Kourosh Zarghooni

Effectiveness, security and height restoration on fresh compression fractures--a comparative prospective study of vertebroplasty and kyphoplasty.

INTRODUCTION Painful fractures of the spine pose a serious clinical problem which gains in importance with the increasing ageing of our population. When conservative treatment of these fractures fails, with vertebroplasty and kyphoplasty we have two percutaneous minimally invasive stabilising procedures at our disposal. PATIENTS AND METHODS We performed a prospective study of 90 patients with fresh osteoporotic vertebral fractures who had been treated with vertebroplasty or kyphoplasty in our clinic between January 1, 2005, and December 31, 2007. Clinical analysis included Oswestry score and VAS index; the vertebral body height restoration (mean vertebral body height, kyphosis angle, anterior/posterior edge) was evaluated radiologically; furthermore, all occurring complications were recorded. The follow-up time was 1 year, 80 patients could be examined at follow-up; 8 patients had died of a tumour disease, lost to follow-up were 2.2%. RESULTS Both procedures succeeded in significantly (p<0.001) increasing quality of life (Oswestry score) and reducing pain (VAS). Following vertebroplasty there were two cases of cement leakage into the spinal canal with consecutive paraparesis which disappeared completely after the cement had been surgically removed. Altogether, 11 adjacent level fractures were observed, 4 in the vertebroplasty and 7 in the kyphoplasty group. CONCLUSION This study compares vertebroplasty and kyphoplasty with regard to their effectiveness, safety, and restoration of vertebral body height, and complications. There were no differences between the groups with regard to quality of life and pain improvement, but the rate of serious complications was higher after vertebroplasty. Mean vertebral body height restoration at 1 year follow-up was significantly higher (p<0.05) in the kyphoplasty group. It remains to be seen in future long-term studies whether or not restoration of vertebral body height has an effect on the clinical result.

Ist eine Höhenrekonstruktion mit vergleichsweise wenig Zement für die Radiofrequenz-Kyphoplastie über einen monopedikulären Zugang möglich?

BACKGROUND Percutaneous cement augmentation systems have been proven to be an effective treatment for vertebral compression fractures in the last 10 years. A special form available since 2009 is the radiofrequency kyphoplasty (RF) in which the applied energy raises the viscosity of the cement. The aim of this study is to find out if a smaller cement amount in radiofrequency kyphoplasty can also restore vertebral body height in osteoporotic vertebral compression fractures. METHODS The treatment was minimally invasive using the StabiliT® vertebral augmentation system by DFine. In a retrospective study from 2011 to January 2012, 35 patients underwent RF kyphoplasty for 49 fresh osteoporotic vertebral compression fractures. From the clinical side the parameters, demographics and pain relief using a visual analogue scale (VAS: 0 to 100 mm) were collected. For the radiological outcome the vertebral body height (anterior, mean and posterior vertebral body height with kyphosis angle) after surgery and after three months was measured and compared to the cement volume. RESULTS All patients still had permanent pain on the fractured level after conservative treatment. The time from initial painful fracture to treatment was 3.0 weeks ± 1.3. Average visual analogue scale results decreased significantly from 71 ± 9.2 preoperatively to 35 ± 6.2 postoperatively (p < 0.001) and to 30 ± 5.7 (p < 0.001) after three months. With a mean cement volume in the thoracic spine of 2.9 ± 0.7 ml (1.8-4.1) and lumbar spine of 3.0 ± 0.7 ml (2.0-5.0) we had a significant vertebral body height restoration. Anterior and mean vertebral body heights significantly increased by an average of 2.3 and 3.1 mm, kyphosis angle significantly decreased with an average of 2.1° at three-month follow-up (p < 0.05). In two vertebrae (4.1 %) a minimal asymptomatic cement leakage occurred into the upper disc. In two patients (5.7 %) we had new fractures in the directly adjacent segment that were also successfully treated with radiofrequency kyphoplasty. CONCLUSION With a mean cement volume of 3.0 ml radiofrequency kyphoplasty achieves rapid and short-term improvements of clinical symptoms with a significant restoration of vertebral body height. There was no correlation between restoration of vertebral body height and pain relief. With a cement leakage of 4.1 % RF kyphoplasty is a safe and effective minimally invasive percutaneous cement augmentation procedure. Our data confirm the higher safety described in literature for kyphoplasty in contrast to vertebroplasty.

