Gregg H. Zoarski

Optimizing patient selection in percutaneous vertebroplasty.

Percutaneous vertebroplasty has emerged as an effective technique for treatment of painful vertebral compression fractures (VCFs) caused by osteoporosis, malignancy, and some benign bone tumors. In selecting appropriate patients for vertebroplasty, it is important to distinguish the pain caused by VCF from other numerous causes of back pain. Careful adherence to clinical and imaging selection criteria is crucial to procedural success.

Mitral Valve Infective Endocarditis: Benefit of Early Operation and Aggressive Use of Repair

BACKGROUND In-hospital mortality rates for left-sided infective endocarditis (IE) exceed 20%. We investigated the outcomes of an aggressive approach to mitral valve IE that emphasizes early surgical intervention and preferential performance of mitral valve repair. METHODS We reviewed 89 consecutive operations in 87 patients for native mitral valve IE at a single institution from 2002 to 2007. Operations occurred promptly after completion of preoperative studies. Independent risk factors for death were investigated using multivariable logistic regression. RESULTS Mitral valve repair was accomplished in 56 of 89 patients (63%). Perioperative mortality was 4.4% (n = 4). Survival rates at 1 and 5 years were 89.9% (80 of 89) and 82.0% (73 of 90). There was a survival benefit for repair vs replacement at 1 (p = 0.03) and 5 years (p = 0.0017). Repair vs replacement (odds ratio [OR], 0.2; 95% confidence interval [CI], 0.06 to 0.72), diabetes (OR, 4.43; 95% CI, 1.18 to 16.66), and renal failure (OR, 3.65; 95% CI, 1.3 to 12.91) were independent risk factors for late mortality. Among 59 patients with active IE, preoperative head computed tomography (CT) showed 29 (49%) had abnormalities, including 12 (41%) with intracerebral hemorrhage. The median interval was 4 days from admission to operation. The rate of permanent postoperative stroke was 1.1% (1 of 89). CONCLUSIONS These results support early surgical therapy for mitral valve IE. Head CT abnormalities do not warrant delay of operation. Mitral valve repair was associated with a long-term survival advantage compared with valve replacement.

An intracranial aspergilloma with low signal on T2-weighted images corresponding to iron accumulation.

Abstract We present a case of cerebral aspergillosis in an immunocompetent patient. The MRI signal characteristics were compared with the histologic findings. Irregular low-signal zones were demonstrated between the wall of the abscess and the central necrosis on T2-weighted images; the pathology specimen revealed concentrated iron in these transitional zones but no hemosiderin. Iron is an essential element for the growth of fungal hyphae. The low-signal zones may represent the areas where there was active proliferation of aspergillus, and the unique location of the low signal may be a helpful imaging characteristic for the diagnosis of an aspergillus abscess.

Epidural Abscess Due to Spinal Cord Stimulator Trial

▪ Abstract:  Spinal cord stimulation is increasingly utilized as a treatment to alleviate low back pain and lumbar radiculopathy, particularly in patients with failed back surgery syndrome. We present an illustrative case of early, rapidly progressive methicillin‐resistant Staphylococcus aureus (MRSA) infection after a brief stimulator trial lead implantation. Operators should maintain a high level of suspicion for deep infection, including epidural abscess, even when only minor symptoms and signs are present. Because of the poor ability to clear infections in the presence of a retained foreign body, the device must be explanted immediately. Subsequent surgical intervention, however, may nevertheless still be needed. While a variety of bacteria may cause epidural abscess, methicillin sensitive Staphylococcus aureus, and increasingly, MRSA and community‐associated MRSA, are the most likely etiologic organisms. ▪

Biomechanics of Vertebral Bone Augmentation

Percutaneous vertebral augmentation is a successful means of relieving pain and reducing disability after vertebral compression fracture; however, the exact mechanism by which vertebral augmentation eliminates pain remains unproven. Most likely, pain relief is because of stabilization of microfractures. The biomechanical effects of vertebral fracture and subsequent vertebral augmentation therapy, however, are topics for continued investigation. Altered biomechanical stresses after treatment may affect the risk of adjacent fracture in an osteoporotic patient; that risk may be different after vertebral augmentation with cavity creation (balloon assisted vertebroplasty or kyphoplasty) when compared with vertebral augmentation without cavity creation (vertebroplasty). Polymethyl methacrylate cement used in these procedures may have an important effect on the load transfer and disk mechanics, and therefore, the variables of cement volume, formulation, and distribution should also be evaluated. Finally, the question of whether prophylactic treatment of adjacent intact levels is indicated must be considered.

Social responsibility in medical reporting

On August 6, 2009, the New England Journal of Medicine (NEJM), arguably the worlds most influential medical journal, published the results of two randomized controlled trials (RCTs) of vertebroplasty that demonstrated equivalence to a controlled intervention.1 2 Set against the backdrop of a heated national health care debate, these articles created a media frenzy and placed the NeuroInterventional community (amongst others) under immediate and intense scrutiny. The articles sparked a sensationalistic and sometimes hostile debate in which vertebral augmentation specialists were called upon to comment, render opinions and seemingly “defend” their practice.3 4 Sadly for our patients, many of these responses were emotional, reactionary and antagonistic to evidence-based medicine (EBM)—an opportunity for a healthy and reasoned debate was lost. The large body of evidence that supports the practice of vertebral augmentation cannot be easily dismissed. Practitioners of vertebral augmentation have seen countless patients …

Technical and Imaging Report: Fluoroscopic Guidance for Diagnosis and Treatment of Lumbar Synovial Cyst

Lumbar synovial cysts can be a source of low back pain with or without radiculopathy depending upon the size and location of the mass. Options for treatment range from analgesics to surgery, depending upon the degree of nerve root or spinal cord impingement. Attempts at minimally invasive treatment such as computed tomography‐assisted aspiration and cyst rupture are documented in the radiology literature with varying degrees of reported success. This case report is the first to document the fluoroscopically‐guided management of a lumbar synovial cyst in the pain medicine literature and highlights the knowledge and technical skills required when treating such cases.