Vertebral Wall Research Articles

The Experience of Eggshell Technique during Kyphoplasty to Prevent Cement Leakage in Treatment of Osteoporotic Vertebral Fracture

Introduction Osteoporosis is the big problem in the aging human. Among these osteoporotic related fractures, vertebral compression commonly is the main one. Pain and disability pose major problems in these patients. To restore the vertebral height for driving physical stiffness, and loading bearing toward normal limited and control the pain, kyphoplasty with variable filling materials (PMMA, CPC etc.) have been used for the treatment. For decreasing the rate of PMMA leakage in various wall injuries in vertebral compression fracture, we performed kyphoplasty with modified eggshell technique in different characteristics of vertebral wall. Material and Methods Twenty-four symptomatic vertebral fractures were enrolled. Visual Analogue Scale, the Oswestry Disability Index and Vertebral Wall Injury Score were assessed. The vertebral height loss and changes of kyphotic angle were also recorded by plain X-ray. Three-dimensional CT will be arranged for evaluating the condition of deficiency vertebral wall and central body collapse if need. After creating cavity by percutaneous bipedicular balloon device, PMMA was injected into weak wall site according the pre-operative evaluation or intra-operative finding. The balloon was once again introduced into the created cavity and inflated to achieve the PMMA shield (regional egg-shell method). Then the PMMA or other materials as CPC materials will be continuously to be fill into the left space. Outcome, fill materials leakage condition, X-ray and CT were reviewed postoperatively. Results Symptomatic cement extravasation related complications or leakage on X-ray were not observed in follow up. Only one adjacent compression fracture was happened in one month. Improvement in vertebral height and the mean kyphotic angle was also noted. The mean VAS and ODI decreased significantly from pre-operation to post-operation ( p < 0.05). The Vertebral Wall Injury Score reviews also told us the eggshell technique is fit for multiple conditions of wall injury Conclusion It's always concerned for the leakage of PMMA during spine surgery. There are many options of new implant for decreasing the rate of leakage. Greene introduces the eggshell technique in 2007, they used the eggshell idea to cover the possible leakage site. They had only 7 patients and those possible cortical defects were noted over superior endplate or lateral wall in their paper. According to our experiences in kyphoplasty with this regional eggshell technique in our 24 patients with various wall injuries. The technique is a safe and significantly functional works for decreasing the leakage of PMMA in various wall injury conditions with experienced surgery operator.

The Position of the Aorta Relative to the Vertebrae in Patients With Lenke Type 1 Adolescent Idiopathic Scoliosis.

A computed tomography study. The aim of the study was to clarify the position of the aorta relative to the spine in patients with Lenke type 1 adolescent idiopathic scoliosis. Several authors have examined the position of the aorta in patients with scoliosis; however, their analysis included several types of curve. There is a possibility that the position of the aorta differs according to the scoliosis curve type. Thirty-eight patients with Lenke type 1 were analyzed. The angle (left pedicle aorta [LtP-Ao] angle) and distance (LtP-Ao distance) from the insertion point of the left pedicle screw to the aorta were measured from T4 through L2. The measured data were evaluated from 4 levels above to 4 levels below the apical vertebra. The difference between lumbar modifiers A and C was examined. Dangerous pedicles, which were defined as those in which the aorta entered the expected area based on the screw direction error and length, were counted from T10 to L2. The aorta was located posterolaterally and adjacent to the vertebra at the middle thoracic level, and anteromedially and distant at the thoracolumbar level. LtP-Ao angle was largest at 1 level above the apical vertebra, and LtP-Ao distance was shortest at 2 levels above. LtP-Ao angle of Lenke 1A was significantly larger than 1C from T11 to L2, and LtP-Ao distance of 1A was significantly shorter than 1C from T11 to L1. When the screw length was 40 mm and the direction error was within 10°, there were a large number of dangerous pedicles at T11, regardless of the lumbar modifier. The direction error has a potential risk of injuring the aorta around the apical vertebra. The selection of screws of the proper length is necessary to avoid a breach of the anterior vertebral wall at thoracolumbar level, especially at T11. 3.

