Spinal trauma.

By London Spine

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Spinal trauma.
Curr Rev Musculoskelet Med. 2014 Sep 17;
Authors: Ellis J, Courson R, Daniels B
Abstract
The practice of spinal immobilization has existed since the 1960s under the pr…

Complete debridement for treatment of thoracolumbar spinal tuberculosis: a clinical curative effect observation.

By London Spine
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Complete debridement for treatment of thoracolumbar spinal tuberculosis: a clinical curative effect observation.

Spine J. 2013 Oct 8;

Authors: Jin W, Wang Q, Wang Z, Geng G

Abstract
BACKGROUND CONTEXT: Traditional focal debridement involves clearing of cold abscesses, caseous necrosis, residual intervertebral disc tissue, sinus tracts, bony sequestration, and inflammatory granulation. Reports have demonstrated that approximately 13% to 26% of patients were not better or relapsed after traditional focal debridement; these patients required a second surgery or prolonged antituberculous therapy. The presence of retained and diseased focal tissues requiring removal remains poorly understood. The contents of these retained tuberculous foci, improvement of surgical strategies, and improvement in spinal tuberculosis success rate are key subjects for discussion.
PURPOSE: To explain the contents of foci and explore the surgical methods and curative effect of complete debridement.
STUDY DESIGN: Retrospective study of the curative effect of treatment of thoracolumbar spinal tuberculosis by using complete debridement.
PATIENT SAMPLE: A total of 289 patients were included.
OUTCOME MEASUREMENT: The outcomes were evaluated clinically by Frankel grading. The status of the anterior fusion was assessed according to the Moon standard. Eradication of infection was determined by the level of C-reactive protein and erythrocyte sedimentation rate. X-ray, computed tomography, and magnetic resonance imaging were used to evaluate disease localization and morphology.
METHODS: A total of 289 patients with spinal tuberculosis (150 male and 139 female patients, aged 18-82; average age, 41.0±1.4 years) were included in this study. Damage to the vertebrae was as follows: 86 patients had thoracic damage, 49 had thoracolumbar damage, 125 had lumbar damage, and 47 had lumbosacral segment damage. After 2 to 4 weeks of antituberculous therapy, all patients underwent anterior debridement, deformity correction, graft fusion, and internal fixation. In this study, complete debridement was defined as the clearing of any damage or disease, including psoas abscesses, granulomas, residual intervertebral disc tissue, sinus tracts, bony sequestration, and inflammatory granulation. Tuberculosis cavities, sclerotic walls, and bony bridges that had no support and that were eroded by the foci were also removed. A total of 108 patients underwent anterior fixation with the Zephir system (Medtronic Sofamor-Danek, Minneapolis, MN, USA), Z plates (Medtronic Sofamor-Danek), or Ventrifix (China Great Wall Corporation, Beijing, China). A total of 181 patients underwent fixation, posterior correction, and one or two second anterior debridements and graft fusions. Posterior fixation, including TSRH (Medtronic Sofamor-Danek), Cotrell-Dubousset (Medtronic Sofamor-Danek), General Spinal System (WeiGao Orthopaedic Devices Company, Weihai City, China), or UPASS (WeiGao Orthopaedic Devices Company), was performed. All patients underwent structural bone grafting, including autologous iliac bone (251 patients), titanium mesh (32 patients), and rib (6 patients).
RESULTS: The 289 patients were followed for 72.0±2.8 months, with 265 patients (91.69%) completely treated and 24 incompletely treated, including 3 who suspended chemotherapy because of liver or renal failure. Twenty-one patients (7.27%) failed to have a complete debridement, including 16 with incomplete bone debridement, 6 of whom underwent a second surgery, and 10 who received conservative therapy; 5 of this group had incomplete abscess debridement, 3 underwent a second surgery, and 2 received puncture aspiration of abscess under computed tomographic guidance; the second surgery rate was 3.81%. Twenty-two patients had surgery complications, including three with graft displacement, five with wound infection and fat liquefaction, four with pleural effusion, six with pain at the graft harvesting site, and four with incisional hernia. Bone graft healing was observed 4.3±1.2 months after surgery. The Cobb angle before and after surgery and at the final follow-up was 22.16±11.51°, 8.11±4.83°, and 9.96±3.49°, respectively, with a mean correction of 63.40% after surgery; however, a 1.85±1.34° loss was observed at the final follow-up with loss rate of 8.35%.
CONCLUSIONS: Sclerotic bone, multiple cavities, and bony bridges are foci in spinal tuberculosis. Clearing tuberculous foci, sclerotic bone, multiple cavities, and bony bridges to increase the curative effect is an effective treatment method.

