Skip hemilaminectomy for the treatment of holospinal epidural abscess: A single-center experience

Background: Holospinal epidural abscesses (HEAs) are rare with potentially devastating consequences. Urgent bony decompression and abscess evacuation with long-term antibiotic therapy are typically the treatment of choice. Methods: We reviewed cases of holospinal HEAs operated on between 2009 and 2018. Variables studied included preoperative laboratories, CT/MR studies plus clinical and radiographic follow-up for between 34 and 60 postoperative months. Results: We utilized skip hemilaminectomies to minimize the risks of segmental instability. Targeted antibiotic therapy was also started immediately and maintained for 6 postoperative weeks. MR/CT studies documented full radiographic and neurological recovery between 6 and 12-months later. Conclusion: HEAs may be treated utilizing multilevel skip hemilaminectomies to help maintain spinal stability while offering adequate abscess decompression/resolution.

Lumbar instability as an etiology of low back pain and its treatment by prolotherapy: A review

BACKGROUND: Low back pain is a significant spinal disorder that affects much of the population at some point during their lives. OBJECTIVE: While proper diagnosis is key, diagnosing the underlying cause of low back pain may often be unclear. METHOD: In this review article, we discuss lumbar instability as an etiology of low back pain and its treatment by prolotherapy. RESULTS: Spinal ligaments may be an underlying culprit in the development of lumbar instability with resultant low back pain and associated disorders. CONCLUSION: In these cases, adequate treatment consisting of non-biologic prolotherapy or cellular prolotherapy, including platelet rich plasma (PRP), can be beneficial in restoring spinal stability and resolving chronic low back pain.

Biomechanical Evaluation of the Lumbar Spine by Using a New Interspinous Process Device: A Finite Element Analysis

Minimally invasive decompression is generally employed for treating lumbar spinal stenosis; however, it results in weakened spinal stability. To augment spinal stability, a new interspinous process device (NIPD) was developed in this study. The biomechanical features of the NIPD were evaluated in this study. Three finite-element (FE) models of the entire lumbar spine were implemented to perform biomechanical analysis: the intact, defect (DEF), and NIPD models. The DEF model was considered for lumbar spines with bilateral laminotomies and partial discectomy at L3–L4. Range of motion (ROM), disc stress, and facet joint contact force were evaluated in flexion, extension, torsion, and lateral bending in the three FE models. The results indicated that ROM in the extension increased by 23% in the DEF model but decreased by 23% in the NIPD model. In the NIPD model, the cephalic adjacent disc stress in flexion and extension was within 5%, and negligible changes were noted in the facet joint contact force for torsion and lateral bending. Thus, the NIPD offers superior spinal stability and causes only a minor change in cephalic adjacent disc stress in flexion and extension during the bilateral laminotomy and partial discectomy of the lumbar spine. However, the NIPD has a minor influence on the ROM and facet joint force for lateral bending and torsion.

A Rare Manifestation of a Presumed Non-Osteophilic Brain Neoplasm: Extensive Axial Skeletal Metastases From Glioblastoma With Primitive Neuronal Components

BackgroundGlioblastoma multiforme (GBM) is the most common malignant tumor of the central nervous system. GBM with primitive neuronal component (GBM-PNC) is an aggressive variant identified in 0.5% of GBMs. Extracranial metastasis from GBM-PNC is a rare and challenging situation.MethodsA special case of early-onset GBM with systemic bone metastasis was enrolled. Clinical data, including patient characteristics, disease course, and serial radiological images were retrieved and analyzed. Tumor tissues were obtained by surgical resections and were made into formalin-fixed paraffin-embedded sections. Histopathological examinations and genetic testing were performed for both the primary and metastatic tumor specimens.ResultsA 20-year-old man suffered from GBM with acute intratumoral hemorrhage of the left temporal lobe. He was treated by gross total resection and chemoradiotherapy following the Stupp protocol. Seven months later, he returned with a five-week history of progressive neck pain and unsteady gait. The radiographic examinations identified vertebral collapse at C4 and C6. Similar osteolytic lesions were also observed at the thoracolumbar spine, pelvic, and left femur. Anterior spondylectomy of C4 and C6 was performed. The resected vertebral bodies were infiltrated with greyish, soft, and ill-defined tumor tissue. One month later, he developed mechanical low-back pain and paraplegia caused by thoracolumbar metastases. Another spine surgery was performed, including T10 total en-bloc spondylectomy, T7-9, L2-3, and L5-S1 laminectomy. After the operation, the patient’s neurological function and spinal stability remained stable. However, he finally succumbed to the rapidly increased tumor burden and died 15 months from onset because of cachexia and multiple organ failure. In addition to typical GBM morphology, the histological examinations identified monomorphic small-round cells with positive immunohistochemical staining of synaptophysin and CD99, indicating the coexistence of PNC. The next-generation sequencing detected pathogenic mutations in TP53 and DNMT3A. Based on above findings, a confirmed diagnosis of systemic metastases from GBM-PNC (IDH-wild type, WHO grade IV) was made.ConclusionsThe present case highlights the occurrence and severity of extensive axial skeletal metastases from GBM-PNC. This rare variant of GBM requires aggressive multimodal treatment including surgery and chemoradiotherapy targeting PNC. The pathological screening of PNC is recommended in patients with early-onset GBM and intratumoral hemorrhage. Surgery for spinal metastasis is appropriate in patients with chemoradioresistance and relatively good general status, with the objectives of restoring spinal stability and relieving spinal cord compression.

