis (n = 5), and sensory deficits (n = 5). Surgical treatment included removal of the mass lesion (total, n = 5; subtotal, n = 5) for decompression, interbody fusion (n = 3), and corporectomy followed by stabilization (n = 1). Histopathological findings revealed NHL in five patients and plasmacytoma/multiple myeloma in five other patients. Postoperatively, all patients underwent chemotherapy or radiochemotherapy. Mean follow-up time was 38 months. At the last follow-up, 2 patients had succumbed to progression of disease. Pain intensity remained significantly reduced as compared to preoperatively (p = 0.049). The KPS was 90–100% in five patients still alive, 70% in two, and 60% in one. SF-36 subscores were lower as compared to age-matched healthy controls.

Conclusions

This retrospective study shows that surgical decompression of spinal mass lesions is a valuable option in selected patients with NHL or plasmacytoma to improve neurological deficits and control pain. Long-term outcome after postoperative adjuvant therapy confirms prolonged stability of quality of life.