Hung-Shu Chen

Clinical evaluation of repeat percutaneous vertebroplasty for symptomatic cemented vertebrae.

Background: Percutaneous vertebroplasty (PV) with polymethylmethacrylate is widely used to treat osteoporotic vertebral compression fracture and satisfactory clinical outcomes have been reported in the literature. However, recurrent or persistent back pain after PV is not uncommon. Sometimes, the pain may result from pathogenesis within the previously treated vertebra. In this study, we evaluated the efficacy and safety of repeat PV for treating patients with recurrent back pain caused by the previously cemented vertebrae. Methods: We retrospectively reviewed the medical records of 18 patients who underwent repeat PV to treat symptomatic cemented vertebrae. Patients were categorized into 3 groups based on clinical presentation and imaging studies: those with refracture (RF), residual vacuum (RV), and osteonecrosis (ON) along the bone-cement interface. A bipedicle approach was used for repeat PV in all patients. The visual analogue scale (VAS) and modified Brodsky criteria were used to evaluate clinical outcomes before and after surgery. The Kruskal-Wallis test, Wilcoxon signed-rank test, and Spearman correlation analyses were used to analyze patient surgical prognosis and radiologic findings. Results: Nine patients were diagnosed with RF, 5 with RV, and 4 with ON. The average VAS score was 77.1 (range, 62–90) before repeat PV (80.1, 72.4, and 76.3 for the RF, RV, and ON groups, respectively) and 34.4 (range, 25–45) after repeat PV treatment (33.1, 36.8, and 34.3 for the RF, RV, and ON groups, respectively). The VAS score significantly decreased in all 3 groups. The vertebral body height was significantly restored by a mean of 13.9% across all groups (17.8%, 12.7%, and 6.8% in the RF, RV, and ON groups, respectively). Fifteen patients recovered from vertebral compression fracture and regained their preinjury activities of daily living. No surgery-related complications occurred except asymptomatic cement leakage in 5 patients. Conclusions: The results of this research demonstrate that repeat PV may be an effective method for relieving recurrent or persistent pain in patients with symptomatic cemented vertebrae, allowing them to regain functional activity.

Minimally invasive endoscopic treatment for lumbar infectious spondylitis: a retrospective study in a tertiary referral center

BackgroundSpinal infections remain a challenge for clinicians because of their variable presentation and complicated course. Common management approaches include conservative administration of antibiotics or aggressive surgical debridement. The purpose of this study was to evaluate the efficacy of percutaneous endoscopic debridement with dilute betadine solution irrigation (PEDI) for treating patients with lumbar infectious spondylitis.MethodsFrom January 2005 to July 2010, a total of 32 patients undergoing PEDI were retrospectively enrolled in this study. The surgical indications of the enrolled patients included single-level infectious spondylodiscitis, postoperative infectious spondylodiscitis, advanced infection with epidural abscess, psoas muscle abscess, pre-vertebral or para-vertebral abscess, multilevel infectious spondylitis, and recurrent infection after anterior debridement and fusion. Clinical outcomes were assessed by careful physical examination, Macnab criteria, regular serologic testing, and imaging studies to determine whether continued antibiotics treatment or surgical intervention was required.ResultsCausative bacteria were identified in 28 (87.5%) of 32 biopsy specimens. Appropriate parenteral antibiotics for the predominant pathogen isolated from infected tissue biopsy cultures were prescribed to patients. Twenty-seven (84.4%) patients reported satisfactory relief of their back pain after PEDI. Twenty-six (81.3%) patients recovered uneventfully after PEDI and sequential antibiotic therapy. No surgery-related major complications were found, except 3 patients with transient paresthesia in the affected lumbar segment.ConclusionsPEDI was successful in obtaining a bacteriologic diagnosis, relieving the patient’s symptoms, and assisting in the eradication of lumbar infectious spondylitis. This procedure could be an effective alternative for patients who have a poor response to conservative treatment before a major open surgery.