Reflexive Response of Neck Muscle to Sudden Perturbation after Prolonged Smartphone Use

Prolonged smartphone use induces passive stretch of neck tissues and muscle fatigue, affecting spinal stability and pain. It is necessary to evaluate the effect of smartphone use on the reflexive response to detect the changes in neck tissues and head stability. A laboratory experiment (n=10) was conducted to investigate the reflexive response of neck muscle to perturbation after 30 minutes of smartphone use. Neck extensor muscle activation and its activation timing to perturbation were investigated before and after smartphone use. Head angle and muscle activation level were collected during smartphone use. During smartphone use, muscle activation gradually increased. After smartphone use, neck muscles showed a higher activation level and significantly delayed onset to perturbation. Smartphone use changed the reflexive response of the neck muscle. Further study is needed to investigate the association between smartphone use and neuromuscular changes to the tissues of the cervical spine.

Waist Circumference, a Clinical Measurement for the Activity of Transversus Abdominis

Objectives: Improving the timing and endurance of the deep abdominal muscles, notably transversus abdominis (TrA), is a known protocol for improving spinal stability. TrA is the deepest abdominal muscle, and monitoring its activity is a difficult task. Ultrasound and pressure biofeedback have been employed for monitoring the activity of TrA; however, these methods are expensive, not always available in all clinical settings, and their application requires formal training. The purpose of this study was to examine the use of a broadly known method, i.e., changes in the waist circumference, to monitor the activity of TrA. Methods: The study was carried out on 14 subjects following a pilot study of 5 participants. The thickness of TrA measured by ultrasound was considered the standard indicator for activity of TrA and was compared with simuObjectives: Improving the timing and endurance of the deep abdominal muscles, notably transversus abdominis (TrA), is a known protocol for improving spinal stability. TrA is the deepest abdominal muscle, and monitoring its activity is a difficult task. Ultrasound and pressure biofeedback have been employed for monitoring the activity of TrA; however, these methods are expensive, not always available in all clinical settings, and their application requires formal training. The purpose of this study was to examine the use of a broadly known method, i.e., changes in the waist circumference, to monitor the activity of TrA. Methods: The study was carried out on 14 subjects following a pilot study of 5 participants. The thickness of TrA measured by ultrasound was considered the standard indicator for activity of TrA and was compared with simultaneous measurement of waist circumference. Results: A significant criterion validity between the thickness of TrA and the waist circumference was established (Pearson correlation=-0.71, P=0.001), indicating an inverse relationship between changes in the thickness of the transversus abdominis muscle and waist circumference. Discussion: This result confirmed the hypothesis that changes in the waist circumference could be employed as a suitable indicator for the activity of TrA.ltaneous measurement of waist circumference. Results: A significant criterion validity between the thickness of TrA and the waist circumference was established (Pearson correlation=-0.71, P=0.001), indicating an inverse relationship between changes in the thickness of the transversus abdominis muscle and waist circumference. Discussion: This result confirmed the hypothesis that changes in the waist circumference could be employed as a suitable indicator for the activity of TrA.

