Kang Yj

Mucormycosis spondylodiscitis after lumbar disc puncture

Vertebral osteomyelitis due to mucormycosis is a rare but fulminant and fatal disease. Only one case has been reported in literature, with postmortem diagnosis. The present paper reports a female case of mucormycosis spondylodiscitis and vertebral osteomyelitis after lumbar disc puncture and radio frequency nucleoplasty. She subsequently underwent two surgical debridements, continuous local irrigation and drainage, together with local and systemic Amphotericin B treatments. The infection was controlled 4 months after the second debridement; however, there was no improvement in the neurological function at the most recent follow-up, 16 months after the surgery. The experience of this patient, though a single case, supports early recognition, surgical debridement, systemic and local antifungal treatment, closed irrigation and drainage as the keys to successful treatment.

Pedicle screw implantation in the thoracic and lumbar spine of 1-4-year-old children: evaluating the safety and accuracy by a computer tomography follow-up.

Study Design: This was a retrospective clinical study. Objective: To evaluate the safety and accuracy of pedicle screw placement in very young children and to observe its influence on vertebral and spinal canal growth. Summary of Background Data: Although widely used, it is not known if pedicle screw fixation is safe and effective in very young children. Methods: Sixteen children, with an average age of 34 months, had received pedicle screw fixation from January 2003 to January 2010. Candidates for surgery were those patients who had hemivertebra deformity (11 patients), eosinophilic granuloma disease with spinal cord compression, and neurological deficit (2 patients), or spinal tuberculosis accompanied with kyphotic deformity (3 patients). The location of involved vertebrae was between T2 and L5. A total of 74 pedicle screws were implanted using a modified free-hand technique. The safety and accuracy of this method, and the influence on vertebral growth, was evaluated using postoperative x-ray and computer tomography scans. Result: The average follow-up was 30.6 months. No patient had any neurological or radicular symptoms related to the placement of pedicle screws. Postoperative computer tomography scans demonstrated a malposition of 5 of the 74 pedicle screws (6.8%). Two screws breached the anterolateral cortical bone of the vertebral body. One screw breached the lateral cortical bone of the pedicle, 1 passed through the anterior vertebral margin by 3 threads, and a third was so laterally placed that it entered into disk space. There was no vessel, visceral complications, or any other adverse effects resulting from these misplacements. No screw was placed so medially that injured the spinal cord. No retardation of vertebral growth was observed in 7 patients who were followed up for at least 3 and up to 7 years. Conclusions: The results indicate that in very young children, pedicle screws can be safely implanted using a modified free-hand implantation technique.

Modified Pedicle Subtraction Osteotomy as a Salvage Method for Failed Short-Segment Pedicle Instrumentation in the Treatment of Thoracolumbar Fracture.

Study Design:Retrospective study. Summary of Background Data:Short-segment pedicle instrumentation (SSPI) is widely used to treat thoracolumbar junction fracture. Implant failure is the most common complication of SSPI and often necessitates revision surgery. The stand-alone anterior technique for failed SSPI provides excellent decompression and anterior column reconstruction, but it is incapable of restoring normal stability. High rate of complications is solely attributable to the anterior approach. Thus, the reconstruction of the anterior column with posterior compression instrumentation is the strategy of choice. In this study, we use a modified pedicle subtraction osteotomy (PSO) technique through a single posterior approach as the salvage method for the failed SSPI. Materials and Methods:Thirteen patients with failed SSPI after thoracolumbar fracture were included and followed up at regular intervals. Revision indications include intractable pain, deteriorating neurological deficits, and progressive deformity. The modified PSO was performed. After osteotomy, the anterior cortex was thinned and the anterior longitudinal ligament was also preserved to maintain stability during correction. Autograft was inserted into the osteotomy gap to increase stability and fusion rate. The correction had been achieved with closure. We evaluated the patients’ clinical symptoms, segmental kyphosis correction, bony fusion time, and complications. Results:Segmental kyphosis correction was from preoperative average 20.9 degrees (range, 9.5–38.5 degrees) to 3.0 degrees (range, 1–5.5 degrees) immediately after operation and 6.1 degrees (range, 3–8 degrees at the last follow-up). Bony fusion was confirmed on radiographs in all patients at an average of 9.9 months (range, 7.5–12 mo) after revision surgery. There was no implant failure in any of the 13 patients. Average preoperative visual analog scale was 6.5 (range, 5–9) and reduced to 3.7 (range, 2–5) at the last follow-up. There was also a significant decrease in mean preoperative Oswestry Disability Index from 55.2 (range, 38–76) to 32.8 (range, 16–56). No patients suffered any neurological deterioration related to revision surgery. Complications were encountered in 6 patients (46.1%), including 4 with cerebrospinal fluid leak and 2 with superficial wound infection. All these complications were managed conservatively and none of them underwent reoperation. Conclusion:We conclude that modified PSO possesses the advantages of excellent kyphosis correction, a safe and reliable salvage alternative for the revision of SSPI failure.

Treatment of Lumbar Split Fracture-dislocation with Short- or Long-segment Posterior Fixation and Anterior Fusion.

