Percutaneous suction and irrigation for the treatment of recalcitrant pyogenic spondylodiscitis.

The primary management of pyogenic spondylodiscitis is conservative. Once the causative organism has been identified, by blood culture or biopsy, administration of appropriate intravenous antibiotics is started. Occasionally patients do not respond to antibiotics and surgical irrigation and debridement is needed. The treatment of these cases is challenging and controversial. Furthermore, many affected patients have significant comorbidities often precluding more extensive surgical intervention. The aim of this study is to describe early results of a novel, minimally invasive percutaneous technique for disc irrigation and debridement in pyogenic spondylodiscitis.This article is freely available via Open Access. Click on the Additional Link above to access the full-text via the publisher's sit

Mid-term results of a modified self-growing rod technique for the treatment of early-onset scoliosis

AimsTo report the mid-term results of a modified self-growing rod (SGR) technique for the treatment of idiopathic and neuromuscular early-onset scoliosis (EOS).MethodsWe carried out a retrospective analysis of 16 consecutive patients with EOS treated with an SGR construct at a single hospital between September 2008 and December 2014. General demographics and deformity variables (i.e. major Cobb angle, T1 to T12 length, T1 to S1 length, pelvic obliquity, shoulder obliquity, and C7 plumb line) were recorded preoperatively, and postoperatively at yearly follow-up. Complications and revision procedures were also recorded. Only patients with a minimum follow-up of five years after surgery were included.ResultsA total of 16 patients were included. Six patients had an idiopathic EOS while ten patients had a neuromuscular or syndromic EOS (seven spinal muscular atrophy (SMA) and three with cerebral palsy or a syndrome). Their mean ages at surgery were 7.1 years (SD 2.2) and 13.3 years (SD 2.6) respectively at final follow-up. The mean preoperative Cobb angle of the major curve was 66.1 degrees (SD 8.5 degrees) and had improved to 25.5 degrees (SD 9.9 degrees) at final follow-up. The T1 to S1 length increased from 289.7 mm (SD 24.9) before surgery to 330.6 mm (SD 30.4) immediately after surgery. The mean T1 to S1 and T1 to T12 growth after surgery were 64.1 mm (SD 19.9) and 47.4 mm (SD 18.8), respectively, thus accounting for a mean T1 to S1 and T1 to T12 spinal growth after surgery of 10.5 mm/year (SD 3.7) and 7.8 mm/year (SD 3.3), respectively. A total of six patients (five idiopathic EOS, one cerebral palsy EOS) had broken rods during their growth spurt but were uneventfully revised with a fusion procedure. No other complications were noted.ConclusionOur data show that SGR is a safe and effective technique for the treatment of EOS in nonambulatory hypotonic patients with a neuromuscular condition. Significant spinal growth can be expected after surgery and is comparable to other published techniques for EOS. While satisfactory correction of the deformity can be achieved and maintained with this technique, a high rate of rod breakage was seen in patients with an idiopathic or cerebral palsy EOS

Double spinal cord tethering and congenital kyphosis in a 4-year-old boy

Purpose Congenital kyphosis (CK) is an uncommon condition that develops due to a defect of formation or segmentation of one or more vertebrae during the first weeks of embryonic life and can be frequently associated with abnormalities of the spinal cord. Meningocele manque (MM) is a rare congenital malformation consisting of intradural fibrous bands tethering the spinal cord, oftentimes in combination with a split cord malformation. The aim of this manuscript is to describe combined surgical management of a rare case of CK associated with double spinal cord tethering. Study design Case report. Methods We report the case of a 4-year-old boy presenting with a combination of congenital kyphosis due to L2 fully segmented posterior hemivertebra and double spinal cord tethering, at the level of the filum terminale and at L1-L2 due to an intradural ventral fibrous band. Results Spinal cord detethering and L2 hemivertebra resection with kyphosis correction were achieved with a single stage procedure. Segmental kyphosis was corrected from 45 degrees to 11 degrees post-operatively. Apart from a transitory sensory impairment, no immediate or delayed complications were noted and, at 2 years follow-up, correction and spinal alignment were stable. Conclusion To the best of our knowledge, this is the first case to report the simultaneous occurrence of congenital kyphosis and double spinal cord tethering due to MM and tethering of the filum terminale. Our case report shows that surgical correction of the deformity and spinal cord detethering can be safely and effectively achieved during the same surgical procedure

