经皮椎体后凸成形术治疗疼痛性椎体血管瘤

目的 探讨经皮椎体后凸成形术(percutaneous kyphoplasty,PKP)治疗疼痛性椎体血管瘤的临床疗效。方法 搜集2008年01月-2017年04月苏州大学附属第一医院骨科行PKP治疗的疼痛性椎体血管瘤(vertebral hemangioma, VH)患者资料。本组32例中男7例、女25例,年龄平均61.3±12.8岁(32-92岁)；血管瘤位于胸椎20例、腰椎9例、胸椎合并腰椎多发者3例,共累计36个椎体,其中2个椎体血管瘤合并椎体压缩骨折。应用视觉模拟评分(visual analogs scales, VAS)评估患者疼痛情况,用Oswestry功能障碍指数(ODI)量表评估患者生活质量,并记录术后并发症。结果 32例患者共计36个血管瘤椎体均顺利完成手术,其中双侧穿刺30个椎体,单侧穿刺6个椎体。所有患者完成随访,平均14.69±4.91月(7-26个月)。VAS评分术前5.63±1.52,术后24h为1.31±1.06,与术前相比有显著统计学差异(p<0.05),术后1月0.88±0.82,末次随访0.69±0.58；ODI评分术前(61.09±18.95)%,术后24h(21.72±10.57)%,与术前相比有显著统计学差异(p<0.05),术后1月(12.66±9.10)%,末次随访(9.31±5.60)%。VAS评分与ODI评分均较术前明显下降,且在术后随访中呈递减趋势。术后X线片4例椎体出现椎旁骨水泥漏,无临床症状,无椎管内渗漏。1例患者术后8月因骨质疏松出现临近椎体骨折再次行PKP术,1例92岁患者术后1年自然死亡。术后影像学资料未显示有血管瘤复发。结论：对于无神经压迫、以疼痛为主要症状的椎体血管瘤,椎体后凸成形术具有良好的安全性和治疗效果；合并椎体压缩骨折的血管瘤患者PKP同样有效。     

Diagnosis and treatment of vertebral hemangiomas with neurologic deficit: a report of 29 cases and literature review

Background contextVertebral hemangiomas (VHs) are called benign tumors but are actually just vascular malformations. The diagnosis and treatment for aggressive VHs is still controversial, due to their rarity.PurposeTo evaluate the safety and efficiency of the present diagnostic methods and treatment choices.Study designA retrospective study of aggressive VHs with neurologic deficit.Patients sampleA total of 29 consecutive aggressive VH cases were diagnosed and treated in our department since 2001.Outcome measuresWe routinely took anteroposterior and lateral spinal roentgenograms, computed tomography, and magnetic resonance images.MethodsTrocar biopsy is indicated in suspected malignant cases. Radiotherapy was usually our first choice if the neurologic deficit was mild or developed slowly. Surgery was indicated if the neurologic deficit was severe or developed quickly or if the radiotherapy was not effective.ResultsThis series included 12 males and 17 females, and the mean age at diagnosis was 44.0 years (range, 21–72 years). Ten patients had radiculopathy, 1 had cauda equina syndrome, and 18 cases had myelopathy. Twenty-one cases had lesions in the thoracic spine, 5 in the lumbar, and 3 in the cervical region. Eleven cases had untypical image findings, including five cases with pathologic vertebral fracture. The neurologic compression came from only epidural soft tumor mass in 18 cases, whereas it came from both bony compression and soft lesion in the other 11 cases. Ten cases had radiotherapy alone, but two failed and had surgery later. Twenty-one cases had surgery. In the 12 cases having surgical decompression without vertebroplasty, the average estimated blood loss was 1900 mL, and it was 1093 mL for the eight cases having decompression with vertebroplasty. The average follow-up was 51.1 months (range, 24–133 months). There was no recurrence in those cases with radiotherapy, whereas three had local recurrence in those six cases treated by surgical decompression alone without radiotherapy.ConclusionsIn aggressive VHs, epidural soft-tissue compression was usually the main reason for neurologic deficit. In cases with rapid progressive and/or severe myelopathy, posterior decompression and stabilization could be combined with intraoperative vertebroplasty to reduce blood loss.     

Assessment of patient's pain-related behavior at physical examination may allow diagnosis of recent osteoporotic vertebral fracture

