Luca Proietti

Complications in lumbar spine surgery: A retrospective analysis

Background: Surgical treatment of adult lumbar spinal disorders is associated with a substantial risk of intraoperative and perioperative complications. There is no clearly defined medical literature on complication in lumbar spine surgery. Purpose of the study is to retrospectively evaluate intraoperative and perioperative complications who underwent various lumbar surgical procedures and to study the possible predisposing role of advanced age in increasing this rate. Materials and Methods: From 2007 to 2011 the number and type of complications were recorded and both univariate, (considering the patients’ age) and a multivariate statistical analysis was conducted in order to establish a possible predisposing role. 133 were lumbar disc hernia treated with microdiscetomy, 88 were lumbar stenosis, treated in 36 cases with only decompression, 52 with decompression and instrumentation with a maximum of 2 levels. 26 patients showed a lumbar fracture treated with percutaneous or open screw fixation. 12 showed a scoliotic or kyphotic deformity treated with decompression, fusion and osteotomies with a maximum of 7.3 levels of fusion (range 5-14). 70 were spondylolisthesis treated with 1 or more level of fusion. In 34 cases a fusion till S1 was performed. Results: Of the 338 patients who underwent surgery, 55 showed one or more complications. Type of surgical treatment (P = 0.004), open surgical approach (open P = 0.001) and operative time (P = 0.001) increased the relative risk (RR) of complication occurrence of 2.3, 3.8 and 5.1 respectively. Major complications are more often seen in complex surgical treatment for severe deformities, in revision surgery and in anterior approaches with an occurrence of 58.3%. Age greater than 65 years, despite an increased RR of perioperative complications (1.5), does not represent a predisposing risk factor to complications (P = 0.006). Conclusion: Surgical decision-making and exclusion of patients is not justified only by due to age. A systematic preoperative evaluation should always be performed in order to stratify risks and to guide decision-making for obtaining the best possible clinical results at lower risk, even for elderly patients.

Analysis of the Catastrophic Failure of a THR: The Role of the Acetabular Component

This paper investigates the failure of a total hip prosthesis due to the disruption of the PE inlay and the Ti-alloy metal back of the acetabular component. The PE inlay was coupled with an alumina ball head. The case analysis showed that the initiator of the failure was the size selection of the prosthesis, followed by the positioning of the acetabular component. The deformation of the PE inlay leads to rupture of the inlay itself, followed by the direct contact between the alumina ball head and the titanium alloy cup, causing the disruption of the Ti-alloy metal back, with massive release of wear debris in the surrounding tissues.

Posterior percutaneous reduction and fixation of thoraco-lumbar burst fractures

BACKGROUND Treatment of A3 thoraco-lumbar and lumbar spinal fractures nowadays remains a controversial issue. Percutaneous techniques are becoming very popular in the last few years to reduce the approach-related morbidity associated with conventional techniques. HYPOTHESIS Purpose of the study was to analyze the clinical and radiological outcome of patients who underwent percutaneous posterior fixation without fusion for the treatment of thoraco-lumbar and lumbar A3 fractures. MATERIALS AND METHODS Sixty-three patients, having sustained a single-level thoraco-lumbar fracture, underwent short segment percutaneous instrumentation and were retrospectively analyzed. sagittal index (SI) was calculated in all patients. Clinical and functional outcome were evaluated by Visual Analog Scale (VAS), Oswestry Disability Index (ODI) and Short Form General Health Status (SF-36). RESULTS Average operative blood loss was 82 mL (50-320). Mean pre-operative SI in the thoraco-lumbar segment was 13.3° decreased to 5.8° in the immediate postoperative with a mean deformity correction of 7.5. Mean pre-operative SI in the lumbar segment was 16.5° decreased to 11.3° in the immediate postoperative with a mean deformity correction of 5.2. Not statistically significant correction loss was registered at 1-year minimum follow-up. Constant clinical conditions improvement in the examined patients was observed. CONCLUSION Percutaneous pedicle screw fixation for A3 thoraco-lumbar and lumbar spinal fractures is a reliable and safe procedure. LEVEL OF EVIDENCE Level IV. Retrospective study.

Degenerative facet joint changes in lumbar percutaneous pedicle screw fixation without fusion

BACKGROUND Aim of the study was to evaluate degenerative lumbar facet-joints changes after percutaneous pedicle screw fixation (PPSF) in the treatment of lumbar fractures. MATERIALS AND METHODS Thirty patients underwent short PPSF without fusion. CT-scan was performed in the pre- and post-operative time at four, eight and 12 months. The six zygapophyseal joints adjacent the fractures level were evaluated. RESULTS At four months patients showed no differences between pre- and post-operative joint radiographic aspect. At eight and 12 months, CT-scan demonstrated a progressive degeneration only in the middle joints respectively in 21.42% and in 76.92% of the cases. All 10 disrupted facet joints showed progressive degenerative changes at eight and 12 months. CONCLUSION Lumbar percutaneous fixation without fusion induces little degenerations essentially collocated in the middle joints close to fracture level at eight and 12 months. In the proximal and distal joints adjacent the screws degenerative changes can be seen only when associated to pedicle-screw encroachment.

