Giant vertebral notochordal rest: a new entity distinct from chordoma.
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Chordoma↗
Biomedical subjects
J M Vital
Publications and source records attributed to J M Vital.
Radiolucent cage for cervical vertebral reconstruction: a prospective study of 17 cases with 2-year minimum follow-up.
In cervical spondylotic myelopathy, extended anterior spinal cord decompression necessitates subsequent stable vertebral reconstruction. Reconstruction with an iliac crest graft and screw-plate fixation gives satisfactory clinical and radiological results, but they are often compromised by morbidity involving the bone harvest. The purpose of this study was to evaluate the contribution to cervical reconstruction of a biocompatible, radiolucent cage combined with screw-plate fixation, making use of bone harvested in situ. This prospective study was performed between July 2000 and March 2001 in eight women and nine men (mean age, 55 years) operated for cervical spondylotic myelopathy. Situated between levels C3 and C6, the cage was inserted after one corporectomy in ten patients, two corporectomies in five patients, and three corporectomies in two patients. The cage consisted of a polyester mesh impregnated with poly-L-lactic acid (PLLA) conferring temporary rigidity to the cage during bony fusion. Clinical and radiological follow-up (plain films, computed tomographic reconstruction in three cases) was performed at 2 months, 6 months, 12 months, 24 months and 36 months, postoperatively, with a mean follow-up of 30 months. Functional results were evaluated according to the Japanese Orthopaedic Association's scoring system. An independent surgeon assessed the radiological evidence of anterior cervical fusion using the grades proposed by Bridwell [6]. Every patient experienced neurological recovery. At last follow-up, radiological findings were consistent with grade I (complete fusion) in five cases, grade II (probable fusion) in ten cases, grade III (radiolucent halo in favor of non fusion) in one case, and grade IV (graft lysis) in one case with persistent neck pain. In three cases there was screw breakage (two grade II, one grade IV). None of these cases required surgical revision at latest follow-up. In extensive spinal cord decompression through an anterior approach, cervical reconstruction using the present type of cage can achieve clinical results comparable to conventional techniques. The rigidity of the cage meets biomechanical imperatives. Its radiolucency permits one to monitor the course of consolidation, contrary to metal cages. The cases of probable non-fusion and screw breakage were not accompanied by signs of instability on the flexion extension films. This cage meets the biologic and biomechanical imperatives of cervical reconstruction. It obviates complications involving bone harvest.
Adult↗
Course of Modic 1 six months after lumbar posterior osteosynthesis.
STUDY DESIGN: A prospective study was conducted to investigate the outcome of the Modic Type 1 inflammatory signal in magnetic resonance imaging (MRI) in 17 patients with chronic low back pain 6 months after instrumented posterior lumbar arthrodesis. OBJECTIVE: To assess the course of the inflammatory signal after stabilization of a painful intervertebral segment by posterior instrumentation alone visualized on MRI systematically performed 6 months after the operation. SUMMARY OF BACKGROUND DATA: In 1988, Modic and colleagues described three degenerative stages of vertebral endplates and subchondral bone. The inflammatory stage, or Stage 1, is correlated with substantial functional disability. According to these authors, Stage 1 lesions naturally transform into Stage 2, the fatty stage. In the literature, patients with Modic 1 signal tend to have good results after arthrodesis, better than those with Modic 2 lesions. METHODS: This study included 17 patients (average age, 46 years) who had experienced chronic low back pain more than 1 year and showed Modic 1 changes in MRI and disc narrowing on plain radiographs. Every patient underwent posterior screw-rod osteosynthesis and posterolateral arthrodesis. Disc disease had occurred subsequently to discectomy (n = 7), rapidly destructive disc disease (n = 5), or spondylolisthesis resulting from spondylolysis (n = 5). Clinical results were assessed according to a visual analog scale for pain, a functional disability score for the evaluation of patients with low back pain (Eiffel), and the validated French version of the self-administered Dallas quality-of-life test (DRAD). RESULTS: Systematic MRI at 6 months showed transformation from Modic 1 to Modic 0 (normal endplate signal) in 4 patients and transformation from Modic 1 to Modic 2 in the remaining 13 patients. Clinical evaluation was performed at 6 months (at the same time as the MRI) and at 1 year. In every patient, there was improvement in the visual analog score and the functional score, which remained stable at 1 year. CONCLUSIONS: According to the literature, most Modic 1 lesions change to become Stage 2 lesions in 18 to 24 months. In this study, 17 patients with Modic Type 1 signal had changes after 6 months. It appears that posterior osteosynthesis combined with posterolateral arthrodesis accelerates the course of Modic 1 lesions, probably by correcting mechanical instability.