Impact of lumbar instrumented circumferential fusion on the development of adjacent vertebral compression fracture

We evaluated the impact of lumbar instrumented circumferential fusion on the development of adjacent level vertebral compression fractures (VCFs). Instrumented posterior lumbar interbody fusion (PLIF) has become a popular procedure for degenerative lumbar spine disease. The immediate rigidity produced by PLIF may cause more stress and lead to greater risk of adjacent VCFs. However, few studies have investigated the relationship between PLIF and the development of subsequent adjacent level VCFs. Between January 2005 and December 2009, a total of 1936 patients were enrolled. Of these 224 patients had a new VCF and the incidence was statistically analysed with other covariants. In total 150 (11.1%) of 1348 patients developed new VCFs with PLIF, with 108 (72%) cases at adjacent segment. Of 588 patients, 74 (12.5%) developed new subsequent VCFs with conventional posterolateral fusion (PLF), with 37 (50%) patients at an adjacent level. Short-segment fusion, female and age older than 65 years also increased the development of new adjacent VCFs in patients undergoing PLIF. In the osteoporotic patient, more rigid fusion and a higher stress gradient after PLIF will cause a higher adjacent VCF rate.

Clinical evaluation of percutaneous vertebroplasty for symptomatic adjacent vertebral compression fracture.

Study Design: A retrospective study. Objective: To evaluate the efficacy and safety of percutaneous vertebroplasty (PV) for treating patients with symptomatic osteoporotic vertebral compression fractures (VCFs) adjacent to lumbar instrumented circumferential fusion. Summary of Background Data: Few studies have investigated adjacent VCFs and their management after spinal fusion surgery for degenerative lumbar disease. Patients and Methods: From January 2005 to July 2011, a total of 23 patients with lumbar instrumented circumferential fusion suffered from adjacent symptomatic osteoporotic VCFs. All of these patients received PV using polymethylmethacrylate bone cement augmentation in our institute. Radiography and magnetic resonance imaging were used for imaging studies. The visual analog scale and modified Brodsky criteria were used to compare clinical outcomes before and after surgery. The minimum follow-up period was 18 months (range, 18–45 mo). Results: One level PV was performed in 18 patients and 2 levels were performed in 5 patients. The patients’ visual analog scale scores improved by an average of 54.3 points after the procedure. Twenty patients returned to their preinjury activities of daily living. Lumbar lordosis was increased from 28.9 degrees before PV to 36.2 degrees after PV. The average restoration of the fractured vertebral body height was 14.0%. No surgery-related complications occurred except asymptomatic cement leakage in 4 patients. Conclusions: PV is a minimally invasive and effective procedure to treat patients with symptomatic osteoporotic VCFs adjacent to lumbar instrumented circumferential fusion.

Single-stage anterior debridement and fibular allograft implantation followed by posterior instrumentation for complicated infectious spondylitis: report of 20 cases and review of the literature.

AbstractComplicated infectious spondylitis is an infrequent infection with severe spinal destruction, and is indicated for combined anterior and posterior surgeries. Staged debridement and subsequent reconstruction is advocated in the literature. The purpose of this study is to evaluate the feasibility and clinical outcome of patients who underwent single-stage combined anterior debridement and fibular allograft implantation followed by supplemental posterior fixation for complicated infectious spondylitis.We retrospectively reviewed the medical records of 20 patients who underwent single-stage combined anterior and posterior surgeries for complicated infectious spondylitis from January 2005 to December 2010. Complicated infectious spondylitis was defined as at least 1 vertebral osteomyelitis with pathological fracture or severe bony destruction and adjacent discitis, based on imaging studies. The severity of the neurological status was evaluated using the Frankel scale. The clinical outcomes were assessed by careful physical examination and regular serological tests to determine the visual analog scale (VAS) score and Macnab criteria. Correction of the sagittal Cobb angle on radiography was also compared before and after surgery. The Wilcoxon signed-rank test was used to analyze patient surgical prognosis and radiological findings.All patients with complicated infectious spondylitis were successfully treated by single-stage combined anterior and posterior surgeries. No patients experienced neurologic deterioration. The average VAS score was 7.8 before surgery and significantly decreased to 2.1 at discharge. Three patients had excellent outcomes and 17 had good outcomes, based on Macnab criteria. The average length of the allograft for reconstruction was 64.0 mm. Kyphotic deformity improved in all patients, with an average correction angle of 13.4°. There was no implant breakage or allograft dislodgement during at least 36 months of follow-up.Single-stage anterior debridement and fibular allograft implantation followed by posterior pedicle screw instrumentation provide immediate stability, satisfactory alignment, and successful infection control. Fibular allograft implantation seems to be a good alternative for anterior reconstruction; it can proceed to bony incorporation and avoids donor site morbidity.