Results of Ballon Kyphoplasty in Osteoporotic Fractures with Posterior Wall Injury

Introduction Cement augmentation techniques are standard treatment for cases of osteoporotic vertebral fractures. Compared with vertebroplasty, kyphoplasty is associated with decreased rates of cement leak. Cases with posterior wall fractures are relative contraindications for both techniques. The aim of this study was to evaluate the results of balloon kyphoplasty in cases of osteoporotic fractures with posterior wall involvement Patients and Methods Forty-eight patients with osteoporotic fractures with injury of the posterior vertebral wall were included. Fractures between T4 and L5 were included. Cases with posterior ligamentous complex injury were excluded. Preoperative evaluation included plain X-rays, CT, MRI, and laboratory diagnosis of osteoporosis. All cases were operated upon with balloon kyphoplasty. Bilateral (bi-pedicular) approach was used in all cases. Injected cement volume and incidence of cement leak were evaluated. The minimum follow-up period was 6 months. Results 18 males and 30 females were operated upon. The average age was 72.4 years. The most common affected vertebra was T12 in 19 patients. The average volume of injected cement was 6.2 ml. Posterior cement leak (in spinal canal) occurred in 2 cases and was asymptomatic. There were no neurologic or embolic complications. Conclusion Balloon kyphoplasty is safe in cases of osteoporotic fractures with posterior wall fractures. Type A3 and A4 fractures (according to AO classification) were not associated with increased incidence of cement leak in spinal canal. The volume of injected cement should not exceed the volume injected to inflate the ballon.

Morphology of the injured posterior wall causing spinal canal encroachment in osteoporotic vertebral fractures

Background ContextThe relationship between fractured posterior vertebral wall patterns and the protrusion of bony fragments into the spinal canal is not clear. PurposeWe sought to elucidate the effects of fracture patterns of the injured posterior wall on posterior wall instability and spinal canal encroachment using computed tomography myelography (CTM) in two different positions. Study Design/SettingThis is a prospective analysis of CTM in both supine and semi-sitting positions. Patient SampleThe sample includes 36 consecutive elderly patients with delayed neurologic disorders due to insufficient bone union at the posterior vertebral wall after vertebral fracture. Outcome MeasuresRadiological parameters, including the rates of dural compression and of occupation by bony fragments (OBFr) and the posterior vertebral body height ratio (PVBHr), were used. MethodsAll patients were examined using CTM in both supine and semi-sitting positions. According to fracture patterns of the posterior vertebral wall, we classified injured posterior walls with one fragment as the simple type and those with two or more fragments as the comminuted type. ResultsThe simple type was found in 19 of 36 cases, whereas the comminuted type was found in 17 of 36 cases. A significant correlation was identified between changes in OBFr and PVBHr in both the simple and comminuted types. The mean change of PVBHr between the two positions in the comminuted type was significantly larger (9.2%) than that in the simple type (4.8%). Likewise, the mean change in OBFr in the comminuted type (14.0%) was significantly larger than that in the simple type (8.2%), indicating that the injured posterior vertebral wall with the comminuted type would be more likely to collapse and protrude into the spinal canal. ConclusionsBoth simple and comminuted fracture types could cause protrusion of vertebral fragments into the spinal canal because of a collapsing non-united posterior vertebral wall; however, the comminuted type showed more severe spinal canal encroachment, with axial loading. The morphology of the injured posterior wall is thus important for estimating instability.

Relative risk factors of bone cement leakage after vertebroplasty and kyphoplasty

Objective To investigate the related risk factors of bone cement leakage after percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) of osteoporotic vertebral compression fracture. Methods A retrospective study was made on 108 patients (114 vertebrae) undergone PVP and PKP between January 2008 and June 2014. There were 32 patients with cement leakage and 76 patients without cement leakage. Between-group differences were analyzed in terms of gender, age, number of one-time treated vertebrae, anatomic dissection, surgical procedures (PKP or PVP), integrity of the posterior vertebral wall, puncture approaches (unilateral or bilateral), technical level of surgeons and bone cement volume. Results Bone cement leakage occurred in 36 vertebrae (with the proportion of 31.6%). Cement leakage was associated with number of one-time treated vertebrae, surgical procedures, fractured condition, and bone cement volume (P 0.05). Conclusions Bone cement leakage after PKP or PVP correlated with number of vertebrae with one-time therapy, surgical procedures, fractured condition, and volume of bone cement. A good master of technical procedures and indications and suitable injection of high viscosity bone cement can help reduce the incidence of cement leakage. Key words: Osteoporosis; Spinal fractures; Vertebroplasty; Bone cement leakage

Long-term results still favor nonoperative treatment of stable thoracolumbar burst fractures: commentary on an article by Kirkham B. Wood, MD, et al.: "Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit. A prospective randomized study with follow-up at sixteen to twenty-two years".

