Management Options in Thoracolumbar Burst Fractures

Background

Both surgery and recumbency have been adopted in the treatment of spinal fractures. Herein we present the indications for each, and our experience with thoracolumbar junction (T12, L1 and L2) burst fractures.

Methods

Sixty-eight patients with thoracolumbar burst fractures were treated operatively in 36 cases, and nonoperatively in 32 with recumbency for 1–6 weeks. Treatment was based on clinical and radiological criteria. Eighty-one percent of the recumbency patients, but only 14% of the surgical patients were intact on admission. Patients were followed for a mean ± SD of 9 ± 10 months in the recumbency group, and 21 ± 21 months in the surgical group.

Results

Neurological improvement and progressive angular deformity occurred in both groups. The cost of recumbency in our patients was nearly half that of those who required surgery, though the length of hospitalization between the two groups was similar at 1 month ± 2 weeks.

Conclusion

The above study emphasizes that the selection of operative versus nonoperative treatment in burst fractures should not be random but based on clinical as well as radiological criteria. Recumbency is favored in patients who are intact, with angular deformity less than 20°, a residual spinal canal greater than 50% of normal, and an anterior body height exceeding 50% of the posterior height. Surgical intervention is generally indicated in patients with partial neurological deficit, and those with severe instability.     

Computed Imaging-Assisted Stereotactic Brain Biopsy: A Risk Analysis of 225 Consecutive Cases

Background

Treatment strategies for intracranial mass lesions are most effective when based upon histopathological diagnoses. Image-guided stereotaxy has provided the means to sample tissue from small or deeply seated intraparenchymal lesions with a relatively high degree of safety and accuracy. Although procedural complications are infrequent, devastating neurological sequelae may result from hemorrhage or direct trauma. This study was undertaken to identify factors that may confer an increased risk of morbidity from stereotactic brain biopsy.

Methods

Two hundred twenty-five consecutive computer-assisted stereotactic brain biopsy procedures were reviewed. Patient age averaged 47.4 years (range, 3–84 years); gender ratio was approximately 2:1 (male:female). Pre-existing medical conditions were identified in nearly half of the cohort. 61.3% of biopsied lesions were lobar; the remainder (38.7%) were “deep-seated” (thalamus, basal ganglia, pineal, hypothalamus, cerebellum, brainstem). Glial tumors accounted for the majority (44.4%) of biopsied lesions; metastases (12.9%) and lymphoma (11.6%) were also relatively common. Demographical, anatomical, surgical, and histological data were compiled and putative risk factors for morbidity identified. These variables were then subjected to univariate and logistic regression analyses to determine their significance as independent predictors of operative risk.

Results

Twelve patients suffered complications as a consequence of the biopsy procedure (eight from hemorrhage, four from direct trauma). Major morbidity (hemiparesis, aphasia, obtundation) occurred in eight patients (3.6%). Three patients (1.3%) suffered minor morbidity (transient, mild neurological deficits). One operative fatality occurred (0.4%). An increased risk of morbidity was associated with the preoperative use of antiplatelet agents, chronic corticosteroids, deep-seated lesions, malignant gliomas, and a greater number of biopsy attempts (p < 0.05). Factors not conferring increased morbidity included gender, age, pre-existing illness, extracranial malignancy, cardiac disease, hypertension, diabetes, HIV status, and instrument used to procure the specimen.

Conclusions

Complications arising from stereotactic brain biopsy are infrequent but can be disastrous. Operative risk is a function of several independent variables, including lesion properties (location, histology), preoperative pharmacological therapy (corticosteroids, antiplatelet agents), and operative technique. This analysis suggests that the morbidity of stereotactic brain biopsy may be minimized by risk factor modification.     

Idiopathic and glucocorticoid-induced spinal epidural lipomatosis

Pathological overgrowth of the epidural fat in the spine has been described and reported nearly exclusively in patients either with Cushing's syndrome or on chronic intake of glucocorticoids for a variety of clinical disorders. The authors report four patients with documented spinal lipomatosis (three pathologically and one radiologically). Only one of these patients received corticosteroids, and none had an underlying endocrinological abnormality. All four patients were adult males with a mean age at onset of symptoms of 43 years (range from 18 to 60 years). The symptoms ranged from simple neurogenic claudication and radicular pain to frank myelopathy. Myelography followed by computerized tomography were instrumental in the diagnosis of the first three patients; the fourth was diagnosed by magnetic resonance imaging. The thoracic spine was involved in two cases and the lumbosacral area in the other two. The different treatment modalities were tailored according to the symptomatology of the patients. These included weight reduction of an overweight patient with minimal neurological findings in one case and decompressive laminectomy and fat debulking to achieve adequate cord decompression in the remaining three cases. Two patients improved significantly, the condition of one stabilized, and the fourth required a second decompression at other spinal levels. The various modalities of treatment and their potential complications are discussed.     

Response of intractable pain to continuous intrathecal morphine: a retrospective study.