Comparison of sacroplasty with or without balloon assistance for the treatment of sacral insufficiency fractures

Purpose: Sacral insufficiency fractures (SIFs) can cause severe lower back pain and immobility, which have limited therapeutic options. No previous studies have compared clinical outcomes and radiographic findings of sacroplasty with or without balloon assistance for the treatment of SIFs. Methods: Forty-five patients with SIFs were divided into two groups. One group had 18 patients treated using sacroplasty with balloon assistance, and the other had 27 patients treated without balloon assistance. The operation time and cement injection volume were compared between these two groups. Clinical outcomes were evaluated using visual analog scale (VAS), Oswestry Disability Index (ODI), and Odom’s criteria. Cement leakage rate was examined by postoperative radiography and computed tomography. Results: Sacroplasty with balloon assistance was associated with significantly longer operative time (p = 0.003) and larger cement injection volume (p = 0.038). Cement leakages were found in 4 of 18 patients (22.2%) with balloon assistance and 15 of 27 patients (55.6%) without balloon assistance, which showed significant difference (p = 0.027). No significant differences were observed between sacroplasty with and without balloon assistance with regard to clinical outcomes including improvement in VAS, ODI, and Odom’s criteria. Conclusions: Sacroplasty with balloon assistance was shown to achieve greater cement injection with longer operation time and can decrease the risk of cement leakage. Both sacroplasty with and without balloon assistance showed good-to-excellent clinical outcomes for the treatment of SIFs.

Application of Manometry to Verify Nasogastric Tube Placement in Intubated, Mechanically Ventilated Patients: A Prospective Descriptive Study

Objective: Confirmation of nasogastric tube (NGT) placement is sometimes difficult in clinical practice. Hence, the purpose of this study is to validate the accuracy of manometry for intragastric NGT placement confirmation in intubated, mechanically ventilated patients. Methods: A total of 100 adult patients who underwent elective open abdominal surgery and required gastric decompression were enrolled in this prospective descriptive study at a university-affiliated teaching hospital. The position of NGTs was verified by two blinded investigators, of whom the first investigator used the manometric technique and the second investigator used a fiberscope for verification. The manometric technique involved using a cuff pressure manometer to verify NGT placement. The primary measurements, sensitivity and specificity of the manometric technique in verifying NGT placement were calculated according to the standard findings of fiberoptic inspection. Results: In 81 of 100 NGT placements, intragastric placement was interpreted by the manometric technique. All of these 81 placements were confirmed by fiberoptic inspection. The manometric technique was therefore 100% sensitive. The 19 placements interpreted as extragastric placement by the manometric technique were confirmed by fiberscopy as being in the oral cavity, trachea, or esophagus, indicating 100% specificity. These results revealed 100% accuracy of the manometric technique in verifying intragastric placement of NGTs in intubated, mechanically ventilated patients. Conclusions: The manometric technique is a convenient, inexpensive, and highly accurate method for verifying NGT placement. This technique may be used to verify correct NGT placement for the purpose of gastric decompression and in those environments where a roentgenogram is not available.