Burst fractures of the thoracolumbar spine are common, but no consensus has been reached as to the best treatment. Although all burst fractures are characterized by the common finding of retropulsion of the posterior vertebral body wall into the spinal canal, burst fractures vary in severity with respect to amount of comminution, canal narrowing, associated neurologic deficit, and involvement of posterior structures. The latter structures are of primary importance in defining stability. To determine the best treatment, the authors conducted a randomized clinical trial from 1992 to 1998 in which they compared the outcomes of forty-seven patients who received either surgical or nonoperative treatment of a stable thoracolumbar burst fracture. This type of fracture has an intact posterior osteoligamentous complex. Nonoperative care consisted of bracing or casting. The surgical group was treated by anterior corpectomy and fusion with a plate or short-segment (two to four-level) posterior pedicle-screw instrumentation and arthrodesis. The …

Prevention of Cement Leakage during Kyphoplasty by using the Eggshell Technique

Introduction The most common complication of osteoporotic is vertebral compression in aged people. Pain and disability pose major problems in these patients. To restore the vertebral height for driving physical stiffness, and loading bearing toward normal limited, kyphoplasty and vertebroplasty with variable filling materials (PMMA, CPC, etc.) have been used for the treatment. For decreasing the rate of PMMA leakage, we performed kyphoplasty with eggshell technique in different characteristics of vertebral wall. Materials and Methods Twenty symptomatic vertebral fractures were enrolled. Visual analogue scale (VAS), the oswestry disability index (ODI), and vertebral wall injury score were assessed. The vertebral height loss and changes of kyphotic angle were also recorded by plain X-ray. Three-dimensional CT will be arranged for evaluating the condition of deficiency vertebral wall and central body collapse if needed. After creating cavity by percutaneous bipedicular balloon device, PMMA was injected into weak wall site according the preoperative evaluation or intraoperative finding. The balloon was once again introduced into the created cavity and inflated to achieve the PMMA shield (eggshell method). Outcome, PMMA leakage condition, X-ray, and CT were reviewed postoperatively. Results Symptomatic cement extravasation-related complications or leakage on X-ray were not observed in follow-up. Only one adjacent compression fracture has happened in 1 month. Improvement in vertebral height and the mean kyphotic angle was also noted. The mean VAS and ODI decreased significantly from preoperation to postoperation ( p < 0.05). The vertebral wall injury score reviews also told us that the eggshell technique is fit for multiple conditions of wall injury. Conclusion It is always concerned for the leakage of PMMA during spine surgery. There are many options of new implant for decreasing the rate of leakage. Greene introduces the eggshell technique since 2007. According to our experiences of kyphoplasty with this eggshell technique, the technique is a safe and significantly functional works for decreasing the leakage of PMMA and pain scale in various wall injury conditions. Disclosure of Interest None declared Reference Greene DL, Isaac R, Neuwirth M, Bitan FD. The eggshell technique for prevention of cement leakage during kyphoplasty. J Spinal Disord Tech 2007;20(3):229–232

In Vivo Study of a Self-Stabilizing Artificial Vertebral Body Fabricated by Electron Beam Melting

In vivo assessment of a novel artificial vertebral body fabricated by electron beam melting (EBM) for cervical vertebral body replacement in a sheep model. To investigate the feasibility of a novel artificial vertebral body: a "self-stabilizing artificial vertebral body" (SSAVB) fabricated by EBM in a sheep model. Artificial vertebral body is widely used for vertebral body replacement and spinal fusion, but research on an artificial vertebral body fabricated by EBM has not been reported. An SSAVB made of porous Ti6Al4V was implanted into a sheep cervical spine to replace the C4 vertebral body for 6 and 12 weeks. Bone ingrowth and implant stability were radiologically evaluated, and histological and biomechanical tests were performed. No screw loosening, implant dislocation, or bone fractures occurred during the experimental period. A significant difference (P = 0.001) in bone ingrowth between the 6- and 12-week groups was noted. Comparison of the range of motion of C3-C5 segments between the in vivo group and the control groups (intact C2-C6 segment and fresh sheep cervical spines from C2 to C6 segments that underwent C4 subtotal corpectomy with the posterior vertebral wall retention by SSAVB implantation) suggests that the implant can stably replace this area of the cervical spine. The open porous structure of Ti6Al4V fabricated by EBM facilitated bone ingrowth and the SSAVB can maintain cervical spine stability of the sheep. A porous metal implant can be used for load-bearing applications in a sheep model. It is hoped that these results will stimulate further study in human. 4.