The Orthotic Treatment of Acute and Chronic Disease of the Cervical and Lumbar Spine

BACKGROUND Orthoses are external aids that are often used to treat pain and diseases affecting the spine, such as lumbago, whiplash, and disc herniation. In this review, we assess the effectiveness and complications of orthotic treatment for typical spinal conditions and after spinal surgery. The orthotic treatment of fractures and postural abnormalities are beyond the scope of this article. METHOD This review is based on a selective search in the Medline database with consideration of controlled trials, systematic reviews, and the recommendations of the relevant medical societies. RESULTS Three relevant systematic reviews and four controlled trials were found. Very few controlled trials to date have studied the efficacy of orthotic treatment compared to other conservative treatments and surgery. No definitive evidence was found to support the use of orthoses after surgery, in lumbar radiculopathy, or after whiplash injuries of the cervical spine. In a single trial, short-term immobilization was an effective treatment of cervical radiculopathy. Orthoses are not recommended for nonspecific low back pain. The potential complications of cervical orthoses include pressure-related skin injuries and dysphagia. CONCLUSION No definitive evidence as yet supports the use of orthoses after spinal interventions or in painful conditions of the cervical or lumbar spine. They should, therefore, be used only after individual consideration of the indications in each case.

Injuries and Overuse Syndromes in Competitive and Elite Bodybuilding

Competitive bodybuilding is a weightlifting sport similar to powerlifting, strongman competition and Olympic weightlifting, which aims to increase muscle mass, symmetry, and body definition. Although data regarding rates of injury, overuse syndromes and pain during routine training is available for these other disciplines, it is rare for competitive bodybuilding. The aim of this study was to investigate rates of injury, pain during workouts and/or overuse syndromes, as well as the influence of particular intrinsic and external factors. Data was collected using questionnaires from 71 competitive and elite bodybuilders. The information included training routines and prior injuries. Participants were recruited from bodybuilding clubs in Germany. 45.1% of athletes reported symptoms while training. The overall injury rate was computed to be 0.12 injuries per bodybuilder per year (0.24 injuries per 1 000 h of bodybuilding). Athletes over 40 exhibited higher rates of injury (p=0.029). Other investigated parameters showed no effects. Most injuries occurred in the shoulder, elbow, lumbar spine and knee regions. A large proportion of bodybuilders complained of pain not resulting in interruptions of training/competition. The injury rate is low compared to other weightlifting disciplines such as powerlifting, Olympic weightlifting or strongman competition. In comparison to team or contact sports the injury rate is minimal.

Injuries in Competitive Boxing. A Prospective Study

Boxing remains a subject of controversy and is often classified as dangerous. But the discussion is based mostly on retrospective studies. This survey was conducted as a prospective study. From October 2012 to September 2013, 44 competitive boxers were asked to report their injuries once a month. The questionnaire collected general information (training, competition) and recorded the number of bouts fought, injuries and resulting lost days. A total of 192 injuries were recorded, 133 of which resulted in interruption of training or competition. Each boxer sustained 3 injuries per year on average. The injury rate was 12.8 injuries per 1 000 h of training. Boxers fighting more than 3 bouts per year sustain more injuries (p=0.0075). The injury rate does is not a function of age (age≤19 vs. > 19a, p=0.53). Injuries to the head and the upper limbs occur most frequently. The most common injuries are soft tissue lacerations and contusions. Head injuries with neurological symptoms rarely occur (4.2%). Boxing has a high injury rate that is comparable with other contact sports, but most injuries are minor. Injury frequency is not a function of whether the boxer competes in the junior or adult category. Athletes fighting many bouts per year have a greater risk of injury.

Komplikationsanalyse von spinalen Eingriffen bei adulten zentralen Bewegungsstörungen und Skoliosen

