Revision strategies for failed adult spinal deformity surgery

The aim of this study is to analyse the results of revision surgery for failed adult spinal deformity patients and to describe the surgical strategy selection process, based on the identification of the main clinical diagnosis responsible for failure. We retrospectively reviewed the clinical and radiological data of 77 consecutive patients treated in a 3-year time (2016–2019) for surgical revision of long fusion (more than five levels fused) for adult spinal deformity in a high-volume spine centre, divided into four groups based on the diagnosis: rod breakage (RB) group, proximal junctional failure (PJF) group, distal junctional failure (DJF) group and loss of correction (LOC) group with symptomatic sagittal or coronal malalignment (including iatrogenic flatback). Seventy-seven patients met our inclusion criteria, with a female prevalence (66 F vs. 11 M). The mean age at revision surgery was 63. Fused levels before surgery were averagely 12, and revision added averagely two levels to the preexisting fusion area. Clinical status was apparently improved in ODI scores and VAS scores, while it was slightly worsened in SF36 scores. Different diagnosis groups have been addressed with different surgical strategies, according to the different surgical goals: interbody cages and multi-rod construct to improve stiffness and favour bony fusion, “kickstand” rod and “tie” rod to correct coronal and sagittal malalignment, specific rod contouring and proximal hooks in “claw” configuration to reduce mechanical stress at the proximal junctional area. Intraoperative complications occurred in 18% of patients and perioperative complications in 39%. Revision surgery in long fusions for adult spinal deformity is a challenging field. Surgical strategy should always be planned carefully. A successful treatment is a direct consequence of a correct preoperative diagnosis, and surgery should address the primary cause of failure. All the above-mentioned surgical techniques and clinical skills should be part of surgeon’s expertise when managing these patients. These slides can be retrieved under Electronic Supplementary Material.     

Effects of tramadol on experimental inflammation

We examined the ability of the analgesic drug tramadol to affect the development of inflammation in rats. The acute administration of tramadol significantly reduced the edema and the hyperalgesia induced by yeast injection in the paw. Moreover, in the subcutaneous carrageenin-induced inflammation, tramadol reduced the amount of the exudate, as well as the prostaglandin (PG)E2-like bio- and immuno-activity in the exudate; on the contrary, leukotriene (LT)B4 concentrations in the exudate were not changed. However, tramadol did not affect the ability of macrophages to migrate towards the chemotactic peptide N-formyl-L-methionil-L-leucyl-L-phenylalanine (FMLP). Our results suggest that tramadol is able to inhibit the development of different types of inflammation in the rat without affecting immune mechanisms, and contribute to explain the efficacy of this drug in the treatment of inflammatory pain.     

Cerebellar degeneration and hearing loss in a patient with idiopathic myenteric ganglionitis

A 35-year-old male with an 11-year history of intestinal pseudo-obstruction associated with an idiopathic inflammatory insult of the myenteric plexus and the presence of circulating anti-Hu antibodies developed a neurological syndrome characterized by bilateral hearing loss, deteriorating balance, an unsteady gait and difficulty in estimating distances. A similar neurological syndrome has previously been described in older patients among the paraneoplasic syndromes associated with small-cell lung carcinoma and the presence of circulating anti-Hu antibodies, but never in the rare cancer-free patients with anti-Hu-associated chronic idiopathic intestinal pseudo-obstruction. The patient underwent a steroid treatment. No further episodes of functional intestinal obstruction were observed and, after an initial improvement, the neurological symptoms stabilized, leaving a permanent reduction in hearing function and an unsteady gait. The case shows that an idiopathic inflammatory insult of the myenteric plexus may precede (and perhaps lead to) central nervous system impairment in patients with anti-Hu-associated chronic idiopathic intestinal pseudo-obstruction.     

