Marcelo Valacco

Use of CT-guided periradicular injection for the treatment of foraminal and extraforaminal disc herniations

Study design: Retrospective case series. Evidence level IV. Objectives: To evaluate surgical candidates with foraminal or extraforaminal lumbar disc herniation treated with CT-guided periradicular injection (CTGPI) as a valid treatment option for avoiding surgery. Methods: We carried out a retrospective evaluation of 46 consecutive patients with foraminal or extraforaminal disc herniation treated with CTGPI. CTGPI was performed only when radicular pain could not be controlled, or in patients who continued requiring pain medication following an acute episode and whose radicular pain precluded them from resuming their daily activities. Forty-six patients with a minimum 2-year follow-up met the inclusion criteria. There were 21 women and 25 men, with a mean age of 47 years. Results: At 1 month after injection, 41 (89%) patients experienced a decrease in radicular pain; 3 experienced no change; and 2 had received surgical treatment. At the final follow-up visit (mean, 74 months) 6 additional patients underwent surgery while 38 (83%) did not require surgery. Pain level comparison between pre-injection and last examination showed that low back pain had decreased a mean of 5 points and radicular pain diminished a mean of 7 points. Twenty-two (58%) of the 38 nonoperated patients had no pain at all and 35 patients had resumed their normal daily activities. No complications were recorded. Conclusion: Based on these results, we consider that the use of CTGPI is a reliable alternative before surgery for patients with foraminal or extraforaminal disc herniation without severe motor deficit but with intractable radicular pain. Final Class of evidence (CoE)-treatment Yes Study design: RCT Cohort Case control Case series • Methods Concealed allocation (RCT) Intention to treat (RCT) Blinded/independent evaluation of primary outcome F/U ≥85% • Adequate sample size • Control for confounding Overall class of evidence IV The definiton of the different classes of evidence is available on page 59.

The influence of anatomy (normal versus scoliosis) on the free-hand placement of pedicle screws: Is misplacement more frequent in patients with anatomical deformity?

Study design: Retrospective prognostic study. Objective: To evaluate whether patients with anatomical deformity due to scoliosis have a higher frequency of inaccurate pedicle screw insertion and related complications using the free-hand technique compared with those whose normal anatomy had been impacted by trauma. Methods: Consecutively treated trauma patients with otherwise normal anatomy (48 patients instrumented with 291 screws, group A) and scoliosis patients (24 patients instrumented with 287 screws, group B) were evaluated. Screw position on CT was evaluated using the classification by Gertzbein and Robbins with modification by Karagoz Guzey. (See web appendix at www.aospine.org/ebsj for complete classification description.) Images were examined by two fellows and one junior staff member none of whom participated in patient management. Screw position was determined by consensus. Results: In group A, five (1.7%) out of 289 screws were severely misplaced and 26 (9%) screws caused either medial (3.8%) or lateral (5.2%) cortical breeches. The other 258 (89.3%) screws were fully contained within the cortical boundaries of the pedicle. In group B, seven (2.8%) out of 256 screws were severely misplaced. Thirty-three (13%) screws caused cortical breeches, either medial (9%), lateral (2%), or anterior (2%), and 216 (84.3%) screws were fully contained within the cortical boundaries of the pedicle and the vertebra. Neurological complications were reported in one patient with scoliosis. No vascular complications were reported in either group. Conclusions: The percentage of incorrectly placed screws was similar in both groups, trauma and deformity patients. The presence of vertebral anatomical changes related to adult scoliosis was not associated with an increase in the screw-related neurological or vascular complications. Methods evaluation and class of evidence (CoE) Methodological principle: Study design: Prospective cohort Retrospective cohort • Case control Case series Methods Patients at similar point in course of treatment Follow-up ≥85% • Similarity of treatment protocols for patient groups • Patients followed for long enough for outcomes to occur • Control for extraneous risk factors Evidence class: III The definiton of the different classes of evidence is available on page 73.

