Bruce Frankel

Segmental polymethylmethacrylate-augmented pedicle screw fixation in patients with bone softening caused by osteoporosis and metastatic tumor involvement: a clinical evaluation.

OBJECTIVEInstrumentation of the osteoporotic spine may result in bone failure because of pedicle screw loosening and pullout. A clinical evaluation of a novel fenestrated bone tap used in pedicle screw augmentation was performed to determine the performance and safety of this technique. METHODSOver a 2.5-year period, the clinical and radiographic results of 119 consecutive patients who underwent instrumented arthrodesis were reviewed. Of these patients, 23 had bone softening secondary to osteoporosis and/or metastatic spinal tumor involvement. These patients underwent surgical decompression and spinal instrumentation. RESULTSSix patients (26%) had metastatic spine disease (squamous cell lung carcinoma, renal cell carcinoma, bladder carcinoma, breast, prostate, and uterine adenocarcinoma); five patients (22%) had a degenerative spondylolisthesis; and 12 patients (52%) had burst fractures, eight as a result of benign causes and four as a result of metastatic disease. Four (17%) patients underwent revision surgery of previous pedicle screw failure resulting from bone softening and pseudarthrosis. A total of 98 levels were fused using 158 polymethylmethacrylate-augmented screws. None of the patients experienced operative death, myocardial infarction, hypoxemia, intraoperative hypotension, radiculopathy, or myelopathy. Asymptomatic anterior cement extravasation was observed in nine patients (39%). There was one asymptomatic polymethylmethacrylate pulmonary embolus and one wound infection. There was no significant relationship between cement extravasation and the quantity used, levels augmented, or location (P > 0.05). There were no construct failures. CONCLUSIONPolymethylmethacrylate-augmented pedicle screw fixation reduces the likelihood of pedicle screw loosening and pullout in patients with osteoporosis requiring instrumented arthrodesis.

Intracranial complications before and after endoscopic skull base reconstruction.

Background Endoscopic skull base reconstruction (ESBR) has been widely accepted in the management of cerebrospinal fluid (CSF) leaks. However, it is not the CSF leak itselfbut the potential for life-threatening intracranial complications (ICCs) that is of primary clinical concern. The risk of developing complications, such as meningitis, in a skull base defect is unknown. Many ESBR are multilayered soft tissue repairs, and long-term prevention of ICCs is not well described. Methods Retrospective chart review and telephone consultation was used to assess patients who had an ESBR from 2002 to 2008. The incidence of an ICCs (meningitis, cerebral abscess, and pneumocephalus) and associated risk factors were assessed before and after surgery. Results One hundred six patients underwent ESBR (mean age (∓SD), 47.7 ∓ 18.5 years; range, 2–78 years) with 95.3% long-term follow-up (mean, 19.9 ∓ 16.3 months). ICCs occurred in 21.7% of patients at presentation, in 2.8% of patients during the perioperative period (<2 weeks), and in one patient (0.9%) during the postoperative period. Risk factors for presenting with an ICC and meningitis were revision cases performed elsewhere (χ2 = 9.10; p = 0.007) and leaking encephaloceles (χ2 = 5.98; p = 0.014). Factors not associated with increased ICC were an active CSF leak at presentation (χ2 = 3.03; p = 0.082) and previous radiotherapy. Conclusion ESBR offers an excellent long-term option in preventing subsequent ICC with low perioperative complications. ESBR is robust with delayed (>2weeks) CSF leakage occurring in only 1.9% regardless of etiology. The presence of identifiable risk factors for ICC may guide the surgeon in determining the urgency of ESBR.

Factors contributing to failure in endoscopic skull base defect repair.

Background Endoscopic repair of skull base (SB) defects is successful in over 90% of cases. Certain factors may contribute to failure of SB repair techniques or need for secondary repair. Methods Five-year retrospective review of endoscopic SB defect repairs performed by a single surgeon. Results Eighty-nine patients undergoing 110 procedures to repair 97 SB defects were evaluated. Etiology of defects included surgical/iatrogenic (64%), spontaneous (17%), traumatic (12%), congenital (6%), and idiopathic (1%). Defects occurred in the sella (41%), sphenoid sinus (18%), ethmoid roof (17%), olfactory cleft (16%), frontal sinus/recess (6%), and middle cranial fossa (2%). Sixty-three patients (71%) underwent primary SB defect repair and 26 patients underwent secondary repair (29%). In revision cases, mean number of prior repair attempts was 1.5 (range, 1-4). Factors potentially contributing to need for secondary SB defect repair included inability to localize SB defect (p =0 008), development of new SB defect, prior sinus or SB surgery (p < 0.001), prior craniotomy (p < 0.001), prior radiation therapy (p = 0.002), and intracranial infection (p = 0.023). SB defects were successfully closed in 83 patients overall (93%), with success achieved in 97% of primary patients and 85% of secondary patients. Of failures, 3 patients required craniotomy for defect closure, 2 patients underwent permanent cerebrospinal fluid (CSF) diversion, and 1 patient has persistent CSF rhinorrhea. Conclusion Although endoscopic repair of SB defect remains largely successful, certain factors should alert the surgeon to the potential for failure of repair or need for secondary SB defect repair.