We have treated 37 patients with intractable pain (35 with cancer-related pain) by continuous intrathecal morphine infusion via implanted pump. These patients were carefully selected according to specific criteria, and each demonstrated a significant reduction in pain following a test dose of intrathecal morphine. All patients had good pain relief from intrathecal morphine infusion, even with pain located in cervical dermatomes. Systemic narcotics could be withdrawn from most patients. Significant side effects were rare and typically self-limited. Many patients required gradually increasing doses, seemingly related to disease progression. Two patients with non-malignant pain have had variable dose requirements over 28 and 44 months without clear tolerance. In these patients we observed a reduction in side effects associated with systemic opioids when continuous intrathecal opioid infusion was instituted. Intrathecal opioid administration may have fewer complications than ablative pain relief procedures. In properly selected patients, this method offers an effective alternative for pain relief.     

High Adherence to System‐Level Performance Measures for Rheumatoid Arthritis in a National Early Arthritis Cohort Over Eight Years

Objective

To assess adherence to 3 system‐level performance measures in a national early rheumatoid arthritis (RA) cohort.

Methods

Patients enrolled in the Canadian Early Arthritis Cohort (2007–2015) who met 1987 or 2010 American College of Rheumatology/European League Against Rheumatism criteria with <1 year of symptom duration and ≥1 year of followup after enrollment were included. Performance measures assessed were the percentage of RA patients seen in yearly followup, and the number of gaps between visits of >12 or >14 months, the percentage of RA patients treated with a disease‐modifying antirheumatic drug (DMARD), and days from RA diagnosis to initiation of a DMARD. Results are shown stratified by enrollment year to assess for temporal changes in performance.

Results

A total of 1,763 early RA patients were included (mean age 54 years, 73% female, and 82% white). At enrollment, mean ± SD disease duration was 6 ± 3 months, and Disease Activity Score in 28 joints was 5.1 ± 1.5. Over 8 years, the proportion of patients seen in annual followup declined from 100% to 91%. Over followup, 42% of patients had 0 gaps in care of >12 months, and 64% had 0 gaps >14 months. The percentage of DMARD‐treated early RA patients was and remained high (95–87%), and the percentage receiving DMARDs within 14 days of diagnosis was 75%. Median time‐to‐DMARD therapy was 1 day, indicating DMARDs were initiated at diagnosis (90th percentile 93 days).

Conclusion

There was evidence of high adherence to system‐level performance measures in this early RA cohort following a protocol. Small declines in performance were noted with increasing length of patient followup. Our findings are useful for performance measure benchmarking.     

Orbital roof encephalocele mimicking a destructive neoplasm

The purpose of this case report is to report an orbital roof encephalocele mimicking a destructive orbital neoplasm. Orbital roof encephalocele is uncommon but can mimic neoplasm. One potential mechanism for the orbital roof destruction is a post-traumatic "growing orbital roof fracture." The growing fracture has been reported mostly in children but can occur in adults. Alternative potential etiologies for the encephalocele are discussed, including Gorham syndrome. Orbital roof encephalocele is uncommon in adults, and the findings can superficially resemble an orbital neoplasm. Radiographic and clinical features that might suggest the correct diagnosis include a prior history of trauma, overlying frontal lobe encephalomalacia without significant mass effect or edema, and an orbital roof defect. The "growing fracture" mechanism may be a potential explanation for the orbital roof destruction in some cases.     

The Doppler ultrasonic flowmeter as an adjunct to operative management of cerebral arteriovenous malformations.

The Doppler ultrasonic flowmeter has been used to assist in the removal of five intracranial arteriovenous malformations. The instrument is generally available in most institutions, and is simple and easy to use. It provides a means for locating and confirming the boundaries of a malformation, distinguishing feeding arteries from arterialized draining veins, determining whether the artery is going to the malformation or normal brain, and evaluating the completeness of obliteration.     

Locked facets in the thoracic spine: report of three cases and a review

Facet dislocation is a rare finding in the thoracic spine. This article presents three cases of bilateral locked facets in the thoracic region. Two were due to car accidents and the third was secondary to a vertical fall. The level of the injury was T2-T3 in two cases and T9-T10 in the third. Two patients were completely paraplegic on admission, whereas the third was neurologically intact. All patients had various associated injuries and fractures. The diagnosis of locked facets was not suspected in any of the cases, but was later made by computerized tomography with parasagittal reconstructions. All patients underwent surgery. The radiological diagnosis was confirmed intraoperatively in two cases. The facets were relocated by manual traction in one case and by Harrington distraction in the other. Fixation and fusion were performed in all three. Stability and vertebral alignment were achieved in all cases postoperatively.     

Treatment options in primary Ewing's sarcoma of the spine: report of seven cases and review of the literature.

Primary Ewing's sarcoma of the spine is reviewed, and seven cases are presented. Ewing's sarcoma of the spine is a rare condition that appears with a clinical triad of local pain, neurological deficit, and a palpable mass. The clinical picture, imaging characteristics, and management are discussed. The definitive management of Ewing's sarcoma of the spine, as in other locations, could include three main modalities: surgery, radiotherapy, and combination chemotherapy. In the presence of acute neurological decompensation, decompressive surgery via an appropriate approach should be performed. Because Ewing's sarcoma is usually sensitive to chemotherapy, initial chemotherapy, in neurologically stable patients, could be attempted first without surgical resection. Further management could then be gauged according to the response.