C. Doria

Cauda Equina Syndrome Secondary to Idiopathic Spinal Epidural Lipomatosis

Study Design. Three cases of idiopathic epidural lipomatosis are reported. Objectives. Description of the relationship between spinal pathologic overgrowth of fat tissue and neurologic symptoms. Summary of Background Data. Idiopathic epidural lipomatosis is a very rare condition; it is usually secondary to chronic steroid therapy or endocrinopathic diseases. Methods. Three men with a mean age of 58.5 years, who experienced intermittent claudication, bilateral radicular pain in both legs, and urinary dysfunction with hypoesthesia in the perineal region, were evaluated by plain radiography and magnetic resonance imaging, the results of which demonstrated a pathologic overgrowth of fat tissue in the spinal canal with a marked impingement of the dural sac. Obesity, endocrinopathic diseases, and chronic steroid therapy were excluded for all patients. Surgical treatment was performed by wide multilevel laminectomies, fat debulking, and instrumented posterolateral fusion. Results. After surgery there was a gradual improvement in symptoms and signs so that 2 years later the patients returned to daily activities and were neurologically normal. Conclusions. Spinal epidural lipomatosis can be a cause of back pain but rarely radicular impingement. Magnetic resonance imaging is the procedure of choice. The treatment must be performed early by wide surgical decompression.

Transthoracic lateral retropleural minimally invasive microdiscectomy for T9-T10 disc herniation

Thoracic disc herniation (TDH) is a rare pathology, its prevalence estimated in 1:1.000.000 [2]. Its etiology remains unclear; symptoms are variable, ranging from mild back pain to moderate sensorial or motor deficits to severe paraparesis and bladder disfunction [1, 2, 9, 10]. Diagnosis is confirmed by MR of the thoracic spine; CT scan is helpful to better identify disc calcifications or osteophytes, which are frequent and pose significant additional difficulties during surgical excision [3]. Surgery is the treatment of choice in cases of severely symptomatic TDH [1, 2]. Different surgical approaches have been proposed in the past: posterior laminectomy associated or not to costo-transversectomy, has been almost completely abandoned because of poor results related to insufficient decompression and high rate of complications-including spinal cord injuries, dural tears and death [2]; transthoracic thoracotomic approaches were then postulated [7]; videoassisted thoracoscopic surgery allowed for significative reduction of thoracic exposure and consequently reduced postoperative pain related to thoracotomy [6]; disadvantages of the thoracoscopic approach are the need for selective intubation with lung collapse on the side of the access, the additional technical difficulty related to the specific skills that thoracoscopic surgery requires, which can hardly be kept trained with a low case load, as typically in TDH [8]. Lateral access, minimally invasive transthoracic retropleural discectomy and spinal cord decompression with the assistance of operative microscope is an excellent less invasive alternative to transthoracic open and thoracoscopic techniques in the treatment of symptomatic TDH [4, 5, 9].

Percutaneous techniques in the treatment of osteoporotic, traumatic and neoplastic fractures of thoraco-lumbar spine: Our institutional experience

Fifty-eight (30 females) patients with a mean age of 55 were treated in our institution with minimal invasive surgery techniques for osteoporotic, traumatic and neoplastic fractures of the thoraco-lumbar spine. All patients completed pre-operatively and post-operatively the VAS score (0-10, 10 being the worst state for pain) as well as the Oswestry low back pain disability questionnaire at 3, 12, 24 and 36 months intervals. Overall the VAS score was reduced from 7.8 points pre-operatively, to 2.1 points at the 36 month follow up. Oswestry disability score improved from a pre-operative severe disability to moderate disability at 3 months up to a minimum disability at 36 months. The minimally invasive surgical techniques can significantly improve clinical outcomes by preventing many of the drawbacks associated with open approaches whilst also allowing to associate other methods such as coblation, vertebroplasty, interbody fusion that can be complementary to vertebral fixation.

Treatment of Early Hip Osteoarthritis: Ultrasound-Guided Platelet Rich Plasma versus Hyaluronic Acid Injections in a Randomized Clinical Trial

Purpose  The aim of this study was to compare the clinical efficacy of ultrasound-guided intra-articular injections of autologous platelet rich plasma (PRP) versus hyaluronic acid (HA) for symptomatic early osteoarthritis (OA) of the hip. Methods  A prospective controlled double-blinded randomized trial on 80 patients with hip OA was conducted. The patients were divided in two groups of 40 patients each: group 1 underwent three PRP intra-articular ultrasound-guided injections, whereas group 2 underwent three HA injections. WOMAC, VAS, and Harris Hip Score were evaluated for both groups before and at 6 and 12 months after treatment. Results  The two groups were comparable in age, sex, body mass index, and severity of hip OA. Both groups showed a significant improvement from baseline at 6-month and 12-month follow-ups for all the outcome measures. No major complications were observed during the treatment and at follow-ups in both the groups. Conclusion  PRP did not offer significantly better results compared with HA in patients with moderate signs of OA, and thus it should not be considered as first-line treatment. Level of Evidence  Level II, randomized controlled trial.