Bone mineral density in patients with symptomatic vertebral compression fractures after instrumented spinal fusion: A retrospective analysis

Background: Few studies have been published concerning about the osteoporotic symptomatic vertebral compression fractures (VCFs) following instrumented spinal fusion for degenerative spinal disease. Purpose: The purpose of this study was to evaluate the incidence of symptomatic VCFs and the differences in the timing of occurrence and bone mineral density (BMD) between patients with adjacent and remote VCFs after instrumented spinal fusion. Methods: We performed a retrospective analysis of 1,936 patients who received posterior instrumentation for degenerative spinal disease at our institution and were followed-up for at least 3 years. Dual-energy X-ray absorptiometry surveys were arranged, and symptomatic subsequent VCFs were identified during regular follow-up. Eligible patients were divided into two groups (adjacent or remote to instrumented spinal fusion, based on the location of their VCFs. The Wilcoxon signed-rank test or chi-square test was used to assess between-group differences. Linear regression analysis was used to examine the relationship between the timing of the occurrence of VCFs and BMD (T-score). Results: The incidence of symptomatic VCFs following instrumented lumbar spine fusion was 2.37% (46/1,936), which accounted for 20.53% (46/224) of patients with VCFs. Linear regression analysis revealed a positive trend between the timing of the occurrence of symptomatic VCFs and values of BMD (T-score). The mean time to develop adjacent VCFs was 6.8 months, while that to develop remote VCFs was 13.7 months (p ＜ 0.05). Conclusion: Symptomatic adjacent VCFs occurred much earlier than remote VCFs. Device-related osteoporosis may be one of risks in subsequent VCFs, which highlight the importance of osteoporosis medication.

Single-stage anterior debridement and reconstruction with tantalum mesh cage for complicated infectious spondylitis

AIM To evaluate the clinical and radiographic results of patients with complicated infectious spondylitis treated with single-stage anterior debridement and reconstruction using tantalum mesh cage (TaMC) followed by immediate instrumentation. METHODS Single-stage radical debridement and subsequent reconstruction with TaMC instead of autograft or allograft were performed to treat 20 patients with spinal deformity or instability due to complicated infectious spondylitis. Clinical outcomes were assessed by careful physical examination and regular serological tests to determine the infection control. In addition, the visual analog score (VAS), neurologic status, length of vertebral body reconstruction, and the correction of sagittal Cobb angle on radiography were recorded and compared before and after surgery. The conditions of the patients were evaluated based on the modified Brodsky’s criteria. RESULTS The average VAS score significantly decreased after the surgery (from 7.4 ± 0.8 to 3.3 ± 0.8, P < 0.001). The average Cobb angle correction was 14.9 degrees. The neurologic status was significantly improved after the surgery (P = 0.003). One patient experienced refractory infection and underwent additional debridement. Eighteen patients achieved good outcome based on the modified Brodsky’s criteria and significant improvement after the surgery (P < 0.001). No implant breakage or TaMC dislodgement was found during at least 24 mo of follow-up. CONCLUSION Single-stage anterior debridement and reconstruction with TaMC followed by immediate instrumentation could be an alternative method to manage the patients with spinal deformity or instability due to complicated infectious spondylitis.

Endovascular retrieval of a migrating pedicle screw within the inferior vena cava after instrumented spinal surgery: case report

During L3-5 instrumented spinal surgery for degenerative spondylolisthesis in a 75-year-old woman, the right L-3 pedicle screw was accidentally pushed into the retroperitoneum and then migrated to the inferior vena cava (IVC). The patient was transferred to the surgical intensive care unit, and after careful discussion with cardiology specialists, a minimally invasive endovascular technique was used to remove the migrating pedicle screw within the IVC and thus salvage this critical case. Pedicle screw instrumentation is an effective procedure, but not risk free. Every detail should be scrutinized during surgery, even instrument construction. A minimally invasive endovascular technique should be considered in this patient population.