Zdenek Klezl

Instrumented posterolateral lumbar fusion using coralline hydroxyapatite with or without demineralized bone matrix, as an adjunct to autologous bone.

BACKGROUND CONTEXT Autogenous posterolateral fusion with and without instrumentation has been reported with good results. However, difficult-to-fuse patients, such as smokers, elderly patients with poor bone quality and/or quantity, or patients with prior posterior surgeries, may have somewhat lower fusion rates. PURPOSE To determine the efficacy of coralline hydroxyapatite with or without demineralized bone matrix as a bone graft extender in a human clinical model with long-term follow-up. STUDY DESIGN/SETTING A retrospective series of 40 patients undergoing instrumented autogenous posterolateral lumbar fusion augmented with coralline hydroxyapatite with or without demineralized bone matrix. PATIENT SAMPLE Long-term clinical and radiographic follow-up were examined for 40 patients who underwent an instrumented posterolateral fusion only. Patients undergoing anterior lumbar interbody fusion (ALIF) procedures were not considered part of the sample. METHODS All patients underwent successful transpedicular fixation with autogenous posterolateral lumbar fusion. Fifteen cc of Pro Osteon 500 coralline hydroxyapatite (Interpore Cross International, Irvine, CA) was used at each level. An additional 10 cc of Grafton demineralized bone matrix gel (Osteotech, Eatontown, NJ) was used in 70% of these patients. RESULTS An overall fusion rate of 92.5% was achieved. Pain and function improvement were good but somewhat age dependent and correlated with the number of comorbidities. Patients with Grafton DBM gel had a lower fusion rate of 89.3%. CONCLUSIONS Based on this small retrospective review, coralline hydroxyapatite is an effective bone graft extender in difficult-to-fuse patients as an adjunct to autologous bone for posterolateral fusion of the lumbar spine when combined with rigid instrumentation.

Early results after vertebral body stenting for fractures of the anterior column of the thoracolumbar spine.

INTRODUCTION Vertebroplasty and balloon kyphoplasty have shown to improve pain and functional outcome in cases with symptomatic vertebral fractures. Although restoration of the vertebral body height and kyphosis seemed to be easier with balloon kyphoplasty, it became clear that some of the correction achieved by the balloon is lost once it was deflated. Vertebral body stent was developed to eliminate this phenomenon. To our knowledge this is the first study in describing this technique in clinical settings. MATERIALS AND METHODS Seventeen patients with 20 fractured vertebral bodies were included. All fractures were Type A1.3 or A3.1 (incomplete burst). Information about pain (visual analogue scale-VAS) and function (Oswestry disability index-ODI) and vertebral body deformity (vertebral angle-VA) was recorded in a prospective way at regular intervals. Patients were classified into osteoporotic group (7 patients) and traumatic groups (10 patients, younger than 60 years). RESULTS There were 6 male and 11 female patients with mean age of 58.1 years (31-88 years). Mean follow up was 12 months. The preoperative pain level showed a mean VAS score of 8.9 in osteoporotic group and 9.7 in traumatic group. Postoperatively, in osteoporotic group, mean VAS was 4.8 at 6 weeks, 4.0 at 6 months and 2.5 at 12 months compared with traumatic fracture group where it was 2.7 at 6 weeks, 2.2 at 6 months and 1.6 at 12 months. Mean ODI in osteoporotic group was 41.7% (14-58%) and in traumatic group it was 20.4% (6-33%). Mean vertebral body angle prior to surgery in osteoporotic group was 9.7 whilst postoperatively it was 5.2°; so the mean correction achieved was 4.5°. In traumatic group preoperative VA was 13° whilst postoperatively it was 5.7°; therefore the mean correction achieved was 7.3°. None of the patients lost reduction at their last follow up. CONCLUSION Vertebral body stenting leads to satisfactory improvement in pain, function and kyphosis correction in the treatment of osteoporotic and traumatic fractures. Anterior spinal column, especially the fragmented superior endplate is nicely reconstructed by the stent provided it is inserted accurately. With addition of posterior transpedicular instrumentation, indications for this technique may be wider covering some Type B and C fractures with similar vertebral body damage.

Accuracy of prognostic scores in decision making and predicting outcomes in metastatic spine disease