Posterior epidural migration of an extruded free fragment from a lumbar disc herniation

Abstract The majority of symptomatic lumbar disc herniations are located in a posterolateral position with resultant nerve root compression. Although caudal, rostral and lateral migrations of disc fragments are common, posterior epidural migration of an extruded free fragment from a lumbar disc herniation is a rare occurrence and sometimes may cause a dural sac compression with cauda equina syndrome. This retrospective case report describes a 63-year-old man with intractable lower back pain and cauda equina syndrome. Emergency magnetic resonance imaging (MRI) revealed a posterior epidural soft tissue compressing the dural sac. The lesion was hypointense on T1-weighted images, hyperintense on T2-weighted images and showed rim enhancement after intravenous injection of gadolinium. A laminectomy at L3 was performed and the extruded disc fragment was removed with dural sac decompression. Postoperatively the patients radicular symptoms completely resolved. At the 2-year follow-up visit, the patient had recovered full motor, sensory and urinary functions.MRI is the modality of choice in the evaluation of an extruded free disc fragment and a cauda equina compression. In such cases a wide decompressive laminectomy is recommended.

Peri-prosthetic humeral non-union: Where biology meets bio-mechanic. A case report

Highlights • Periprosthetic fracture non-unions are a medical challenge that requires a multi-level treatment.• Aggressive revision surgery and bone healing therapy are the best solutions for those cases.• The association of mechanical stability and the support to osteogenic processes can lead to fracture healing in non-union cases. Our method follows the Giannoudis’ “Diamond concept” about fracture healing.

Safety and effectiveness of teriparatide vs alendronate in postmenopausal osteoporosis: a prospective non randomized clinical study

In this work we study the safety and effectiveness of teriparatide and alendronate in patients with postmenopausal osteoporosis at high risk of fracture; it was a double-blinded and it was done by examining the comparisons between teriparatide 20 μg/day and alendronate 10 mg/day. Safety and effectiveness analyses were based on data from 355 woman with a mean age of 68 years. Two groups (A and B) with T-score ≤-2.5 at bone mineral density were analyzed and 3 or more vertebral fractures on radiograph. Group A: was treated with teriparatide 20 μg/day and composed from 182 women, in post-menopausal age, without a history of cancer. Group B: was treated with alendronate 10 mg/day composed from 173 women, postmenopausal age, with previous history of cancer (non-active during the study). Clinical evaluations were on bone turnover markers (alkaline phosphatase, procollagene type 1 N-terminal propeptide, and N-telopeptide cross-links), dual-energy X-ray absorptiometry and health-related quality of life (HrQoL). Safety was assessed by reporting of adverse drug reactions (ADRs). The results of this study imply that teriparatide comparated with alendronate has a favorable safety profile and is effective in the treatment of patients with osteoporosis at high risk of fracture.

Percutaneous treatment of the spinal metastases

Background: The spinal column is the most frequent site of bone metastases, and between 30% and 70% of patients with cancer will have evidence of spinal metastasis at autopsy [1,2]. The majority of metastasis occurs in the thoracic spine (70%) followed by the lumbar (20%) and cervical region (10%), [2-4]. The surgical treatment of the vertebral metastases remains a real challenge in spine surgeons. Recent advancements in surgical techniques allow a less aggressive approach of the patient with better results in terms of decreasing pain, improvement of the quality of life. We must avoid the overtreatment of terminally ill patients; some patients may survive for several years and benefit from surgery. Materials and methods: The surgical techniques that we used from August 2006 to October 2011 were the coablation (Figures 2a,2b) associated with vertebroplasty (Figures 3a,3b) and percutaneous osteosynthesis (Figures 4-6). Very important were the operating room set up and the surgical technique. In our clinic, in the last 5 years, were treated 115 patients. With vertebroplasty (Figures 3a,3b) and ablation (Figures 2a,2b) 76 patients (94 vertebrae). We used the percutaneous osteosynthesis (Figures 4-6) in 39 patients aged between 42 and 88 years (mean 65 years). Results: In both types of treatment, the postoperative elapsed were regular with early mobilization and regression of pain. Conclusion: The diagnosis and treatment of spinal metastases require multidisciplinary review. The optimal treatment depends from a balance between the morbidity of the surgical procedure, the estimated survival time, and the overall quality of life. We believe that these minimally invasive techniques are certainly a viable alternative to “open’’ traditional spine surgery and can help in order to reduce the pain and to restore the stability.

Instrumented posterior interbody fusion in degenerative and multioperated lumbar spine

Lumbar interbody fusion is a valid technique for the treatment of disc diseases. We report a series of 37 patients who underwent posterior lumbar interbody fusion with titanium cylindric screwing-expansion cages. Clinical outcomes and radiological results were evaluated 3 years after surgery. After surgery, the majority of patients returned to their normal activities. Follow-up plain roentgenograms showed no loss of disc height and no signs of implant looseness. Computed tomography (CT) showed the presence of mineralized autologous bone grafts inside the interbody cages. Expandable interbody cages allow the restoration of disc space height, giving support to the anterior column, opening the neuroforaminal area and providing increased stability. The interpretation of fusion on the basis of roentgenograms is difficult; CT offers more information than radiography about the fusion process, but a bony arthrodesis cannot be demonstrated with certainty.

Far lateral lumbar disc herniations: 3- to 14-year results

Abstract A retrospective review of 38 patients who underwent surgical treatment for far lateral lumbar disc herniation (FLLDH) using two different techniques is reported.Between October 1986 and October 1997, we operated on 38 patients with FLLDH: 12 had extraforaminal disc herniation and 26 had foraminal disc herniation. Plain roentgenograms, computed tomography (CT) scans and magnetic resonance (MR) images were obtained before surgery. Postoperative outcomes showed a relief of clinical symptoms with recovery of neurological signs. There was no difference among the results encountered in the two surgical groups. A diagnosis of level based on physical examination alone is difficult. The combined use of CT and MR imaging helps to confirm the exact localization of disc herniation.