Elastic stable intramedullary nailing (ESIN) in paediatric femur and tibia shaft fractures: Comparison between titanium and stainless steel nails

Introduction: Elastic stable intramedullary nailing (ESIN) is currently considered the gold standard in surgical treatment of femur and tibial shaft fractures in school age paediatric patients. Although elastic intramedullary nails are available in both titanium (Ti) and stainless steel (SS) alloy, titanium nails are most commonly used. Nevertheless, there is still contrasting evidence as to whether the use of Ti nails can offer better outcomes in terms of fracture healing and stability over SS nails. The aim of this study was to compare outcomes and complications of Ti and SS ESIN for femur and tibia shaft fractures in a population of school age paediatric patients.Materials and methods: All consecutive patients who underwent ESIN for femoral or tibial shaft fracture from June 2012 to May 2015 at our centre were retrospectively reviewed. Standard demographic data were collected. Pre-operative and post-operative X-rays were reviewed, complications were collected from patients charts. Patients were divided in two groups, titanium nails (Ti group) and stainless steel nails (SS group) and outcomes compared between the two.Results: A total of 34 patients were included (17 patients Ti group, 17 patients SS group) with a total of 14 femur and 21 tibia fractures. Average age at surgery was 9.4 +/- 2.5 years in Ti group and 10.4 +/- 2.4 years in SS group (p = 0.21). The average time to bone healing was 3 months in Ti group, and 2.8 months in SS group (p = 0.63). At final follow-up (12 months), no patient showed a coronal plane or sagittal plane deformity > 10 degrees and > 15 degrees, respectively. Complication rate was similar between the two groups (24% Ti group, 22% SS group).Conclusions: We did not observe any significant difference in terms of bone healing, fracture mechanical stability, return to full activity, and complication rate between Ti and SS ESIN for paediatric femoral and tibial shaft fractures. While Ti nails remain a better choice for patients with metal allergy, SS nails may offer safe, effective, and cheaper alternative to Ti nails in school age femur and tibial shaft fractures. (C) 2018 Elsevier Ltd. All rights reserved