INTRODUCTION Management of metastatic spinal disease has changed significantly over the last few years. Different prognostic scores are used in clinical practice for predicting survival. The aim of this study was to assess the accuracy of prognostic scores and the role of delayed presentation in predicting the outcome in patients with metastatic spine disease. METHODS Retrospectively, four years of data were collected (2007-2010). Medical records review included type of tumour, duration of symptoms, expected survival and functional status. The Karnofsky performance score was used for functional assessment. Modified Tokuhashi and Tomita scores were used for survival prediction. RESULTS A total of 55 patients who underwent surgical stabilisation were reviewed. The mean age was 63 years (range: 32-87 years). The main primary sources of tumours included myeloma, breast cancer, lymphoma, lung cancer, renal cell cancer and prostate cancer. Of the cases studied, 29 patients had posterior instrumented stabilisation alone, 10 patients had an anterior procedure alone and 16 patients (with an expected survival of more than one year) had both anterior and posterior procedures performed. Twenty-three patients presented with spinal cord compression. The mean follow-up duration was 9 months (range: 1-39 months). Patients who were treated within one week of referral survived longer than anticipated. Patients were divided into three groups based on their expected survival. Actual survival was better in all three groups after surgery. Discrepancies in scores were prominent in patients with myeloma, breast and prostate cancers. Functional outcome was better in patients under 65 years of age. CONCLUSIONS The prognostic scoring systems are not uniformly effective in all types of primary tumours. However, they are useful in decision making for surgical intervention, taking other factors into account, in particular the age of the patient, the type and stage of the primary tumour and general health.

Total spondylectomy of C2: report of three cases and review of the literature.

Study Design A report on 3 patients undergoing total spondylectomy of the C2 vertebra for tumor and the technique for C1-3 reconstruction. Objective To illustrate the feasibility of complete resection of the C2 vertebra with preservation of the vertebral arteries and cervical nerve roots. Background Total spondylectomy provides improved progression free survival in many patients with locally aggressive spinal tumors. However, the perceived technical demands of effectively preserving both vertebral arteries, maintaining cervical nerve roots, and biomechanical reconstruction of the cranial-cervical junction often dissuades surgeons from carrying out total spondylectomy of the C2 vertebra. Methods A review of 3 patients undergoing total C2 spondylectomy for tumor (thyroid adenocarcinoma, chordoma, and solitary plasmocytoma) was done. The surgical procedure that was undertaken and the technique used are described. Results Postoperatively, all 3 patients had uneventful postoperative recovery with gradual improvement in their neurologic functions. Conclusion Preservation of bilateral vertebral arteries and all cervical nerve roots is feasible when carrying out intralesional total spondylectomy in patients with C2 vertebral body tumors and should be considered in patients thought to benefit from total C2 vertebra excision. In an attempt to augment construct stability and provide anterior column load sharing, we have used mesh cage and iliac crest graft between C1 and C3 held in place with a short cervical plate without complications.

Harms titanium mesh cage fracture

Interbody fusion has become a mainstay of surgical management for lumbar fractures, tumors, spondylosis, spondylolisthesis and deformities. Over the years, it has undergone a number of metamorphoses, as novel instrumentation and approaches have arisen to reduce complications and enhance outcomes. Interbody fusion procedures are common and successful, complications are rare and most often do not involve the interbody device itself. We present here a patient who underwent an anterior L4 corpectomy with Harms cage placement and who later developed a fracture of the lumbar titanium mesh cage (TMC). This report details the presentation and management of this rare complication, as well as discusses the biomechanics underlying this rare instrumentation failure.

Role of Intraoperative Red Cell Salvage and Autologus Transfusion in Metastatic Spine Surgery: A Pilot Study and Review of Literature

Study Design Prospective cohort study. Purpose There has been no research examining the use of intraoperative cell salvage during metastatic spinal surgery. The present work is a pilot study investigating the role of cell salvage during metastatic spine surgery. Overview of Literature There is no spinal literature about role of cell salvage and autologus transfusion in metastatic spinal cancer. Methods Sixteen spinal metastases patients who received red cell salvage using a leucocyte depletion filter were enrolled. Of these, ten patients who received salvaged blood transfusion were included in the final analysis. Data collection involved looking at the case notes, operating room records and the prospectively updated metastatic spinal cancer database maintained in the spinal department. Cell salvage data was recovered from the central cell salvage database maintained in the anesthetic department. Results Amount of salvaged blood ranged from 120 to 600 mL (average, 318 mL). The average drop in hemoglobin was 1.65 units (range, 0.4-2.7 units). Three patients (30%) required postoperative allogenic blood transfusion. The average follow up was 9.5 months (range, 6-6 months). One patient developed new lung metastasis, at seven months. No patient developed new liver metastases. Preoperatively, six patients had diffuse skeletal metastases. Of this subgroup, three developed new skeletal metastases. No cases showed any wound related problems in the postoperative period. Conclusions In our study transfusion of intraoperatively salvaged blood did not result in disseminated metastatic cancer. We would suggest that red cell salvage might have a role during metastatic spine surgery.

Coccydynia - could age, trauma and body mass index be independent prognostic factors for outcomes of intervention?