Study Design: Retrospective analysis of 16 patients. Summary of Background Data: The lumbar split fracture-dislocation is a rare but severe injury, which is type C1.2.1 fracture in the Association for the Study of Internal Fixation spine fracture classification. The axial compressive and torsional force shattered the vertebral body into 2 halves and displaced them rotationally. This kind of fracture is so highly unstable that the treatment is very challenging. Purpose: The purpose of this study was to report and compare on clinical outcome and complications of patients with lumbar split fracture-dislocation which had been treated either short-segment or long-segment posterior fixation and anterior fusion. Materials and Methods: A total of 16 patients with acute, split fracture-dislocation of the lumbar spine from March 2000 to May 2009 in our department were recruited. Seven patients (group I) treated by long-segment posterior fixation (2 levels above and 2 below the fracture) and anterior corpectomy and strut grafting. With the improvement of surgical technique and instrument, 9 patients after August 2004 were treated by short-segment posterior fixation (1 level above and 1 below, and included the fractured vertebrae itself) and anterior discectomy and strut grafting. The intraoperative blood loss, operation time, complications of operation, time to achieve bony fusion, Frankel scale, Oswestry Disability index, and Visual Analogue Pain Scale the Cobb angle were collected and compared. Results: The mean follow-up was 33.4 months for group I and 36.2 months for group II. The operation time was 457.1 minutes in group I which was significantly longer than 240.0 minutes in group II. The total blood loss was for group I was 2001.4 mL (range, 1580–2500 mL) and for group II was 730.6 mL (range, 430–950 mL). There was no neurological deterioration after surgery in both group and no difference in neurological outcome between the 2 groups. The loss of correction in Cobb angle averaged at the final evaluation was 2 and 5 degrees for groups I and II, respectively. There was no radiologically visible pseudarthrosis. The postoperative Visual Analogue Pain Scale score was 3.3 and 2.7 for groups I and II, respectively. In the SF-36 survey, after surgery the domains Role physical and Bodily pain improved significantly only in group B (P<0.05 and P=0.06, respectively). Time to achieve bony fusion in group I was 7.9 months which was significantly longer than 3.8 months in group II. Complications included 3 urinary infections, 1 decubitus ulcer, and 1 superficial infection that were cured by antibiotics. Screw breakage was found in 1 patient in the group II. Conclusions: The lumbar sagittal split fracture-dislocation is a rare but severe injury, which can be treated either with short-segment or long-segment posterior fixation and anterior fusion. The short construct with pedicle screws in the fractured vertebrae followed by the maneuver of rod derotation can obtain anatomic reduction, restoration of 3-column alignment, and decompress the affected neural elements by restoration of the normal canal dimension. It may be a better therapeutic option for the highly unstable lumbar fracture of C1.2.1.

Vertebral fusion and bony obliteration of intervertebral discs in a neurofibromatosis type 1 patient

A 40-year-old woman with a decade-old scoliosis aggravated with upper back pain and dyspnea of 2 year’s duration was admitted to our clinic. Physical examination revealed multiple cutaneous neurofibromas and café-au-lait macules. Freckling was observed in the axillary region. On neurologic examination, an abnormal thoracic curve and “razor back” deformity were found. The coronal computed tomography scan showed a thoracic dextroscoliosis with rare vertebral fusion and bony obliteration penetrating the intervertebral discs between T4 and T5 and T5 and T6 (Fig. 1). The patient was diagnosed with dystrophic scoliosis secondary to neurofibromatosis type 1. Surgical intervention was performed, and the outcome was satisfactory.

Factors and revision strategy for failure of thoracolumbar spine internal fixation after burst fracture

OBJECTIVE To analyze the reasons for the failure of thoracolumbar spine internal fixation after burst fracture, and to discuss the strategy for revision surgery. METHODS From January 2005 to September 2010, 21 patients with thoracolumbar burst fracture received revision surgery after the failure of internal fixation. The etiology included loose of the fixation after anterior surgery in 4 patients, involving malunion with severe kyphosis in 1 patient, pedicle screw malposition in 3, fracture of adjacent segment vertebra in 2, broken of the fixation as non-union of the fracture vertebra in 10 comprising obvious kyphotic deformity in 5, and 2 had developing kyphosis for over distraction of the vertebra followed by pseudarthrosis after removing the internal fixation. After the first operation, symptoms remained in 6 patients, deteriorated in 7, light to moderate improved in 8. Surgical procedures such as anterior corpectomy and reconstruction, replacement of the internal fixation and canal decompression, vertebroplasty, and posterior pedicle subtraction osteotomy were directed based on individual situation. RESULTS Patients were followed-up for 6-68 (27.0±13.2) months, and demonstrated solid fusion 6 to 12 months postoperatively. No failure of the internal fixation reccurred. No major complications or deterioration of neurologic status were noted. At the last follow-up, the improvement of Frankel grade was 0-2 (1.3±0.7). The mean visual analog scale (VAS) dropped down from 7.6 to 2.1, and the mean oswestry disability index (ODI) decreased from 48.7 to 10.3. Preoperative angle of 7 kyphotic deformity patients was 10 degree-75 degree (42.5 degree±15.3 degree), and was improved to -3 degree-10 degree (2.3 degree±3.7 degree). At the last follow-up, the loss of correction was 0 degree-1.3 degree (0.7 degree±0.3 degree), with the correction rate of 92.3%. CONCLUSION Solid reconstruction of the anterior and middle column of the spine is the imperative procedure to prevent failure of internal fixation in thoracolumbar burst fractures. Revision surgery with reasonable strategy is beneficial and rewarding with few complications.