Security analysis of the preservation of the intraspinal rib head when correcting the spinal deformity in neurologically intact patients with scoliosis secondary to Neurofibromatosis type 1

Objective To observe the safety and efficacy of the posterior spinal instrumentation （PSI） with preserving of the intraspinal rib head in neurologically intact patients with scoliosis secondary to Neurofibromatosis type 1 （NF1）. Methods The clinical and radiographic data of nine NF1 scoliosis patients with rib head protrusion into the spinal canal, who had undergone PSI from August 1998 to March 2012, were retrospectively investigated. The average age of these patients （4 males, 5 females） was 15.4±7.6 years, and their neurological status all were Frankel grade E preoperatively. The intraspinal rib head was not resected in all patients intraoperatively. The following parameters, including the magnitude of rib head penetration into the spinal canal （MRPC）, the angle between the bilateral rib （ABR）, the angle between the dislocated rib and the posterior vertebral wall （ARV）, the coronal Cobb angle and the sagittal Cobb angle, were measured before and after surgery. Results The follow-up period was 0.5 to 4.8 years. The average MRPC decreased from preoperative 32.8%±9.9% to postoperative 16.8%±15.2% （P= 0.026）; the average ARV increased from preoperative 34.7°±16.4° to postoperative 47.8°±17.5° （P=0.O01）; the average ABR decreased from preoperative 83.0°±19.5° to postoperative 67.9°±13.3° （P=0.009）; the average coronal Cobb angle decreased from preoperative 70.7°±17.7° to 35.4°±17.0° immediately after operation （P=0.000） and the sagittal Cobb angle decreased from preoperative 59.7°±17.6° to 24.7°±10.8° immediately after operation （P=0.001）. The coronal Cobb angle and sagittal Cobb angle had no significant change during follow-up period. The neurological status was Frankel grade E in all patients immediately after operation and at final follow-up. Conclusion For NF1 scoliosis patients with rib head penetration into the spinal canal without impingement of the spinal cord and neurological deficits, the deformity can be corrected safely and effectively without resecting the intraspinal rib head. Key words: Neurofibromatoses; Scoliosis; Ribs; Dislocations; Orthopedic procedures

Osseofix® System for Percutaneous Stabilization of Osteoporotic and Tumorous Vertebral Compression Fractures – Clinical and Radiological Results After 12 Months

Determining whether implantation of an expandable titanium mesh cage (Osseofix® system) is a successful and safe minimally invasive therapy for osteoporotic and tumorous vertebral compression fractures (VCFs). 32 patients (25 women, 7 men, mean age 71) with 46 osteoporotic or tumorous VCFs (T6 to L4) from June 2010 to January 2012 were included. All of them were stabilized with the Osseofix® system. Preinterventionally we performed X-ray, MRI, and bone density measurements (DXA). The clinical and radiological results were evaluated preop, postop and 12 months postop based on the visual analog scale (VAS) and the Oswestry Disability Index (ODI), X-ray (Beck Index, Cobb angle) and CT. There was a significant improvement in pain intensity (VAS) (7.8 to 1.6) as well as a significant reduction in the mean ODI (71.36 % to 30.4 %) after 12 months. The mean kyphotic angle according to Cobb showed significant improvements (12.3° to 10.8°) after 12 months. Postinterventional imaging showed one case of loss of height in a stabilized lumbar vertebral body (2.2 %) in osteoporosis and one case with adjacent fracture (2.2 %) in osteoporosis. We saw no changes in the posterior vertebral wall. Except for one pronounced postoperative hematoma, we saw no surgical complications including no cement leakage. The clinical mid-term results are good at a low complication rate. The stabilization of symptomatic osteoporotic and tumorous VCFs with the Osseofix® system is a safe and effective procedure, even in fractures with posterior wall involvement. The Osseofix® system is an interesting alternative to the established procedures of cement augmentation. • The Osseofix® system is well suited for stabilizing osteoporotic and tumorous VCFs.• It is a safe and effective procedure without cement leakage and with a low complication rate.• The procedure is an interesting alternative to established cement augmentation procedures.