INTRODUCTION The aetiology of coccydynia can be multifactorial, with several associated factors such as obesity, female gender and low mood. The long‐term results of operative interventions, such as manipulation under anaesthesia and coccygectomy are variable, ranging from 63‐90%. MATERIALS AND METHODS Our aim was to identify whether age, trauma and body mass index (BMI) were independent prognostic factors in coccydynia treatment. All patients who presented to the Royal Derby Hospital with a primary diagnosis of coccydynia between January 2011 and January 2015 who had injections, manipulation under anaesthesia or coccygectomy were included. We used patient‐reported satisfaction score as the primary outcome measure. We hypothesised that patients with preceding history of trauma and with high BMI (> 25) would be less satisfied. We divided patient BMI into four groups, following World Health Organization guidelines: group A (18.5‐24.9), group B (25‐29.9), group C (30‐39.9) and group D (> 40). RESULTS A total of 748 patients were diagnosed with coccydynia. Of these, 201 patients had 381 injections, 40 had 98 manipulations under anaesthesia and 9 had coccygectomy. Mean age was 46.4 years; 26% of patients had trauma to the coccyx. The mean time to follow‐up was 7.3 months. We found a statistically significant difference (P = 0.03) between satisfaction scores in groups B and D. Patients who had trauma improved significantly (P = 0.04). The odds ratio calculation of coccygectomy and BMI revealed a higher risk of coccygectomy in Group A. DISCUSSION This is the first study to establish BMI and trauma as independent prognostic factors for coccydynia treatment. Our hypothesis that patients with higher BMI would have lower satisfaction levels has been proven true.

Impact of the quantity of intradiscal cement leak on the progression of intervertebral disc degeneration

INTRODUCTION We aim to assess the impact of the quantity of intradiscal cement leak during kyphoplasty on the rate of progression of degenerative changes in the affected disc. METHODS Of 316 kyphoplasty procedures, we identified 32 episodes of intradiscal cement leak in 26 patients. The quantity of cement leaked was graded from I to IV. Disc degenerative changes were assessed at presentation and follow‐up using radiographical scoring and magnetic resonance imaging (MRI) grading systems. Data for low‐grade leaks (grade I) were compared with the medium‐ and high‐grade leaks (grades II‐IV) using a chi‐squared test. RESULTS Median follow‐up radiographic and MRI assessments were made at 18 and 21 months, respectively. Medium‐ and high‐grade leaks were associated with a significantly higher radiographic disc degeneration scores compared with low‐grade leaks (P = 0.04295) but no difference was found in MRI disc degeneration grades and in adjacent vertebral fracture rates. CONCLUSIONS Our findings indicate that the quantity of cement leaking into the disc space significantly influences the rate of progression of disc degeneration.

Treatment of Cervical Facet Subluxations, Dislocations and Fracture-Dislocations

Cervical facet dislocations are potentially devastating injuries which account for 75 % of subaxial spine injuries. Classification, timing of surgery and types of fixation vary between surgeons and there is still no gold standard. There remains open debate regarding the role of MRI in the diagnostics and selection of the optimal treatment strategy, anterior, posterior or combined approach. In the presence or suspicion of disc herniation behind the displaced vertebral body, anterior approach is indicated. Posterior approach alone is recommended in cases where successful closed awake reduction was achieved or the presence of disc herniation was ruled out by MRI. Because most of these injuries lead to significant damage of both the anterior and posterior column, combined approach is commonly performed, especially in poly-traumatized, alcoholics or other non-compliant patients or in those with additional injury of the superior end-plate of the inferior vertebra.

Skeletal Muscle Mass Is a Prognostic Marker at Diagnosis in Patients with Metastatic Spinal Cord Compression

Introduction Age-related loss of functional muscle mass is associated with reduced functional ability and life expectancy. In disseminated cancer, age-related muscle loss may be exacerbated by cachexia and poor nutritional intake, increasing functional decline, morbidity, and accelerate death. Patients with spinal metastases frequently present for decompressive surgery with decision to operate based upon functional assessment. A subjective assessment of physical performance has, however, been shown to be a poor indicator of life expectancy in these patients. We aimed to develop an objective measure based upon lean muscle mass to aid decision-making, in these individuals, by investigating the association between muscle mass and 1-year survival. Materials and Methods Muscle mass was calculated as total psoas area (TPA)/vertebral body area (VBA), by two independent blinded doctors from CT images, acquired within 7 days of spinal metastases diagnosis, at the L3 level. Outcome at 1 year following surgery was recorded from a prospectively updated metastatic spinal cord compression database. Results A total of 86 patients were followed for 1 year, with overall mortality at 39.5%. There was no gender difference although those alive at 1 year were of a significantly younger age. Alive at 1 year mean age was 62 years (IQR 53–71.75) versus dead at 1 year mean age was 68 years (IQR 61.75–76.25); (p = 0.04). Significantly more patients in the lowest quartile of muscle mass died within 1 year, compared with the highest quartile (57.1 vs. 23.8%, p = 0.02). Individuals who died within a year had significantly lower lean muscle mass on initial CT compared with those alive at the end of 1 year (p = 0.05). Patients with lung and gastrointestinal primary malignancies were more likely to die at 1 year, with both groups having 1-year survival rates less than 50%. Of the malignancies recorded, lung primary patients had a significantly lower muscle mass on CT than breast and lymphoma patients (p < 0.01). Conclusion Death within 1 year in individuals with spinal metastases is related to lean muscle mass at presentation. Assessment of lean muscle mass may influence decision to operate patients with spinal metastases.