Adult↗
[Long head of the triceps brachii in axillary nerve injury: anatomy and clinical aspects].
PURPOSE OF THE STUDY: Earlier work has demonstrated possible paralysis of the long head of the triceps brachii (LTB) after surgical repair of traumatic injury to the axillary nerve. Anatomy textbooks describe the motor branch of the LTB arising from the radial nerve within the body of the triceps. We studied the position of the motor branch for the LTB to determine its exact origin. MATERIAL AND METHODS: Three groups were studied: Group I included 9 traumatic injuries of the axillary nerve associated with clinical involvement of the LTB; Group II included 20 secondary posterior trunks dissected from cadaver specimens; Group III included 15 dissections of the infraclavicular plexus with complete dissection of the secondary posterior trunk. The position of the axillary nerve injury was retrieved from the operative reports for Group I. The precise origin of the motor branch for the LTB was identified for Group II. Neurostimulation was used to identify the origin of the motor branch for the LTB in Group III. RESULTS: For Group I: injury to the axillary nerve was situated 10 mm (mean) from the bifurcation of the secondary posterior trunk in 6 cases and at the bifurcation in 3. Type IV injury was identified in 4 cases and type V in 5. For Group II: the motor branch for the LTB arose 6 mm (mean) from the bifurcation of the secondary posterior branch in 13 cases, at the bifurcation in 5, and 10 mm proximally in 2, but never from the radial nerve. For Group III: the motor branch for the LTB arose 4.5 mm (mean) from the bifurcation of the secondary posterior trunk in 11 cases, at the bifurcation in 4, and never from the radial nerve. DISCUSSION: Observed injuries to the axillary nerve with an associated paralysis of the long head of the triceps brachii were located proximally and were severe. Our dissections always located the motor branch of the LTB arising from the axillary nerve or the secondary posterior branch. We thus deducted that associated LTB paralysis is a sign of poor prognosis. In patients with axillary nerve injury it is a sign favoring a proximal and severe lesion of the axillary nerve. CONCLUSION: When examining patients with traumatic injury involving the axillary nerve, it is important to search for paralysis of the long head of the triceps brachii. If present, it is a sign of a severe axillary nerve lesion requiring early repair at 3 months.
Aged↗
Pharmacological therapy of spinal cord injury during the acute phase.
STUDY DESIGN: Prospective, randomized clinical trial. SETTING: France. OBJECTIVES: To evaluate the safety and effect on neurological outcome of nimodipine, methylprednisolone, or both versus no medical treatment in spinal-cord injury during the acute phase. METHOD: One hundred and six patients who had spinal trauma (including 48 with paraplegia and 58 with tetraplegia) were randomly separated into four groups: M=methylprednisolone (30 mg x kg(-1) over 1 h, followed by 5.4 mg x kg(-1) x h(-1) for 23 h), N=nimodipine (0.015 mg x kg(-1) x h(-1) for 2 h followed by 0.03 mg x kg(-1)h(-1) for 7 days), MN (both agents) or P (neither medication). Neurological assessment (ASIA score) was performed by a blinded senior neurologist before treatment and at 1-year follow-up. Early spinal decompression and stabilization was performed as soon as possible after injury. RESULTS: One hundred patients were reassessed at 1 year. Neurological improvement was seen in each group (P<0.0001), however no additional neurological benefit from treatment was observed. Infectious complications occurred more often in patients treated with M. Early surgery (49 patients underwent surgery within 8 h of their accident) did not influence the neurological outcome. The only predictor of the latter was the extent of the spinal injury (complete or incomplete lesion). CONCLUSION: The present study confirms the absence of benefit of pharmacological therapy in this indication. Because of the paucity of clinical studies that demonstrate the efficacy of pharmacological treatment in spinal injury during the acute phase, systematic use of pharmaceutical agents should be reconsidered.