Background contextAlthough innumerable studies have analyzed the multiple aspects of osteoporotic vertebral fractures, no study has focused on the clinical features related to spine pain in patients with recent osteoporotic vertebral compression fractures (VCFs).PurposeTo determine whether the assessment of pain-related behavior (P-RB) of patients with osteoporotic VCFs of recent onset may allow the fracture to be strongly suspected, or even diagnosed, at physical examination.Study designPain-related behavior of elderly patients attending an outpatient spine clinic was evaluated on the basis of six consecutive movements made on the examining table.Patient sampleFifty-six patients complaining only of lumbar or thoracic pain. The fractured patients (FPs), representing the fracture group (FG), were the 19 who had a recent VCF, whereas the control group (CG) consisted of the remaining 37 patients.MethodsAssessment of P-RB was based on six parameters: grimacing, sighing, clenching or blocking eyelids, gaping or strongly tightening the lips, need for help to take positions, and extreme difficulty to turn in the prone position. A score of 1 or a decimal was assigned to each parameter, the final score to each patient being 0 to 6. Three types of injury, acute (I), subacute (II), or chronic (III), were identified on the basis of the time elapsed from the probable occurrence of the fracture. The diagnosis of recent fracture was based on magnetic resonance images. Patients were videotaped during their movements. An examiner, unaware of the clinical history and diagnosis, gave a P-RB score to all patients and indicated whether they had to be placed in FG or CG, and also their presumable type of fracture. Subsequently, a DVD with the videotapes of all patients was given to three independent examiners, not specifically expert of spine conditions, who were asked to make the same evaluations as the first examiner.ResultsThe mean scores for P-RB given by the first examiner were 4.6 to FG and 0.7 to CG (p<.01). He identified as FPs 89% of those who were in FG. The type of fracture was indicated correctly in 88% of patients identified as FPs. The mean scores for the three types of fracture ranged from 5.4 (Type I) to 3.3 (Type III) (p<.001). The mean scores for P-RB given by the independent examiners to FG and CG were similar to those of the first examiner. The rates of correctness in identifying the type of fracture in patients indicated as FPs varied from 87% to 80%. The mean scores assigned to the patients included in the three types of fracture ranged from 5.4 to 2.8.ConclusionsPain-related behavior evaluation of patients with osteoporotic VCF during their movements on the examining table may allow to suspect, or even diagnose, the presence of a fracture, particularly in the initial 4 to 6 weeks after the occurrence. Even orthopedic surgeons not particularly familiar with spine care may be able to suspect the injury during physical examination.     

Panoramic radiomorphometry and vertebral fractures in Spanish postmenopausal women

ObjectiveTo evaluate the relationship between panoramic radiomorphometric indexes, and the presence of osteoporotic fractures in a Spanish postmenopausal women.MethodsA sample of 120 women (60 with fragility spine fractures and 60 healthy), aged 55–70 years, with fragility spine fractures, were included in this cross-sectional study that was conducted from 2008 to 2011. All the women were referred to undergo a radiological spine examination, spinal densitometry and a panoramic radiograph for assessing osteoporosis using 3 radiomorphometric indexes: Panoramic Mandibular Index (PMI), Mental Index (MI) and Mandibular Cortical Index (MCI). According to mandibular cortical shape, in MCI, three groups were defined: C3 (osteoporosis), C2 (osteopenia), C1 (health).ResultsSignificant differences were found between all the MCI groups due to their composition between fractures and non-fractures. C1 group (healthy) has less fractures women than C2 (Bonferroni p < 0.001), C1 has less fractures than C3 (Bonferroni p < 0.001) and finally, C2 has less fractures than C3 (Bonferroni p < 0.006). PMI and MI values were significantly lower in cases than in controls (U Mann–Whitney p < 0.001).ConclusionsPanoramic radiomorphometrics mandibular indexes such as MCI, PMI, and MI, may be useful for identifying the population at higher risk for fracture. The relationship between panoramic index and osteoporosis remains unclear and further studies using fragility fracture as a real marker of osteoporosis are warranted to clarify the exact role and effect of one condition on the other and the corresponding clinical implications.     

Cervical fracture patterns associated with blunt cerebrovascular injures when utilizing computed tomographic angiography: a systematic review and meta-analysis