Debridement and corpectomy via single posterior approach to treat pyogenic spondylitis after vertebral augmentation

Background Infection after vertebral augmentation (VA) often limits the daily activities of patients and even threatens their life. The operation may be one of the effective treatments if the patient suffers from intolerable severe pain, neurological deficits, and damage to spinal stability. This study aimed to investigate the clinical efficacy of the treatment of pyogenic spondylitis after vertebral augmentation (PSVA) with Single posterior debridement, vertebral body resection, and intervertebral bone graft fusion and internal fixation (sPVRIF). Methods The study was performed on 19 patients with PSVA who underwent VA at 4 hospitals in the region between January 2010 and July 2020. Nineteen patients were included. Among them, 16 patients underwent sPVRIF to treat the PSVA. Results A total of 2267 patients underwent VA at 4 hospitals in the region. Of the 19 patients with postoperative PSVA, suppurative spondylitis was misdiagnosed as an osteoporotic vertebral fracture(OVF) in 4 patients and they underwent VA. Besides osteoporosis, 18 patients had other comorbidities. The average interval between the first surgery and the diagnosis of PSVA was 96.4 days. Of the 19 patients, 16 received surgical treatment. The surgical time was 175.0±16.8 min, and the intraoperative blood loss was 465.6±166.0 mL. Pathogenic microorganisms were cultured in 12 patients. Conclusion PSVA is a severe complication that can even threaten the life of the patients. sPVRIF may be one of the effective treatments if the patient suffers from intolerable severe pain, neurological deficits, and damage to spinal stability.

Numerical Evaluation of Spinal Stability after Posterior Spinal Fusion with Various Fixation Segments and Screw Types in Patients with Osteoporotic Thoracolumbar Burst Fracture Using Finite Element Analysis

The aim of this study was to analyze the spinal stability and safety after posterior spinal fusion with various fixation segments and screw types in patients with an osteoporotic thoracolumbar burst fracture based on finite element analysis (FEA). To realize various osteoporotic vertebral fracture conditions on T12, seven cases of Young’s modulus, namely 0%, 1%, 5%, 10%, 25%, 50%, and 100% of the Young’s modulus, for vertebral bones under intact conditions were considered. Four types of fixation for thoracolumbar fracture on T12 (fixed with T11-L1, T10-T11-L1, T11-L1-L2, and T10-T11-L1-L2) were applied to the thoracolumbar fusion model. The following screw types were considered: pedicle screw (PS) and cortical screw (CS). Using FEA, four motions were performed on the fixed spine, and the stress applied to the screw, peri-implant bone (PIB), and intervertebral disc (IVD) and the range of motion (ROM) were calculated. The lowest ROM calculated corresponded to the T10-T11-L1-L2 model, while the closest to the intact situation was achieved in the T11-L1-L2 fixation model using PS. The lowest stress in the screw and PB was detected in the T10-T11-L1-L2 fixation model.

Debridement and Corpectomy Via Single Posterior Approach to Treat Pyogenic Spondylitis after Vertebral Augmentation

Background Infection after VA often limits the daily activities of patients and even threatens their life. Operation has become an indispensable choice for such patients. sPVRIF may be one of the effective treatments if the patient suffers from intolerable severe pain, neurological deficits, and damage to spinal stability. This study aimed to investigate the clinical efficacy of treatment of PSVA with sPVRIF. Methods The study was performed on 19 patients with PSVA who underwent VA at 4 hospitals in the region between January 2010 and July 2020. Nineteen patients were included. Among them, 16 patients underwent sPVRIF to treat the PSVA.Results A total of 2267 patients underwent VA at 4 hospitals in the region. Of the 19 patients with postoperative PSVA, suppurative spondylitis was misdiagnosed as an osteoporotic vertebral fracture in 4 patients and they underwent VA. Besides osteoporosis, 18 patients had other comorbidities.The average interval between the first surgery and the diagnosis of PSVA was 96.4 days. Of the 19 patients, 16 received surgical treatment.Among the patients undergoing surgery, one died of refractory septic shock after the surgery, and one died of prostate cancer. The surgical time was 175.0±16.8min, and the intraoperative blood loss was 465.6±166.0 mL.Fourteen patients recovered from the infection.Pathogenic microorganisms were cultured in 12 patients. Conclusion PSVA is an extremely serious complication that can even threaten the life of the patients.sPVRIF may be one of the effective treatments if the patient suffers from intolerable severe pain, neurological deficits, and damage to spinal stability.