BACKGROUND Adult central movement disorders, malpostures, and scolioses can have their cause in various neurological underlying diseases such as Morbus Parkinson, Pisa syndrome, or segmental dystonia. Important clinical characteristics are marked postural distortions such as camptocormia (bent spine) or laterocollis. In cases of these adult scolioses, surgical spine treatment puts high demands on the surgeon. Surgery in Parkinsons disease, for example, is associated with serious surgery-specific as well as general complications. The more rarely occurring Pisa syndrome is an entity primarily requiring medical therapy. PATIENTS AND METHODS A series of ten case reports of patients with Morbus Parkinson and Pisa syndrome who underwent spinal surgery is presented and discussed. From these reports, treatment recommendations have been derived and complemented by references from the literature. An extensive MEDLINE search was performed for this purpose. RESULTS AND CONCLUSION In patients suffering from Parkinsons disease, even minor surgical interventions can lead to instability of whole spine segments or even the entire spine. Implant loosening, adjacent segment instability, general perioperative complications, and progressive malposture due to disease progress can bring forth disastrous treatment courses. Spinal fixation should be performed long-segmented in combination with ventral stabilisation. Due to osteoporosis, pedicle screw cement augmentation is recommended in this collective. If the diagnosis of Pisa syndrome is established, an optimised preoperative preparation should be initiated in close cooperation with neurologists. In many cases medical therapy is sufficient and surgical interventions can be avoided.

Indications and contraindications: interspinous process decompression devices in lumbar spine surgery.

BACKGROUND Interspinous process decompression devices (IPD) allow a minimally invasive treatment of lumbar spinal stenosis (LSS), but their use is discussed highly controversial. Several level I studies suggest that IPD implantation is a viable alternative for both conservative treatment and decompression, but clear indications and contraindications are still missing. This study was designed to explore the perspectives and limitations of IPDs and to evaluate the role of these devices in general. MATERIAL AND METHODS The study is based on a questionnaire sent to all hospitals registered in the German Hospital Address Register 2010 with an orthopedic, neurosurgerical, or spine surgery department (n = 1,321). The questionnaire was reviewed by experienced spine surgeons and statisticians, and included both single-response, close-ended, and multiple-response open-ended questions. RESULTS We received 329 (24.9%) entirely analyzable questionnaires. A total of 164 respondents (49.8%) stated that IPDs are a treatment option for LSS, and 135 of the 164 respondents (82.3%) use them. Poor clinical experience (60%) and lack of evidence (53.9%) are the main reasons cited for not using IPDs. We detected a high negative correlation between the size of the hospital, the number of outpatients and inpatients treated for LSS and other spine pathologies, and the use of IPDs (p = 0.001). Most respondents prefer the combination of open decompression and IPD (64.4%; n = 87). A total of 9.6% (n = 13) of the users favor IPD implantation as a stand-alone procedure. Overall, 25.9%  n = 35  use both options. Most surgeons aim to relieve the facet joints (87.7%) and to stabilize a preexisting instability (75.4%). They recommend IPDs in the segments L2-L3 (77%), L3-L4 (98.5%), and L4-l5 (99.3%) and consider that IPD implanation also could be done at the L5-S1 segment (40.1%). Overall, 64.4% (n = 87) of the users recommend limiting IPD implantation to two segments. Infection (96.3%), fracture (94.8%), isthmic spondylolisthesis (77%), degenerative spondylolisthesis (higher than Meyerding I [57%]), lumbar spine scoliosis (48.1%), and osteoporosis (50.4%) are seen as contraindications for IPD. CONCLUSION No clear consensus exists among spine surgeons concerning the use of IPD for LSS treatment. The study showed that hospital-related parameters also influence decision making for or against the use of IPDs. However, despite the lack of evidence, the indications and contraindications which had been identified in the present study might contribute to improved outcomes after IPD implantation or at least prevent harm to patients.

Analgesic Efficacy and Tolerability of Intravenous Morphine Versus Combined Intravenous Morphine and Oxycodone in a 2-Center, Randomized, Double-Blind, Pilot Trial of Patients With Moderate to Severe Pain After Total Hip Replacement