Prevalence and disability of comorbid social phobia and obsessive–compulsive disorder in patients with panic disorder and generalized anxiety disorder

Objective. Generalized anxiety disorder (GAD) and panic disorder (PD) are disabling conditions, often comorbid with other anxiety disorders. The present study was aimed to assess prevalence and related disability of comorbid social phobia (SP) and obsessive–compulsive disorder (OCD) in 115 patients with GAD (57) or PD (58). Methods. Patients were classified as having threshold, subthreshold, or no comorbidity, and related prevalence rates, as well as disability (Sheehan Disability Scale, SDS), were compared across diagnostic subgroups. Results. SP and OCD comorbidities were present in 30.4% of the sample, with subthreshold comorbidities present at twice the rate of threshold ones (22.6% vs. 11.3%). Compared with GAD patients, PD patients showed significantly higher subthreshold and threshold comorbidity rates (27.6% and 13.8% vs. 17.5% and 8.8%, respectively). Comorbid PD patients had higher SDS scores than the comorbid and non-comorbid GAD subjects. The presence of threshold SP comorbidity was associated with the highest SDS scores. Conclusions. SP and OCD comorbidities were found to be prevalent and disabling among GAD and PD patients, with higher subthreshold than threshold rates, and a negative impact on quality of life. Present findings stress the importance of a dimensional approach to anxiety disorders, the presence of threshold and subthreshold comorbidity being the rule rather than the exception.     

Parathyroid-hormone variance is only marginally explained by a panel of determinants: a cross-sectional study of 909 hip-fracture patients

Several factors affect the levels of parathyroid hormone (PTH) in hip-fracture patients. We hypothesized that a panel of easily assessable determinants could account for both a substantial proportion of PTH variance and the occurrence of secondary hyperparathyroidism. We evaluated 909 of 981 hip-fracture inpatients admitted consecutively to our Rehabilitation division. In each patient we assessed PTH, 25-hydroxyvitamin D, albumin-adjusted total calcium, phosphate, magnesium, and creatinine on a fasting blood sample 21.3 ± 6.1 (mean ± SD) days after fracture occurrence. Glomerular filtration rate (GFR) was estimated by the 4-variable Modification of Diet in Renal Disease Study equation. Functional level was assessed using the Barthel index. On multivariate analysis, six factors (phosphate, albumin-adjusted total calcium, estimated GFR (eGFR), 25-hydroxyvitamin D, age, and magnesium) were significantly associated with PTH levels. Overall, the panel of variables accounted for 23.7 % of PTH variance. Among the 909 patients, 304 (33.4 %) had PTH levels exceeding the normal range. Six factors (phosphate, albumin-adjusted total calcium, eGFR, 25-hydroxyvitamin D, age, and Barthel index scores) were significantly associated with the category of PTH level (either normal or elevated). The model correctly classified 70.4 % of cases. For the optimal cut-off point, sensitivity was 80 % and specificity was 61 %. Data shows that six factors were significantly associated with PTH levels in hip-fracture inpatients. However, the six factors accounted for only 23.7 % of PTH variance and the presence or absence of secondary hyperparathyroidism was correctly categorized in a modest proportion of cases. We conclude that more knowledge is needed on the factors affecting PTH levels after hip fracture.     

It's time for Mohs: Micrographic surgery for the treatment of high‐risk basal cell carcinomas of the head and neck regions

Basal cell carcinoma (BCC) is the most common variety of non‐melanoma skin cancer and its incidence is increasing worldwide. The centrofacial sites (area H) are considered a high‐risk factor for BCC local recurrence. Mohs micrographic surgery (MMS) is a technique that allows intraoperative microscopic control of the surgical margins and is a good treatment option when tissue conservation is required for esthetic or functional reasons or for high‐risk lesions. The present study aimed to evaluate the recurrence rate of head and neck high‐risk BCCs comparing MMS vs conventional surgical excision. Clinical data of patients diagnosed from September 2014 to March 2017, referring to the Dermatology Unit of the Policlinico Sant'Orsola‐Malpighi, University of Bologna, were retrospectively evaluated (285 treated with MMS and 378 treated with traditional surgery). Of the 285 patients treated with MMS, 9 experienced a recurrence (3.1%). Of the 378 patients treated with traditional surgery, 53 relapsed (14%), 13 of whom presented residual tumor on the deep or lateral margins of the main surgical specimen. Our study confirms the trend reported in the literature that MMS represents the best treatment option for high‐risk BCCs arising in the head and neck region or presenting as a recurrence (P < .00001). Many more MMS centers and more trained dermatologists are needed worldwide in order to deal with the increasing number of BCC diagnosed every year.