PMID: 24119880 [PubMed – as supplied by publisher]

One-year results of a randomized, double-blind, active controlled trial of fluoroscopic caudal epidural injections with or without steroids in managing chronic discogenic low back pain without disc herniation or radiculitis.

By London Spine
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One-year results of a randomized, double-blind, active controlled trial of fluoroscopic caudal epidural injections with or without steroids in managing chronic discogenic low back pain without disc herniation or radiculitis.

Pain Physician. 2011 Jan-Feb;14(1):25-36

Authors: Manchikanti L, Cash KA, McManus CD, Pampati V, Smith HS

Abstract
BACKGROUND: Lumbar radicular pain pathophysiology continues to be the subject of research and debate as discogenic pain is increasingly seen as a cause of non-specific low back pain. Among non-surgical methods used to manage chronic low back pain with or without disc herniation, epidural injections are one of the most common modalities. However, there is little evidence utilizing contemporary methodology for using epidural injections in patients with discogenic pain.
STUDY DESIGN: A randomized, double-blind, active-controlled trial.
SETTING: An interventional pain management practice, a specialty referral center, a private practice setting in the United States.
OBJECTIVES: To evaluate the effectiveness of caudal epidural injections with local anesthetic, with or without steroids, in managing chronic low back pain without disc herniation or radiculitis.
METHODS: A total of 120 patients were assigned to one of 2 groups. Group I patients received caudal epidural injections with local anesthetic (lidocaine 0.5% 10 mL); Group II patients received caudal epidural injections with 9 mL of 0.5% lidocaine mixed with 1 mL of steroid (either brand name or non-particulate betamethasone [6 mg] or methylprednisolone [40 mg]). Computer-generated randomization and random allocation sequence by simple randomization were the randomization techniques utilized.
OUTCOMES ASSESSMENT: Multiple outcome measures were utilized which included the Numeric Rating Scale (NRS), the Oswestry Disability Index 2.0 (ODI), employment status, functional status, and opioid intake at 3, 6, and 12 months post treatment. Significant pain relief and functional status improvement were described as a 50% or more reduction in scores from baseline.
RESULTS: Significant pain relief and functional status improvement were observed in 55% of the patients in Group I and 68% of the patients in Group II. In contrast, 84% of patients in Group I and 85% in Group II saw significant pain relief and functional status improvement in the successful group (62% in Group I and 68% in Group II). The average procedures per year were 3.8 ± 0.9 for Group I and 4.3 ± 0.9 for Group II. Average pain scores decreased from 8.0 ± 0.9 to 4.3 ± 1.79 for Group I and from 7.9 ± 1.0 to 3.8 ± 1.59 for Group II. There were no differences among the patients receiving one of the 3 steroids.
LIMITATIONS: The results of this study are limited by lack of a placebo group.
CONCLUSION: Caudal epidural injections with local anesthetic with or without steroids are effective in patients with chronic low back pain of discogenic origin without facet joint pain, disc herniation, and/or radiculitis.

PMID: 21267039 [PubMed – indexed for MEDLINE]

Penetration of a cervical radicular artery during a transforaminal epidural injection.

By London Spine

Penetration of a cervical radicular artery during a transforaminal epidural injection.

Pain Med. 2010 Feb;11(2):229-31

Authors: Verrills P, Nowesenitz G, Barnard A

Inadvertent cannulation or penetration of the cervical radicular arteries during cervical transformaminal epidural injections (TFESIs) is a serious clinical risk, and purportedly, the cause of possible spinal cord injury sustained during this procedure.

PMID: 20447301 [PubMed – indexed for MEDLINE]

Cervical sagittal alignment variations in adolescent idiopathic scoliosis patients treated with thoraco-lumbo-sacral orthosis.

By Kamruz Zaman
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Cervical sagittal alignment variations in adolescent idiopathic scoliosis patients treated with thoraco-lumbo-sacral orthosis.