Percutaneous Vertebral Augmentation Assisted by PEEK Implant in Painful Osteolytic Vertebral Metastasis Involving the Vertebral Wall: Experience on 40 Patients

Background: Vertebral metastases are associated with significant pain, disability, and morbidity. Open surgery for fracture stabilization is often inappropriate in this cancer population due to a poor risk-benefit profile, particularly if life expectancy is short. Vertebroplasty and kyphoplasty are appealing adjunctive procedures in patients with malignancy for alleviation of intractable pain. However, these patients have a higher risk of serious complications, notably cement extravasation. Study Design: We prospectively evaluated clinical results of polyetheretherketone (PEEK) implant (Kiva) assisted vertebroplasty performed in malignant painful osteolytic lesions at risk for cement extravasation due to vertebral wall involvement. Setting: Department of Interventional Radiology, Institute for Cancer Research and Treatment, Candiolo, Turin, Italy Methods: Forty patients (22 women; mean age 66.8 ± 12.4), suffering from a painful spine malignancy with vertebral wall involvement not responding to conventional therapies and without surgical indications, underwent vertebral augmentation with Kiva intravertebral implant for pain palliation. The procedure was performed with moderate sedation and local anesthesia under combined digital fluoroscopy and computed tomography guidance. After the coil-shaped PEEK implant was deployed within the vertebral lesion, bone cement was injected under continuous digital fluoroscopic control. Patients were discharged from the hospital the next procedural day. The Visual Analog Scale (VAS) for pain, Oswestry Disability Index (ODI), analgesic requirement, and use of external brace support were evaluated to determine efficacy. The primary end-point was safety and efficacy at one month after the procedure. However, all the patients were scheduled to be followed-up at month 3, 6, and every 6 months thereafter. Follow-up was prospectively evaluated in all patients after Kiva with clinical interviews. The Institution’s Internal Review Board approved this study. Results: Median pre-treatment VAS of 10 (range 6 – 10) significantly (P < 0.001) dropped to one (range 0 – 3), with all patients achieving a clinically relevant benefit on pain at one month. Differences in pre- and post-treatment analgesic therapy were significant (P < 0.001). All patients no longer use an external brace after Kiva. In 7 out of 43 (16.3%) treated vertebrae a bone cement leakage was detected. Limitations: This is a not randomized study. Participants were limited to 40 patients. Conclusion: The Kiva System potentially represents a novel and effective minimally invasive treatment option for patients suffering from severe pain due to osteolytic vertebral metastases. Key words: Vertebroplasty, metastases, pain palliation, Kiva, spine

Percutaneous Stabilization System Osseofix® for Treatment of Osteoporotic Vertebral Compression Fractures - Clinical and Radiological Results after 12 Months

Study DesignA prospective consecutive cohort study (follow-up study).ObjectiveOur study investigated whether implantation of an expandable titanium mesh cage (Osseofix®) is a successful and safe minimally invasive therapy for osteoporotic vertebral compression fractures (VCF). Our experiences, clinical and radiological findings after 12 months follow-up are presented. Kypho- and vertebroplasty are well-established minimally invasive procedures for the treatment of osteoporotic VCF. The main complications associated with both procedures are uncontrolled bone cement leakage. Therefore a suitable alternative has been investigated.MethodsDuring June 2010 to May 2011 24 patients were included with 32 osteoporotic VCF (T6 to L4). All of them were stabilized with the Osseofix® system. Preinterventionally we performed X-ray, MRI, and bone density measurements (DXA). Clinical and radiological results were evaluated preop., postop. and after 12 months postop. based on the Oswestry Disability Index (ODI) and the Visual Analogue Scale (VAS), X-ray (Beck Index, Cobb-angle) and CT.ResultsThere was a significant improvement in the mean ODI (70,6% to 30,1%) as well as a significant reduction in pain intensity (VAS) (7,7 to 1,4) after 12 month. The mean kyphotic angle according to Cobb showed significant improvements (11,7° to 10,4°) after 12 months. Postinterventional imaging showed only one case of loss of height in a stabilized vertebral body (3.1%). We saw no changes in posterior vertebral wall or adjacent fractures. Except for one pronounced postoperative hematoma we saw no surgical complications including no cement leakage.ConclusionsStabilization of symptomatic osteoporotic VCF with Osseofix® system is a safe and effective procedure, even in fractures with posterior wall involvement. The clinical mid-term results are good at a very low complication rate. The Osseofix® system is an interesting alternative to the established procedures of cement augmentation.

Targeted radiofrequency ablation of metastatic posterior vertebral body lesions in patients with soft tissue sarcomas.

