251/851. En bloc vertebrectomy and dural resection for chordoma: a case report. STUDY DESIGN: Case report. OBJECTIVES: Report a surgical technique for dural reconstruction after vertebrectomy. SUMMARY OF BACKGROUND DATA: None available. methods: Clinical case analysis: chordoma from T12 to L2 with infiltration of the dura. RESULTS: Forty-six months after vertebral resection and reconstruction, the patient is disease free. CONCLUSIONS: Wide en bloc resection is required for local control in chordoma. When the tumor permeates the dura, resection not including the dura is intralesional with high risk of local recurrence. Therefore, a proper wide resection consists in vertebrectomy removing the dura infiltrated by the tumor. The two-stage dural reconstruction had strongly limited the leakage of liquor during surgery, and the dural patch provided extra strength anteriorly, where the dural suture is more difficult. ( info) |
252/851. Computed tomography-guided screw fixation of a sacroiliac joint dislocation fracture: a case report. A 19-year-old woman sustained a vertical shear type pelvic fracture. Sacroiliac fixation using computed tomography (CT)-guided cannulated screws was performed for a left sacroiliac dislocation fracture, and a satisfactory result was obtained over time. Patients who have posterior instability of the lateral compression or vertical shear type do not obtain adequate stability by fixation of the anterior part alone; and they often have persistent residual pain, necessitating internal fixation of the posterior part later. Advantages of CT-guided sacroiliac screw fixation include precise evaluation of the degree of reduction and absence of nerve and vascular damage during the time the screw is inserted into the sacral body. This procedure is a useful, safe method owing to its minimal invasiveness in patients with unstable pelvic fractures that are reducible by manual manipulation or traction. ( info) |
253/851. Osteoporotic vertebral fracture adjacent to a nonsegmented hemivertebra. A combination of osteoporotic vertebral fractures and congenital spinal deformity is theoretically possible, but there have been no reports on this combination in the literature. We describe a rare case of an osteoporotic vertebral fracture adjacent to the nonsegmented hemivertebra. A 60-year-old postmenopausal woman who did not recall any specific trauma presented with severe back pain. She had markedly decreased bone mineral density and significant lumbar kyphoscoliosis with a nonsegmented hemivertebra between L1 and L2 on radiographs of the lumbar spine. magnetic resonance imaging (MRI) revealed a vertebral fracture adjacent to the nonsegmented hemivertebra. Laboratory studies showed increased serum bone-specific alkaline phosphatase (BAP) and urinary type I collagen crosslinked N-telopeptide (NTx). A thoracolumbar brace was applied for 3 months. Daily administration of alendronate normalized her serum BAP and urinary NTx levels. MRI scans of the lumbar spine after 6 months also confirmed normalized signal intensities of the fractured vertebra adjacent to the nonsegmented hemivertebra. The vertebral fracture seemed to be induced by spinal malalignment, increased stress on the adjacent level of the fused segment, and its fragility due to osteoporosis. ( info) |
254/851. Successful management of a large pulmonary cement embolus after percutaneous vertebroplasty: a case report. Percutaneous vertebroplasty is increasingly used for the treatment of vertebral compression fractures. Local leakage of polymethylmethacrylate cement into the perivertebral space is a common complication, but important systemic effects have rarely been reported. The authors describe the case of a 52-year-old patient with central pulmonary embolism after percutaneous vertebroplasty of the eleventh thoracic vertebral body. The large cement embolus was removed from the right pulmonary artery with a hybrid technique combining an interventional catheter procedure with an open heart operation. The patient made an uneventful recovery. The authors review how appropriate arthroplasty techniques might minimize the risk of this dreadful complication. ( info) |
255/851. Surgical treatment for thoracic spine fracture-dislocation without neurological deficit. Complete fracture-dislocation of the thoracic spine is a rare injury resulting from high-energy impaction that commonly presents with severe neurological deficit. We report a case of this condition in a patient who was involved in a motorcycle-vehicle collision, that resulted in multiple trauma and complete fracture-dislocation of the T7-T8 with middle column-posterior column dissociation. A posterior approach was used for decompression and immediate stabilization of this severe, unstable injury, combined with an anterior approach for anatomic reduction and intervertebral body fusion. No neurological complications occurred either preoperatively or postoperatively. ( info) |
256/851. reoperation of the cervical spine for degenerative disease and tumor. Despite improvements in treatment for cervical spine disease over the last decade, failure that requires a reoperative procedure may represent up to 14% of the cases. With the exception of posterior foraminotomy, the most common failure that requires intervention is instability, which results in an anterior compression of the neural elements. With the advent of new operative approaches and innovative stabilization techniques, the options available to treat these patients have improved. ( info) |