A Modified Self-Growing Rod Technique for Treatment of Early-Onset Scoliosis

Background: Surgical treatment of early-onset scoliosis (EOS) remains challenging as no definitive surgical technique has emerged as the single best option in this varied patient population(1-3). Although the available surgical techniques may differ substantially, they all share the same goals of achieving and maintaining deformity correction, allowing physiological spinal growth, and reducing the number of operations and complications. Herein, we present a modified self-growing rod technique that represents a valid alternative to the existing surgical procedures for EOS.Description: The patient is positioned prone on a radiolucent table, and the spine is prepared and draped in a standard fashion. A posterior midline skin incision is made from the upper to the lower instrumented level. Subperiosteal exposure of the spine is carried out, ensuring that capsules of the facet joints are spared. Pedicle screws are inserted bilaterally at the cranial and caudal ends of the instrumentation. Fixation with pedicle screws of at least 3 levels at the top and bottom end is usually advised; in nonambulatory patients with pelvic obliquity, caudal fixation can be extended to the pelvis with bilateral iliac screws. Sublaminar wires are positioned bilaterally at every level between the cranial and caudal ends of the instrumentation and are passed as medially as possible to avoid damage to the facet joints. Four 5-mm cobalt-chromium rods are cut, contoured, and inserted at each end of the construct. Ipsilateral rods are secured with use of sublaminar wires, making sure that they overlap over a sufficient length to allow for the remaining spinal growth. Correction of the deformity is achieved with use of a combination of cantilever maneuvers and apical translation by progressive and sequential tightening of the sublaminar wires. The wound is closed in layers over a subfascial drain. The patient is allowed free mobilization after surgery. No postoperative brace is required.Alternatives: Nonoperative alternative treatment for EOS includes serial cast immobilization and bracing(4). Alternative surgical treatments include traditional growing rods(5), magnetically controlled growing rods(6), the vertical expandable prosthetic titanium rib-expansion technique(7), and the Shilla technique(8). The use of compression-based systems (i.e., staples or tether)(9) or early limited fusion has also been reported by other authors.Rationale: The main advantage of our technique is that it relies on physiological spinal growth and does not require surgery or external devices for rod lengthening, which is particularly beneficial in frail patients with a neuromuscular disease in whom repeated surgery is not advised. Segmental fixation by sublaminar wires allows good control of the deformity apex during growth. Concerns regarding early fusion of the spine have not been confirmed in our mid-term follow-up study(10).Expected Outcomes: This technique allows correction of the deformity and continuous spinal growth in the years following surgery. At 6.0 years postoperatively, the average main curve correction was reported to be 61% and the average pelvic obliquity correction was 69%. The spine was reported to lengthen an average of 40.9 mm (range, 14.0 to 84.0 mm) immediately postoperatively, and the T1-S1 segment was reported to continue growing at 10.5 mm/year (range, 3.6 to 16.5 mm/year) thereafter(10). The most common complication is rod breakage at the thoracolumbar junction, which seems to be more common in patients with idiopathic or cerebral palsy EOS and during the pubertal growth spurt(10).Important Tips: Subperiosteal exposure of the spine should be carried out, making sure to preserve facet joints in the unfused area of the spine. Achieve segmental fixation with use of sublaminar wires at every level and pedicle screws at the top and bottom ends of the instrumentation. If pelvic imbalance is present and the patient is nonambulatory, pelvic fixation with iliac screws is advised. First round correction of the deformity is achieved with a cantilever technique; correction fine-tuning can be performed by tightening sublaminar wires. Consider utilizing thicker rods in cases of idiopathic or cerebral palsy EOS

Total Disc Replacement Versus Anterior-Posterior Interbody Fusion in the Lumbar Spine and Lumbosacral Junction: A Cost Analysis

Study Design: Prospective observational cohort study.Objectives: To analyze clinical and economic results in patients with degenerative disc disease in the lumbar area for patients who received combined anterior and posterior fusion or total disc replacement (TDR).Methods: The study included 75 patients, 38 in the fusion group and 37 in the TDR group, who received either anterior/posterior fusion or TDR for lumbar disc disease from January 2005 to December 2008 with a minimum follow-up of 24 months. We collected data with regard to clinical parameters, demographics, visual analogue scale scores, Oswestry Disability Index scores, SF-36 and SF-6D data, surgery time, amount of blood loss, transfusion of blood products, number of levels, duration of hospital stay, and complications. For cost analysis, general infrastructure, theatre costs, as well as implant costs were examined, leading to primary hospital costs. Furthermore, average revision costs were examined, based on the actual data. Statistical analysis was performed using t tests for normal contribution and Mann-Whitney test for skew distributed values. The significance level was set to.05.Results: There was a higher surgery time, more blood loss, and longer hospital stay for the fusion group, compared with the TDR group. In addition, the hospital costs for the primary procedure and revision were 35% higher in the fusion group. The clinical data in terms of SF-36 and SF-6D showed no difference between these 2 groups.Conclusions: TDR is a good alternative to anterior and posterior lumbar fusion in terms of short follow-up analysis for clinical data and cost analysis. General advice cannot be given due to missing data for long-term costs in terms of surgical treatment of adjacent level or further fusion techniques

Stepwise approach for vertebral hemangioma in children: case-reports and treatment algorithm proposal