Dysphagia Due to Ossification of the Cervical Anterior Longitudinal Ligament. Report of Three Cases

Introduction Symptomatic ossification of the anterior longitudinal ligament is rarely pathology. Diffuse idiopathic skeletal hyperostosis (DISH) is a common condition in the aging spine. DISH, also called with the eponym Forestiers disease, is a clinical syndrome characterized by the abnormal formation of osteopytes involving the spine. These are largely asymptomatic, however are recognized as an unusual cause of dysphagia, which may occur secondary to the mechanical compression with partial obstruction or perioesophageal inflammation caused by pharyngo- esophageal motion over the osteophytes. Dysphagia is reported in up to 28% of patients. Surgical treatment is advocated only after failure of conservative therapies. Conversely, in absence of relevant clinical signs due to the presence of DISH, surgery is not considered mandatory. However, surgical resection of the osteophyte has been reported to be an effective treatment for severe cases. Therefore, from 1995, we started to observe long-term postoperative courses of DISH patients with recalcitrant dysphagia who underwent surgical resection of osteophytes. The purpose of this study was to examine these surgical outcomes and literature review. Material and Methods Case 1. A 70-year-old man referred to our clinic because of progressive dysphagia for solids and liquids and cervical pain. A lateral cervical spinal X-ray and cervical MRI revealed giant cervical osteophytes at the ventral portion of the C 2/3/4 vertebral bodies and contiguous calcification of the anterolateral cervical vertebral bodies. Case 2. A 57-year-old man presented with a 1.5-year history of increased difficulty swallowing. A plain lateral radiograph revealed OALL ventral to the C3–5 vertebral bodies. Three- dimensional computerized tomography studies further demonstrated extensive C3–5 OALL. Case 3. A 75-year-old white man was seen at Hospital with the main complain of increased difficulty in swallowing solid food over the past two years. Routine cervical spine films revealed prodigious osteophytes of the cervical spine involving the bodies of C-2, C-3, C-4, C-5 and C-6 consistent with DISH. A magnetic resonance imaging (MRI) scan of the cervical spine revealed an elongated ossification of the frontal planes of the vertebral bodies, with spurs projecting into the soft tissues of the neck. Results The three patients underwent uneventful operative excision of the anterior cervical osteophytes. Surgery was performed with an anterolateral approach. They had marked improvement in swallowing function and were able to resume a normal diet after one to two months. Conclusion Diffuse idiopathic skeletal hyperostosis or Forestiers disease is an uncommon etiology of progressive dysphagia. This unrecognized condition may provide a new challenge for spine surgeons who are not as familiar with DISH as rheumatologists. Surgical decompression through osteophytectomy is effective for patients who fail conservative treatment

Diagnosis and Treatment Options for Cervical Spondylodiscitis

Introduction Cervical spondylodiscitis can present through a variety of unspecific signs and symptoms usually associated with a delay diagnosis. The close anatomic relation of the infection process with the spinal cord at this mobile area leads to a serious medical situation. Its low incidence and the lack of papers with high level of evidence in the literature explain why there are no well-established treatment protocols. Our objective was to evaluate retrospectively the treatment of a consecutive series of 19 adult patients treated for cervical spondylodiscitis. Material and Methods 19 patients were evaluated with an average of 4 years of follow up. Eleven patients with a diagnosis of mechanical instability, neurologic compromise, or abscess formation were treated surgically; the remaining 8 were managed conservatively with external immobilization while all received intravenous antibiotics. Staphylococcus aureus, identified in 9 patients, was the most frequent etiologic agent. Results At final follow up all patients presented resolution of signs and symptoms of infection; a solid fusion was obtained in every case. In 5 patients with incomplete spinal cord compromise the remission was complete. Only 1 of the 5 patients with radicular compromise remains with paresthesias. Conclusion According to our selection guidelines, the combination of parenteral antibiotic treatment and external immobilization or surgery proved to be an adequate treatment in our small series of patients with cervical spondilodiscitis.