257/851. Pathogenesis and diagnosis of delayed vertebral collapse resulting from osteoporotic spinal fracture. BACKGROUND CONTEXT: In recent years there have been an increasing number of reports on surgical cases involving delayed neurological deficits caused by vertebral collapse after osteoporotic vertebral fracture. PURPOSE: We do not yet know which patients are most susceptible to delayed vertebral collapse and subsequent neurological deficits, or whether this pathological condition can be prevented or predicted. In this study, we investigated the mechanism of progression and radiographic features characteristic of this disease, and we report here the predictive or risk factors for delayed osteoporotic vertebral collapse. STUDY DESIGN: Retrospectively, we investigated the pathogenesis and diagnosis of delayed vertebral collapse with neurological deficit resulting from osteoporosis. PATIENT SAMPLE: A total of 28 patients (7 men and 21 women) with neurological deficits resulting from vertebral collapse caused by osteoporotic vertebral fractures were the subjects for this study. OUTCOME MEASURES: Comparisons and investigations about clinical features and radiographic findings between the patient group of delayed vertebral collapse with neurological deficits and the group of osteoporotic spinal fracture with no neurological deficits. methods: The following factors were examined: the cause of injury; the length of time from injury, or the onset of pain, to the onset of neurological symptoms; radiographic findings obtained during the above period; the clinical course of vertebral fracture on plain X-ray films; time of appearance of the intravertebral cleft, and its localization and changes. RESULTS: Six patients were hospitalized and prescribed a period of 2 weeks of bed rest followed by the fitting of a corset; seven outpatients were corseted but not prescribed bed rest; 15 patients were given medication only at an outpatient clinic. At radiography, intravertebral clefts were detected in 22 patients (79%) during the period from the appearance of pain to the onset of neurological deficit. In 14 patients (50%) who were radiographed every 1 to 2 weeks from the injury to the onset of neurological symptoms, the course of progression to collapse of the vertebral body could be observed. CONCLUSION: Initial correct diagnosis and immobilization are important in preventing the delayed collapse with neurological deficit. The presence of an intravertebral cleft and instability of the affected vertebra represent risk factors for vertebral collapse with neurological deficit, requiring careful observation. ( info) |
258/851. An unconventional indication for open kyphoplasty. BACKGROUND CONTEXT: kyphoplasty is a means of treatment for painful osteoporotic vertebral body compression fractures. Its efficacy has not yet been totally proven. Even though the conventional percutaneous kyphoplasty is a relatively safe procedure, it is not routinely recommended for use in vertebral body fractures that involve posterior cortical compromise/retropulsion or in fractures associated with neurological deficit. PURPOSE: To see whether the open kyphoplasty procedure can be used in patients with painful vertebral body compression fractures who also have bony retropulsion into the spinal canal. STUDY DESIGN/SETTING: This technical report is based on the experience of one patient. methods: A 79-year-old woman with a history of osteoporosis presented with a painful vertebral body compression fracture at T12. magnetic resonance imaging of her lumbar spine demonstrated an acute compression fracture at T12 with significant decrease in vertebral body height and retropulsion of bone resulting in one-third reduction in canal width. She was not considered a candidate for percutaneous kyphoplasty. Three months after the injury, an open kyphoplasty was performed after a decompression laminectomy at T12. RESULTS: The fractured vertebral body was successfully reduced, and there was no leakage of polymethylmethacrylate into the spinal canal through the fractured posterior cortex using the open kyphoplasty procedure. One month after the operation, the patient was free from mid-back pain and was again able to walk. CONCLUSION: Open kyphoplasty procedure allows direct visualization to the spinal canal. It can be performed safely and effectively in selected vertebral body compression fractures with retropulsed bone associated with neurological deficit. ( info) |
259/851. A new scale for the clinical assessment of spinal cord function. The systems currently used for grading the severity of neurologic injuries have serious limitations. The authors have developed a neurologic grading system to assess spinal cord function. This is a new, functionally oriented scale which can be used at the bedside and requires no special tests other than those done in a routine clinical neurological examination. This scale includes assessment of motor and sensory function, rectal tone, and bladder control. A major advantage of this scale is that motor function is assessed on a functional rating system. To evaluate the usefulness of this scheme, patients who have been previously entered into a prospective study on the surgical treatment of burst fractures were re-evaluated. A significant number of patients under our new reclassification system were noted to have had significant improvement which had been overlooked using the Frankel Grade system. The authors conclude that their new spinal cord assessment technique has many advantages and suggest that it be used by spinal cord injury centers. ( info) |
260/851. Polymethylmethacrylate cement dislodgment following percutaneous vertebroplasty: a case report. STUDY DESIGN: A case report is presented. OBJECTIVES: To report a rare complication of delayed cement displacement following percutaneous vertebroplasty. SUMMARY OF BACKGROUND DATA: Although percutaneous vertebroplasty is considered a minimally invasive procedure, it may result in several complications. To our knowledge, this is the first report of delayed cement displacement after percutaneous vertebroplasty. methods: A 69-year-old man with T12 osteoporotic compression fracture received percutaneous vertebroplasty. One month after surgery, the patient complained of progressive severe back pain, and roentgenographic image revealed a breakdown of the anterior cortex of the T12 vertebral body with anterior displacement of the bone cement. RESULTS: The complication was solved by one stage anterior and posterior operation: thoracoabdominal approach with removal of the displaced cement and posterior instrumentation from T11 to L1. The severe back pain with associated weakness improved after surgery. CONCLUSIONS: This complication is rare and likely to occur in treatment of osteoporotic vertebral fracture with avascular necrosis and anterior cortical defect. ( info) |