Purpose To discuss a treatment algorithm for vertebral hemangioma in children. Methods Vertebral hemangioma (VH) is a rare cause of low back pain in children. In most cases, VHs present as incidental findings and do not require invasive diagnostic procedure. In case of symptomatic presentation, different approaches can be used. Over the years, we have developed a treatment algorithm for VH in children based on our clinical experience. In this manuscript, we propose a stepwise approach to treatment of VHs based on tumor extension and the degree of spinal cord/nerves compression with or without neurological deficit. Results According to the proposed protocol, we discuss two cases of aggressive VH treated at our institution by a multidisciplinary team. The first case is about a young girl treated with percutaneous one-level posterior instrumentation followed by medical adjuvant therapy for an L4 "Stage 3" VH. The second case is about an 8-year-old boy with rapidly progressive myelopathy due to T11 "Stage 4" VH treated with a combined anterior and posterior surgery (i.e., posterior decompression and fusion followed by vertebrectomy and expandable cage placement) after preoperative arterial embolization. Conclusion Given the lack of international guidelines and consensus with regard to treatment of VHs in children, we believe our proposal for a stepwise approach combining clinical and radiological characteristics of the lesion may help guide treatment of this condition in children

Percutaneous electrochemotherapy in the treatment of portal vein tumor thrombosis at hepatic hilum in patients with hepatocellular carcinoma in cirrhosis: A feasibility study

To treated with electrochemotherapy (ECT) a prospective case series of patients with liver cirrhosis and Vp3-Vp4- portal vein tumor thrombus (PVTT) from hepatocellular carcinoma (HCC), in order to evaluate the feasibility, safety and efficacy of this new non thermal ablative technique in those patients

A Detailed Analysis of Clinical Features and Outcomes of Patients with Pyogenic Spondylodiscitis Presenting without Axial Back Pain

Study design: Retrospective analysis of a single institution prospective, longitudinal database of spinal pyogenic infections. Diagnosis of pyogenic spondylodiscitis (PS) can be challenging. Although presenting symptoms are often non-specific, acute non-remitting axial back pain is the most striking feature. Nevertheless, several authors have reported on the uncommon occurrence of patients with PS without axial back pain. The aim of this study was to characterize presenting symptoms, causative agents, comorbidities, and treatment outcomes of patients presenting with painless pyogenic spondylodiscitis. A total of 214 patients diagnosed with PS were reviewed; patients were divided into two groups: patients presenting with no axial back pain (no pain group, n = 16), and patients presenting with axial back pain (control group, n = 198). Analyzed data comprised general demographics, presenting symptoms, comorbidities, spinal infection location, and amount of spinal involvement. While average age (62.4 vs. 65.0) and sex distribution was similar between the two groups, a significant diagnostic delay was noted in the control group (53 vs. 17 days, p < 0.001). Patients in the no pain group were more likely IV drug abusers or have had liver failure/cirrhosis. Anatomic distribution (i.e., cervical vs thoracolumbar) of the infection did not differ between the two groups, but a higher number of post-surgical infections was noted in the no pain group (37.5 vs. 15.6%, p = 0.026). E. coli and Pseudomonas spp. were more commonly seen in no pain group patients, and mortality was also higher in this group (12.5 vs. 6.0%, p = 0.004)

10-Year Clinical, Functional, and X-ray Follow-Up Evaluation of a Novel Posterior Percutaneous Screw-Rod Instrumentation Technique for Single-Level Pyogenic Spondylodiscitis

Medical treatment with antibiotic therapy remains the mainstay of treatment for pyogenic spondylodiscitis (PS). Nevertheless, orthopaedic treatment is also very important in relieving pain, preventing neurological damage, and avoiding development of spinal deformities (e.g., scoliosis, kyphosis) due to spinal instability. Rigid thoracolumbosacral orthosis (TLSO) bracing is often needed in patients with PS, and average duration of treatment of 3 to 4 months. However, TLSO bracing can be poorly tolerated and limit ability of the patient to go back to a normal life. In 2004 our group developed an alternative surgical treatment to TLSO bracing by percutaneous posterior screw-rod bridge instrumentation of the infected level. This treatment allows early and free mobilization of the patients and is associated with faster recovery, lower pain scores and improved quality of life as previously reported. Herein, we report the clinical outcome of the first 3 patients who have completed the 10 years follow-up mark after the procedure. A case report is also described and details of the procedure are provided