10585 Background: Metastatic spinal lesions can be debilitating with significant impact on patients quality of life. Concern for damage to adjacent neural elements during treatment exist due to high radiation doses required to treat certain radioresistant spinal lesions such as soft tissue sarcoma. Radiofrequency ablation (RFA) of metastatic lesions has been shown to be effective in bone. Spine anatomy presents challenges for minimally invasive (MI) treatment of posterior vertebral body lesions. Targeted RFA (t-RFA) using a novel tumor ablation system, designed for spinal anatomy is evaluated in patients with symptomatic posterior vertebral wall spinal lesions. Methods: Five patients with metastatic leiomyosarcoma or liposarcoma and posterior vertebral body spine lesions, treated by prior radiation with continued progression of lesion size and pain received t-RFA, using a novel spinal tumor ablation system (STAR, DFINE), which contains an articulating bipolar, extensible electrode for navigation. Device thermocouples (TC) permit real time monitoring of the ablation zones to determine size. Sequential post-procedural pain scores, PET and contrast enhanced magnetic resonance imaging, and histopathology of treated area was performed. Results: No complications or thermal injury occurred. Intra-procedural imaging demonstrated the articulated, bipolar instrument was able to navigate to posterior lesions. Post-ablation MRI demonstrated lesion necrosis within a discrete ablation zone. No evidence of malignancy by PET or histopathology was noted through 10 months. All patients reported post procedural pain relief. Systemic therapy was not interrupted. Conclusions: Navigational t-RFA proved a safe and effective, non-ionizing palliative therapy alternative for radio-resistant lesions . Post-ablation imaging and histology confirmed metastatic lesions were necrotic and included in ablation zone with tumor control 10 mos post treatment. Ablation zone was very consistent with real time temperature readings. t-RFA permitted MI targeted treatment of lesions within close proximity of spinal cord, not controlled by systemic therapy. Prospective clinical trial is under preparation.

Vertebral artery injury and third-party liability: the wrongful attack to whiplash injury, L.27/12 (G.U.n.71 del 24.03.12)

Lesions after blunt cervical trauma could be, infrequently, associated with complications that require a discussion under clinical and legal medical point of view. Vertebral artery dissection as a serious consequence of a cervical trauma is a rare complication of patients with blunt injury mechanisms. Artery lesions could be frequently initially unrecognized or they may present a variety of symptoms ranging from a simple pain involving neck to ischemic lesions and cerebral ictus. Arterial dissection can cause ischemic stroke either by thromboemboli forming at the site of injury or as a result of hemodynamic insufficiency due to severe vascular stenosis or occlusion. Vertebral artery injury and third-party liability: the wrongful attack to whiplash injury, L. 27/12 (G.U. n.71 del 24.03.12) www.preventionandresearch.com 311 Oct-Dec 2012|P&R Scientific|Volume 2|N°4 In medical literature several injury hypotheses which may cause a dissection of the arterial walls of vertebral arteries have been analyzed. Among them, repeated micro-traumatism which, acting on already altered wall, cause the dissection. Some jobs or sports are characterized by this risk because they imply frequent and repeated flexoextension movements or head rotations. Also a single minor trauma, such as a blunt cervical trauma following car accident, could cause the dissection of the vertebral arterial wall. The case reported concerns a 43 year-old man who suffered a bruising trauma following a car accident (a bumper-tobumper crash with an articulated lorry). The reported symptomatology consisted of pain along the rachis and on the back on the neck and a diagnosis of cervical whiplash was made. After the worsening of the symptomatology, neurological tests revealed right hemiataxia and dysarthria. Succeeding MRI scanning with angiographic sequences revealed a dissection of the left vertebral artery with a hyperdense lesion of the right cerebellar hemisphere, as an outcome of an infarct in the area of a postero-inferior cerebellar artery. Vertebral artery stretch during trauma is a possible pathogenic mechanism that could explain some aspects of the whiplash symptom complex and serious consequences. At the present this issue shows many controversial points from a pathogenetic point of view. The described uncertainties and the rareness of this kind of injury may explain the “superficiality” of a doctor giving first-aid to a patient with cervical whiplash and “generic” symptoms and it could be related to possible economical benefits consequent from insurance indemnity. However the persistence of symptoms or the negative evolution of the same suggests that it wasn’t the “usual whiplash invented for compensation purposes” and that late complications of an injury of the walls of encephalic arteries must be taken into serious consideration specially under clinical point of view.