Percutaneous Vertebroplasty for Osteoporotic Vertebral Compression Fractures in the Nonagenarians : A Prospective Study Evaluating Pain Reduction and New Symptomatic Fracture Rate

Study Design. A prospective observational cohort study of consecutive osteoporotic vertebral compression fractures (VCFs) in ≥90-year-old patients evaluated at a multidisciplinary, university spine center. Objective. Assess efficacy, safety, and new fracture occurrence after percutaneous vertebroplasty (PV) in a large uncontrolled cohort of ultra elderly VCF patients. Summary of Background Data. VCFs are associated with increased morbidity and mortality. Percutaneous injection of polymethylmethacrylate into the fractured vertebral body, vertebroplasty, has been extensively performed as an effective minimally-invasive treatment option for VCF patients. The patient sample included consecutive, osteoporotic patients with symptomatic VCFs electing to enter the study. Methods. Baseline visual analogue scale rating, analgesic usage, duration of symptoms. Subsequent VAS ratings, analgesic utilization, and new fractures were assessed within 30 minutes after the procedure, at 2 weeks, 1 month, 3 months, 6 months, 1 year, and 2 years postprocedure. Outcome measures: Visual Analogue Scale score, analgesic utilization, patient satisfaction, cement extravasation, and new fractures. Results. A total of 123 (74% female) underwent PV for 163 VCFs. Eleven patients did not complete final follow-up at 2 years due to death unrelated to the PV procedure. The mean VAS score was 7.6 at baseline and 3.1 at 30 minutes after the procedure, and 2.3, 1.2, 1.1, 0.9, 0.8, and 0.5 at 2 weeks, 1 month, 3 months, 6 months, 1 year, and 2 years, respectively. Improvement over time was statistically significant using repeated measures analysis of variance (P < 0.05). No complications were encountered during the follow-up intervals. Thirteen new fractures were observed (10.6%) at a mean 20.8 weeks (1–52 weeks) after PV with 6 new fractures (4.9%) involving an adjacent level in 5 patients (4.1%). Conclusion. Vertebroplasty for VCFs in the very elderly appears effective and safe without increased risk of adjacent level fracture.

Natural History and Risk Factors for Adjacent Vertebral Fractures in the Fracture Intervention Trial

Study Design. Retrospective analysis of prospectively collected follow-up data for 2.9 years. Objective. To determine the natural history of subsequent morphometric fracture rates at adjacent levels (one level above or below a previous known baseline fracture) in a large patient database. Summary of Background Data. The long-term risk and risk factors for adjacent-level vertebral fractures in patients with osteoporosis are unknown. Methods. The fracture intervention trial is a large randomized, placebo-controlled trial of alendronate treatment for osteoporosis. Data from both bisphosphonate-treated and bisphosphonate-naive patients (N = 1950, vertebral fracture arm) was analyzed to detect incident morphometric fracture rates. Results. During a mean follow-up of 2.9 years, 3.4% of patients in the alendronate group and 7.4% in the placebo group experienced adjacent-level vertebral fractures. The annual rate of adjacent-level vertebral fractures was 1.2% in the alendronate group, and 2.5% in the placebo group (overall, 1.8% per year in both groups combined). As expected, the thoracolumbar region (defined as T11, T12, and L1) seemed to be the most prone to new adjacent-level fractures. Among females with baseline prevalent fractures at the thoracolumbar junction, who subsequently experienced at least one new fracture anywhere along the spine (N = 124), 40.3% had a new adjacent-level fracture in this region. Older age at randomization, lower bone mineral density, inactivity, and placebo therapy were significantly associated with the development of adjacent-level fractures in univariate analysis (P ⩽ 0.05). Multivariate analysis indicated decreased odds of adjacent-level fractures with bisphosphonate therapy and higher bone mineral density, and increased odds with older age at randomization (P ⩽ 0.05). Conclusion. New vertebral fractures adjacent to prevalent fractures occurred relatively infrequently in this treatment trial of alendronate in females with osteoporosis, and were more common with older age at randomization, lower bone mineral density and placebo treatment. Level of Evidence: 3

Meta-analysis: vertebroplasty for vertebral compression fracture ineffective in improving pain and function

Commentary on: Staples MP, Kallmes DF, Comstock BA, et al. Effectiveness of vertebroplasty using individual patient data from two randomised placebo controlled trials: meta-analysis. BMJ 2011;343:d3952.[OpenUrl][1][Abstract/FREE Full Text][2] Osteoporotic vertebral compression fractures (VCF) are a significant public health concern worldwide. Percutaneous vertebral augmentation or vertebroplasty was introduced to alleviate the pain and reduce the disability associated with VCF in patients failing conservative therapy, but were at very high-risk for open surgery. Due to the apparent success and low morbidity of vertebroplasty, these indications were expanded and widespread use ensued until several randomised trials evaluated the efficacy of vertebroplasty in VCF.1,–,5 Of these, two double-blind sham-controlled randomised trials (ie, the INVEST and Australian trials) … [1]: {openurl}?query=rft.jtitle%253DBMJ%26rft_id%253Dinfo%253Adoi%252F10.1136%252Fbmj.d3952%26rft_id%253Dinfo%253Apmid%252F21750078%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/ijlink?linkType=ABST&journalCode=bmj&resid=343/jul12_1/d3952&atom=%2Febmed%2F17%2F5%2F142.atom

Concomitant Lymphoma and Cryptococcosis in a Patient With Acquired Immune Deficiency Syndrome

Abstract Cryptococcomas and primary central nervous system lymphomas are rarely seen together in a single mass in patients diagnosed with acquired immune deficiency syndrome [Wang et al, Zhonghua Yi Xue Za Zhi (Taipei) 1997;59:50–4]. This report details the unique presentation, diagnosis and subsequent medical and surgical treatments for this pair of conditions.