BACKGROUND Results from studies with a combination of oral morphine and oxycodone in postsurgical patients demonstrate significant analgesia and a tolerability profile comparable to other pain medications at morphine-equivalent doses. However, an intravenous (IV) combination has not previously been studied. OBJECTIVE This study evaluated the efficacy and tolerability of IV morphine versus a combination of IV morphine and IV oxycodone in a 1:1 ratio. METHODS This was a 2-center, randomized, double-blind, active-controlled pilot trial of 40 patients who had undergone total hip replacement. After surgery, when pain levels reached ≥4 (on the 11-point Numerical Pain Rating Scale), patients were randomized to 1 of 2 treatment groups. In part 1 of the study, patients were dosed every 5 minutes for the first 65 minutes (up to 13 doses) with study drug, provided that vital signs criteria were met. After an initial loading dose of either morphine 1.5 mg coadministered with oxycodone 1.5 mg or morphine 3 mg alone, patients received IV morphine 1.5 mg or IV morphine 0.75 mg/IV oxycodone 0.75 mg every 5 minutes. If patients achieved a pain score of 2 or experienced intolerable adverse events to drug when stable, they were permitted to enter part 2. In part 2, patients received blinded study medication (IV morphine plus IV oxycodone [0.5 mg/0.5 mg] or 1 mg IV morphine alone) via patient-controlled analgesia (PCA) for 47 hours. RESULTS At baseline, treatment groups were comparable except for a higher proportion of females in the IV morphine group. Baseline pain intensity averaged 7 on the Numerical Pain Rating Scale of 0 to 10. One patient in the morphine group and 2 patients in the morphine/oxycodone group discontinued the study. The sum of the pain intensity differences from baseline to 65 minutes during the dose-titration phase was 1.8 for morphine alone versus 2.7 for morphine/oxycodone (P = 0.12); these values occurred at the same median number of doses (12) for each group. In part 2 (PCA dosing) of the study, similar levels of analgesia were achieved. During the study, 24% of the IV morphine/oxycodone group and 37% of the IV morphine group experienced nausea, and 10% of the IV morphine/oxycodone group and 16% of the IV morphine group had emesis. Two patients in the IV morphine/oxycodone group and 4 in the IV morphine alone group experienced oxygen desaturation. CONCLUSIONS The combination of IV morphine and oxycodone provided pain relief with an acceptable tolerability profile in these patients experiencing moderate to severe postoperative pain. However, as an explorative pilot study, the power was not adequate to demonstrate statistical significance for differences between IV morphine/oxycodone and IV morphine alone. European Clinical Trials Data Base registration code: EudraCT-No. 2008-008527-14.

Spondylodiszitis – eineinterdisziplinäre Herausforderung

HISTORY AND ADMISSION FINDINGS A 21-year-old man presented with severe lumbar back pain and progressive paraparesis with clinical signs of spondylitis. Laboratory findings revealed elevated infectious parameters. Because of a positive Mantoux-Test he had been treated with quadruple tuberculostatic drugs for eight weeks without prior identification of the causative pathogen. INVESTIGATIONS Magnetic resonance imaging of the spine revealed a multisegmental spondylitis of the lumbar vertebrae (L3 - L5) with epidural empyema. Computed tomography (CT) of the abdomen confirmed large bilateral abscesses in the psoas muscles. TREATMENT AND COURSE The findings supported the diagnosis of spondylitis. The antibiotic regimen was continued. CT-guided drainage was placed in both psoas muscles. Laminectoma of L3 - 5 and dorsal spondylodesis of L2 - S1 were performed immediately. Mycobacterium tuberculosis was cultured from the intraoperative biopsies and treated according to the drug sensitivity test. After further surgical debridment and corporectomy of L4 and L5 the infection was successfully treated. Ten weeks after admission the patient was transferred to a neurologic rehabilitation unit for mobilization. CONCLUSION Spondylodiscitis treatment is complex and requires a multidisciplinary approach.

Anterior Spinal Artery Syndrome: Reversible Paraplegia after Minimally Invasive Spine Surgery

Background Context. Percutaneous balloon kyphoplasty is an established minimally invasive technique to treat painful vertebral compression fractures, especially in the context of osteoporosis with a minor complication rate. Purpose. To describe the heparin anticoagulation treatment of paraplegia following balloon kyphoplasty. Study Design. We report the first case of an anterior spinal artery syndrome with a postoperative reversible paraplegia following a minimally invasive spine surgery (balloon kyphoplasty) without cement leakage. Methods. A 75-year-old female patient underwent balloon kyphoplasty for a fresh fracture of the first vertebra. Results. Postoperatively, the patient developed an acute anterior spinal artery syndrome with motor paraplegia of the lower extremities as well as loss of pain and temperature sensation with retained proprioception and vibratory sensation. Complete recovery occurred six hours after bolus therapy with 15.000 IU low-molecular heparin. Conclusion. Spine surgeons should consider vascular complications in patients with incomplete spinal cord syndromes after balloon kyphoplasty, not only after more invasive spine surgery. High-dose low-molecular heparin might help to reperfuse the Adamkiewicz artery.