Comparison of the Amounts of Canal Encroachment Between Semisitting and Supine Position of Computed Tomography-Myelography for Vertebral Fractures of the Elderly Involving the Posterior Vertebral Wall

A prospective radiographical trial. To elucidate effects of loading associated with spinal canal encroachment (SCE) in patients with insufficient bone union after vertebral fractures in the elderly, using computed tomography-myelography in 2 different positions. In elderly patients with vertebral fractures, influence of loading would be involved in SCE, but the details are not well understood. Seventeen patients (mean age, 77.4 ± 8 yr; range, 62-91 yr) with various degrees of neurological deficit due to insufficient bone union at both vertebral body and posterior vertebral wall were included in this study. Computed tomography-myelography was performed in both semisitting and supine positions. Kyphotic angle, rate of dural compression, ratio of occupation by bony fragments, and posterior vertebral body height ratio were measured and compared between positions. Mean ratio of occupation by bony fragments was significantly higher in the semisitting position (47.9 ± 9.2%) than in the supine position (33.9 ± 10.0%, P, 0.001). Similarly, mean posterior vertebral body height ratio was significantly lower in the semisitting position (67.8 ± 10.8%) than in the supine position (76.3 ± 13.3%), indicating a significant loss of vertebral height in the semisitting position (P, 0.001). Mean rate of dural compression was likewise significantly higher in the semisitting position (48.6 ± 13.3%) than in the supine position (33.3 ± 16.5%; P, 0.001). Mean change in ratio of occupation by bony fragments, change in posterior vertebral body height ratio, and angular instability between positions were 13.9 ± 8.6%, 8.5 ± 6.7%, and 13° ± 5.7°, respectively. A significant correlation was identified between change in ratio of occupation by bony fragments and change in posterior vertebral body height ratio (P = 0.001). Our study demonstrated that collapse of the nonunited posterior vertebral wall and intracanal protrusion of vertebral fragments would occur simultaneously with axial loading, causing SCE. Computed tomographic scan obtained in semisitting position seems quite useful to evaluate the amount of SCE by an unstable posterior wall.

Vertebral artery dissection associated with viral meningitis

BackgroundVertebral artery dissection (VAD) is often associated with trauma or occurs spontaneously, inevitably causing some neurological deficits. Even though acute infection can be related to the development of spontaneous VAD (sVAD), VAD associated with viral meningitis has never been reported in the literature.Case presentationA 42-year-old man with fever, sore throat, and runny nose developed sudden onset of occipital headache, vertigo, transient confusion, diplopia, and ataxia. Brain stem encephalitis was diagnosed initially because the cerebrospinal fluid (CSF) study showed inflammatory changes. However, subsequent diffusion-weighted (DWI) magnetic resonance imaging of his brain demonstrated left lateral medullary infarction, and the digital subtraction angiography (DSA) confirmed VAD involving left V4 segment of the artery. Consequently, the patient was diagnosed as VAD accompanied by viral meningitis.ConclusionThis case suggests that viral meningitis might lead to inflammatory injury of the vertebral arterial wall, even sVAD with multiple neurological symptoms.

Simultaneous Posterior and Anterior Approaches With Posterior Vertebral Wall Preserved for Rigid Post-Traumatic Kyphosis in Thoracolumbar Spine

A retrospective study. To evaluate the radiological and clinical results of simultaneous surgery with preservation of the posterior vertebral wall for rigid post-traumatic kyphosis in the thoracolumbar spine. Management of rigid post-traumatic kyphosis has been a challenge for surgeons. Current widely used posterior osteotomy procedures have the disadvantages of significant invasiveness, spinal column shortening, and instrumentation-related complications. From 2004 to 2009, 21 patients with rigid post-traumatic kyphosis in the thoracolumbar spine (T11-L2) were managed in our hospital. Average kyphotic angle was 45.2° ± 11.2° (range, 31°-67°). The surgical technique used was posterior and anterior circumferential release and anterior corpectomy with posterior vertebral wall preservation and short segmental instrumentation. Preoperative and postoperative kyphotic angle was measured to assess the degree of kyphosis correction and maintenance. Changes in low back pain were assessed by Japanese Orthopaedic Association scores. All patients were successfully managed with this procedure without major complications. Most patients (19 of 21) were instrumented with anterior-only fixation, while posterior interspinal wire was added in 2 patients with osteoporosis. The mean blood loss was 470 mL (range, 300-700 mL). Patients were followed for an average of 32 months (range, 6-70 mo) postoperatively. Back pain was relieved to some degree in all patients and the improvement in Japanese Orthopaedic Association scores was 76.9% ± 7.9. Average kyphotic angle was 6.0° ± 5.7° (range, -2 to 17) immediately after surgery and 7.2° ± 5.8° (range, -3 to 17) at final follow-up. Average of 1° of correction loss was documented and all patients obtained solid fusion uneventfully. This technique is indicated for most patients with rigid post-traumatic kyphosis in the thoracolumbar spine and can yield satisfactory clinical results not only in terms of pain relief, kyphosis correction, vertebral height restoration, and spinal canal integrity preservation, but also in reducing the risk of excessive bleeding and spinal cord injury.