BACKGROUND CONTEXTPrior studies have demonstrated an association between cervical spine fractures and blunt cerebrovascular injuries (BCVI) due to the intimate anatomic relationship between the cervical spine and the vertebral arteries. Digital subtraction angiography (DSA) has historically been the gold standard, but computed tomography angiography (CTA) is commonly used to screen for BCVI in the trauma setting. However, there is no consensus regarding which fracture patterns mandate screening. Over aggressive screening may lead to increased radiation, increased false positives, and overtreatment of patients which can cause unnecessary patient harm, and increased healthcare costs.PURPOSEThe aim of this meta-analysis is to analyze which cervical spine fracture patterns are most predictive of BCVI when utilizing CTA.STUDY DESIGN/SETTINGSystematic review and meta-analysis.OUTCOME MEASURESOdds ratios for specific cervical fracture patterns and risk of developing a BCVI.METHODSA systematic literature review of all English language studies from 2000-2020 was conducted. The year 2000 was chosen as the cut-off because use of CTA prior to 2000 was rare. Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Scopus, Global Index Medicus, and ClinicalTrials.gov were queried. Studies were included if they met the following criteria: (1) the diagnostic imaging modality was CTA; (2) investigated blunt cervical trauma; (3) noted specific cervical spine fracture patterns associated with BCVI; (4) odds ratios for specific cervical spine fracture patterns or the odds ratio could be calculated; (5) subjects were 18 years old or older. Studies were excluded if they: (1) included DSA or magnetic resonance imaging; (2) included penetrating cervical trauma; (3) included pediatric patients less than 18 years of age; (4) were not written in English. All statistical analysis was performed using R Studio (RStudio, Boston, MA, USA).RESULTSThe initial search, after duplicates were removed, resulted in 10,940 articles for independent review. Six studies met the criteria for inclusion in the meta-analysis. Specific fracture patterns mentioned are isolated C1, C2, C3 fractures, any C1–C3 fracture, any C4–C7 fracture, two-level fractures, subluxation/dislocations, and transverse foramen (TF) fractures. Three studies were included in the meta-analysis for C1, C2, C1–C3, subluxations/dislocations, and TF fractures. Two studies were included in the meta-analysis for C3, C4–C7, and two-level fractures. The pooled odds ratio with 95% confidence interval for: C1 fractures and BCVI is 1.3 (0.8–2.1); C2: 1.6 (0.9–2.8); C3: 1.8 (0.9–3.6); C1–C3: 2.2 (1.1–4.2); C4–C7: 0.7 (0.3–1.7); Two-level: 2.5 (1.4–4.6); Subluxation/Dislocation: 2.9 (1.8–4.5); TF: 3.6 (1.4–8.9).DISCUSSION/CONCLUSIONThis study found that when utilizing CTA for screening of BCVI only fractures in the C1-C3 region, two-level fractures, subluxations/dislocations, and transverse foramen fractures were associated with increased incidence of a BCVI. Further refinement of protocols for CTA in the setting of blunt cervical trauma may help limit unnecessary patient harm from overtreatment and reduce healthcare costs.     

Skipped vertebral spontaneous spondylodiscitis caused by Granulicatella adiacens: Case report and a systematic literature review

BackgroundGranulicatella adiacens is a nutritional variant of streptococcus (NVS), which has been rarely reported as an etiologic agent in spondylodiscitis (SD).Material and methodsWe report a case of a 51-year-old male with from chronic low-back pain associated with right sciatica and ipsilateral monoparesis. Spinal MRI showed radiological signs on L1-L2 and L5-S1 discs consistent with SD. We also performed a systematic review of the pertinent literature in order to retrieve all the key information regarding microbiological and clinical features.ResultsIncluding our patients, seven cases with a mean age 56 ± 10.2 years were reported in English literature. Six patients were conservatively managed with antibiotic therapy (66%), whereas three with surgery in combination with antibiotics (33%). An endocarditis was associated in three cases, and a pacemaker infection in one. All patients received targeted antibiotic therapy resulting in a quick improvement of clinical symptoms with favorable outcome. Our case is the only with a skip spontaneous SD, which needed a surgical decompression due to the associated neurological symptoms.ConclusionsThis incidence of SD sustained by Granulicatella adiances could be underestimated due to their particular microbiological conditions requested for their cultures. However, this infection should be suspected in cases of culture-negative SD, especially when associated with endocarditis.     

颅内段椎动脉夹层动脉瘤的血管内治疗

目的探讨椎动脉夹层动脉瘤的血管内治疗方法。方法回顾性分析本手术组2006年1月~2014年5月间接诊的41例椎动脉夹层动脉瘤病例,其中35例分别采用了3种不同的血管内治疗技术,另6例进行了随诊观察。结果 41例均获得随访,时间为3~18个月。其中1例行支架辅助弹簧圈治疗的病人复发,2例未治疗的病人动脉瘤增大。结论治疗组和观察组做统计学分析(P0.01),血管内治疗椎动脉夹层动脉瘤是一种较为安全、可靠的方法,根据动脉瘤的形态、与小脑后下动脉的关系及对侧椎动脉的发育情况等因素来选择不同的血管内治疗。     

Simulation study on therapeutic vertebral artery occlusion for VA-PICA giant aneurysm

Abstract

We investigated haemodynamic effects of therapeutic vertebral artery (VA) occlusion on giant aneurysms at the bifurcation of the VA-posterior inferior cerebellar artery (PICA). An hydraulic model of the human vertebro-basilar artery was manufactured from glass and silicone tubes. Class-spheres 2.5 cm in diameter were placed at the bifurcation as model aneurysms with respective distances of 8.5, 7.5, 6.5 and 5.5 mm between the VA union and aneurysmal neck. A 40% glycerol solution was perfused in this system and the half-life of the dye injected into aneurysms was regarded as an index of intra-aneurysmal stagnation. Flow conditions in aneurysms depended on the presence or absence of the effect of contralateral VA flow as well as the PICA flow. The half-life increased significantly after VA occlusion proximal to the PICA when the aneurysmal neck was more than 7.5 mm away from the VA union and PICA flow volume was less than 12 ml min^–1 The half-life in aneurysms located within 6.5 mm from the union changed little after VA occlusion regardless of the PICA flow volumes. The haemodynamic simulation study would be helpful in speculating on the efficacy of this treatment. [Neurol Res 1994; 16: 100-103]