Eur Spine J. 2016 Nov 18;

Authors: Corradin M, Canavese F, Dimeglio A, Dubousset J

Abstract
PURPOSE: Thoraco-lumbo-sacral orthosis (TLSO) is an effective treatment in adolescent idiopathic scoliosis (AIS) patients, but cervical sagittal alignment (CSA) variations after bracing have never been evaluated. The purpose of this study was to assess changes in CSA before, during and after TLSO treatment, and to determine whether patients developed cervical pain.
METHODS: This was a retrospective study in 38 AIS patients (33 females; mean age 10.8 years) treated by TLSO. Patients were Risser 0 (n = 34) or 1 (n = 4). Major curve deformity (MC) in the coronal plane and cervical (CSA), thoracic (TSA) and lumbar (LSA) sagittal alignment were evaluated radiographically at start of treatment (t 0), after 1 month of brace treatment (t 1), and 1 year after end of treatment (t 2). Cervical pain was evaluated at t 2 using a visual analogue scale (VAS).
RESULTS: The TLSO was worn for an average of 4.6 years. Mean CSA, TSA and LSA were significantly lower at t 2 than at t 0: 0 ± 2.5° vs. 9.4 ± 2.3°, 24.1 ± 2.6° vs. 29.3 ± 2.4° and 5 ± 1.9° vs. 44.2 ± 2.5°, respectively (p < 0.05). CSA and TSA showed moderate-good correlation (r = 0.57). CSA was normolordotic in 1/38 patients at t 2 compared to 18/38 at t 0 (p < 0.05). MC did not progress during treatment (p > 0.8). VAS score was 0 in all patients.
CONCLUSIONS: The TLSO can control progression of the deformity in the frontal plane, but it influences CSA, TSA and LSA. In particular, it decreases cervical spine lordosis, with reduction maintained 1 year after the end of treatment. Numerical differences, although statistically significant, were not clinically relevant.

PMID: 27864683 [PubMed – as supplied by publisher]

Minimally Invasive, Robotic-vs. Open Fluoroscopic-guided Spinal Instrumented Fusions-a Randomized, Controlled Trial.

By Kamruz Zaman

Minimally Invasive, Robotic-vs. Open Fluoroscopic-guided Spinal Instrumented Fusions-a Randomized, Controlled Trial.

Spine (Phila Pa 1976). 2016 Jul 7;

Authors: Hyun SJ, Kim KJ, Jahng TA, Kim HJ

Abstract
STUDY DESIGN: A prospective randomized clinical trial.
OBJECTIVE: Compare the impact of robotic guidance in a minimally-invasive spine surgery (MIS) to a fluoroscopy-guided, open approach, in lumbar fusions.
SUMMARY OF BACKGROUND DATA: MIS requires a protracted learning curve and excessively exposes the patient and surgical team to harmful radiation. Robotic-guidance has been shown to improve accuracy and radiation in most studies, but there is conflicting prospective data.
METHODS: Patients indicated to undergo a 1 or 2 level spinal fusion were randomized between robotic-guided MIS (RO) and fluoroscopic-guided open surgery (FA). Patient demographics and outcomes were recorded.
RESULTS: Thirty patients were recruited to each arm. Average age was 66.7, 71.5% were females, average BMI was 25.2. Thirty-five levels were instrumented with 130 pedicle screws in RO vs. 40 levels with 140 screws in FA, or 4.3 and 4.7 screws per surgery, respectively. Use of fluoroscopy was 3.5 vs. 13.3 seconds in the RO and FA respectively (p < 0.001). C-arm output in mSv was 0.13 vs. 0.27 in the RO and FA respectively (p = 0.015). By thermo-luminescent dosimeters, the average per-screw radiation in the RO arm was 37.5% of that in the FA arm, demonstrating a mean reduction of 62.5% in use of radiation. There was no difference in the improvement in VAS scores for back and leg or the ODI. All screws were accurate in RO while 2 breached (>2 mm and >4 mm) in FA (p = 0.500). One proximal facet violation occurred in the study, it was in FA (p = 1.000). The average distance from the proximal facets was 5.8 vs. 4.6 mm in the RO and FA respectively (p < 0.001). The average length of stay was 6.8 vs. 9.4 days in RO compared with FA (p = 0.020).
CONCLUSION: MIS using Robotic-guidance significantly reduced radiation exposure and length of stay. Patient outcomes were not affected by the surgical technique.
LEVEL OF EVIDENCE: 1.

PMID: 27398897 [PubMed – as supplied by publisher]