Percutaneous augmented instrumentation of unstable thoracolumbar burst fractures: our experience in preventing cement leakage

To the Editor, It was with great interest that we read the article by N. Rahamimov et al., “Percutaneous augmented instrumentation of unstable thoracolumbar burst fractures,” published in the 2011 December issue of European Spine Journal [1]. This is a well-prepared article, which introduces a novel approach, combining percutaneous posterior short-segment pedicle screw augmentation with polymethylmethacrylate (PMMA) and fractured vertebra kyphoplasty to treat unstable thoracolumbar burst fractures. The kyphoplasty mentioned in the article yielded a high ratio of cement leakage (52/52) mainly through fracture line or segmental veins and caused three cases of PMMA pulmonary emboli. In our experience, the risk of cement leakage can be avoided with some good manners [2–4]. The higher viscosity PMMA injected is the key factor to prevent cement leakage. In the procedure, we control ideal level of viscosity when the cement is not runny any more, becomes doughy, does not stick to the fingers and can stand erect at the tip of the bone cement inserter when pushed out, it is considered to be able to block mostly segmental veins. For the fracture line in the anterior wall, small amounts of middle- or late-stage bone cement in the dough phase are used to block the defect to protect against anterior leakage firstly. After the cement has solidified, late-stage bone cement in the paste phase or early stage bone cement in the dough phase is applied to allow the filling to diffuse evenly. For patients with damaged posterior wall, the filling process is stopped as soon as the bone cement reaches the lateral margin or when one-fourth of the distance to the posterior wall of vertebra left under continuous fluoroscopic monitoring (Figs. 1, ​,2).2). When the lateral wall is damaged, we fill 1 mL of viscous cement after expanding the intravertebral space and removing the balloon. Then we reinsert the balloon into the cement and reinflating it, in order to expand the surrounding cement until it abuts the compromised lateral wall. Finally, conventional cement filling is performed. Fig. 1 Radiographs from a 60-year-old woman with fractures of L2 with anterior and posterior vertebral wall deficiency preoperatively Fig. 2 Postoperative radiographs showed a cement barrier in the anterior wall (white arrows) and a safe distance to posterior wall, no cement leakage was found. A small amount of bone cement was used to prevent anterior leakage, just after the first filling ... In summary, to patients with unstable thoracolumbar burst fractures, regardless of whether the fracture line is located at the anterior, posterior or lateral wall of the vertebral body, bone cement leakage can be prevented by some tips introduced above.

Percutaneous vertebral augmentation for painful osteolytic vertebral metastasis: a case report

IntroductionVertebral metastases are associated with significant pain, disability, and morbidity. Open surgery for fracture stabilization is often inappropriate in this population due to a poor risk-benefit profile, particularly if life expectancy is short. Percutaneous vertebroplasty and kyphoplasty are appealing adjunctive procedures in patients with malignancy for alleviation of intractable pain. However, these patients have higher risk of serious complications, notably cement extravasation. Described in this report is a case of a painful osteolytic vertebral metastasis that was successfully treated by a novel percutaneous vertebral augmentation system.Case presentationA 42-year-old Caucasian female presented with a history of metastatic lung cancer unresponsive to radiation and chemotherapy with symptoms inadequately controlled by opiates over the previous 6 months. Magnetic resonance imaging and spiral computed tomography with two-dimensional reconstruction showed an osteolytic vertebral metastasis with complete involvement of the T10 vertebral body, extending to the cortical vertebral wall anteriorly and posteriorly. The patient was treated with percutaneous vertebral augmentation (Kiva® VCF Treatment System, Benvenue Medical, Inc, Santa Clara, CA) utilizing a novel coil-shaped polyetheretherketone implant designed to minimize the risk of cement extravasation. After the minimally invasive procedure, bone cement distribution within the vertebral body was ideal, with no observed cement extravasation. No complications were reported, pain completely resolved within 24 hours, and use of intravenous narcotics was progressively diminished within 1 week. Complete pain relief was maintained throughout 4 months of follow-up.ConclusionThe Kiva System represents a novel and effective minimally invasive treatment option for patients suffering from severe pain due to osteolytic vertebral metastasis.

Abstract No. 188: Peek endovertebral implant assisted vertebroplasty in painful ostelytic metastases with vertebral wall involvement: clinical experience on 30 patients

Abstract No. 188: Peek endovertebral implant assisted vertebroplasty in painful ostelytic metastases with vertebral wall involvement: clinical experience on 30 patients