Onset of a Charcot spinal arthropathy at a level lacking surgical arthrodesis in a paraplegic patient with traumatic cord injury

The study design included a case report of Charcot spinal arthropathy treated with posterior and anterior spinal instrumentation. The objective of the study was to report an unusual case of Charcot spinal arthropathy as a late complication of traumatic spinal cord injury in a patient previously treated with a long posterior thoraco-lumbar instrumentation and postero-lateral fusion. A 33-year-old man with T10–T11 complete paraplegia presented with focal low back pain, kyphotic deformity of the lumbar region with L2–L3 fracture–dislocation and hardware failure. Our treatment consisted of a circumferential arthrodesis performed with a combined anterior and posterior approach. Spinal stabilization was achieved and the patient was pain free and able to resume a sitting posture. This report suggests that the development of a Charcot spine arthropathy must always be considered as a late complication of a spinal cord injury. Moreover, we would emphasize the fundamental role of a strict clinical and radiological follow-up in order to detect an early Charcot spine complication.

Cervical myelopathy due to ossification of the transverse atlantal ligament: A Caucasian case report operated on and literature analysis.

One case of cervical myelopathy associated to ossification of transverse atlantal ligament (OTAL) and C1 posterior arch hypoplasia in a Caucasian adult female is reported. A 53-year-old female affected by cervical myelopathy was treated with C1 laminectomy and posterior arthrodesis. CT scan demonstrated that the distance between ossification of the ligament and anterior cortex of the posterior arch of atlas was 6,2mm leading to consistent space reduction for spinal cord at this level. Patient underwent spinal cord decompression and fixation with C1 poliaxial screws in lateral masses and two bilateral crossing C2 laminar screws with an improvement of neurological functions at 4-years follow-up. The association between OTAL and C1 hypoplasia was reported in very few cases. The treatment with C1 laminectomy without fusion is reported in medical literature with good clinical outcome. Our patient obtained a neurological improvement at midterm follow-up with spinal cord decompression and fusion.

Spine fusion: cages, plates and bone substitutes

Abstract: Spine fusion is the surgical procedure to obtain bony union between two vertebrae, required in the treatment of many pathologies. The necessity for this procedure is increasing, and complications such as non-union remain high in spite of the great progress that has been made in recent years. Many surgical techniques have improved the effectiveness of this procedure in the past, involving very sophisticated techniques. Bone substitutes may enhance bone healing, though many are not especially effective. Bone grafts still remain the best option, but many concerns are raised about their safety, stockage, availability and properties. Synthetic bone substitutes were proposed as a resolution to this problem, but none of them has achieved the ideal standard. Growth factors are the ‘new’ expected ideal bone substitutes, but little is known about their function, and results are contradictory, except for BMP-2 and BMP-7 in spine fusion. This chapter will discuss these problems and evaluate the options and the advantages and disadvantages of bone substitutes that are available in spine fusion.

Pathophysiology of Avascular Necrosis of the Femoral Head

The interruption of arterial blood flow in the superior segment of the femoral epiphysis is a common event in pathological conditions, e.g., gas embolism in Caisson disease, traumatic vessel injuries in neck femoral fractures or hip dislocation, vascular occlusion in Gaucher’s disease, sickle cell anemia, and radiation exposure. When arterial blood impairment occurs without a documented etiology, the term idiopathic avascular necrosis must be employed.

Etiopathogenesis of Traumatic Spinal Epidural Hematoma

Spinal epidural hematoma (SEH) is a rare cause of nerve root or cord compression; its pathogenesis is not always clearly recognizable. The aim of this paper was to investigate possible etiopathological factors in a consecutive series of patients affected by traumatic SEH treated at our institution. Seven patients with neurologic impairment due to traumatic SEH were retrospectively analyzed after diagnosis and surgical treatment. Thoracic localization was found in 5 cases, and lumbar and cervical localization were found in 1 patient each. One patient was affected by ankylosing spondylitis and one by diffuse idiopathic skeletal hyperostosis. SEH was associated with spine fractures in 6 cases. Only 2 cases of traumatic SEH resulted from high-energy trauma. All patients underwent surgical decompression within 24 hours after admittance to the hospital. Three patients recovered completely, 3 remained paraplegic, and 1 remained monoplegic. Several concomitant conditions are suggested to be predisposing factors for the development of SEH, although its inherent mechanism is still unknown. Two patients in the present series were affected by rheumatologic disorders, confirming the elevated incidence of hematomas in such patients compared to the normal population. Three very unusual cases of SEH occurred in senile patients affected by osteoporotic fractures. Early diagnosis and urgent decompression of the hematoma remain mandatory.

Response to the letter by Minghui Peng, MD, Baohua Jiao, MD

Firstly, the authors would like to thank Dr Jiao for his interest in ur study and his interesting questions. The authors agree about the need of a CT scan exam in order to etect a burst fracture. All our patients underwent a CT scan exam t their hospital arrival in order to classify the fracture type and to ecide the appropriate treatment. Only when the authors identify n A3 fracture at CT scan, they decide to perform a percutaneous edicle screw fixation. The case reported in the Fig. 6 is surely a case of multilevel fracures. As said, all patients in our study underwent a preoperative T scan. In this case, the CT scan points out the fractures both in L1 nd L2, which are both A1.1 fractures and a single A 3.1 fracture in 3, which the authors decide to surgically treat. Exclusion criteria efer only to single A 3 fractures, without considering A1 fracture hich treatment is generally conservative. Exclusion criteria are lso represented by the association with more complex fractures n which a percutaneous pedicle screw fixation is an insufficient reatment.