Acute Disease↗
[Neurofibromatosis of the lower cervical spine: an operative case report].
PURPOSE OF THE STUDY: We report a case of type 1 neurofibromatosis (von Recklinghausen's disease) of the lower cervical spine in a 13-year-old girl. CASE REPORT: There was no neurological deficit. Plain films showed dysplastic 82 degrees kyphosis centered on the C4-C5 disc. Surgical treatment consisted in anterior multilevel interbody grafting and plate osteosynthesis combined with posterior arthrodesis. Good bone fusion was obtained with acceptable cervical mobility. The residual cervical kyphosis was 18 degrees. DISCUSSION: An evaluation of the cervical spine should be proposed for patients with neurofibromatosis even if there is no thoracic scoliosis. Severe cervical deformities can lead to serious neurological complications. Circumferential arthrodesis appears to provide optimum results.
Adolescent↗
[Evaluation of the efficacy of foraminal infusions of corticosteroids guided by computed tomography in the treatment of radicular pain by foraminal injection].
PURPOSE: To evaluate the efficacy of foraminal steroid injections performed under CT guidance for the management of radicular pain. METHODS: Periganglionic infiltrations were performed in 160 patients with radicular pain refractory to medical treatment. Imaging showed either degenerative foraminal stenosis, herniated disk or postsurgical fibrosis. RESULTS: 102 patients (63.8%) had significant pain reduction. Pain relief was lasting in 68 (66.6%). CT showed the position of the needle tip, as well as the diffusion of the therapeutic compounds. CONCLUSION: We consider that CT-guided periganglionic steroid injections should be an integral part of the management strategy for radicular pain resistant to medical treatment.
Adrenal Cortex Hormones↗
Reduction technique for uni- and biarticular dislocations of the lower cervical spine.
STUDY DESIGN: A technical report concerning the methods of reduction of dislocations of the lower cervical spine used in 168 consecutive cases (77 unilateral and 91 bilateral dislocations). OBJECTIVES: To evaluate the efficacy of a reduction protocol comprising three successive phases: reduction by traction, reduction by closed maneuvers with the patient under general anesthesia, and open reduction. SUMMARY OF BACKGROUND DATA: Management of cervical dislocations varies greatly among spine treatment centers, especially concerning the upper limit of traction, the safety of closed manipulations in anesthetized patients, and the approach preferred when surgical reduction is necessary. METHODS: Reduction by gradual traction without anesthesia was attempted first. In case of failure, specific closed manipulations were used with the patient under general anesthesia just before anterior arthrodesis was performed. If this failed, anterior surgical reduction was attempted. Anterior fusion was performed in every patient, even when closed reduction was successful, because of the lasting instability produced by attending ligamentous lesions. RESULTS: Of the patients in 168 cases of dislocation, the protocol failed in 5, all of whom had longstanding unilateral dislocation. Of the 91 with bilateral dislocation, reduction was achieved by simple traction in 39 (43%), by maneuvers with the patient under general anesthesia in 27 (30%), and by anterior surgery in 25 (27%). Among the patients in 77 cases of unilateral dislocation, reduction was achieved by traction in 18 (23%), by external maneuvers in 28 (36%), and by anterior surgery in 26 (34%). In 7 patients, discal herniation engendering neurologic signs was resected during anterior surgery. No neurologic deterioration during or immediately after reduction by this protocol was observed. CONCLUSIONS: This protocol consists of application of rapidly progressive traction, followed if necessary by one or two reduction maneuvers with the patient under general anesthesia. If both methods fail, specific surgical procedures using an anterior exposure seem to be reliable, in that anatomic reduction was obtained in 163 of 168 patients without neurologic deterioration.
Adolescent↗
Complications of vertebral metastasis surgery.
The authors report their experience concerning complications of spinal metastasis surgery. The purpose of this study was to assess the frequency of such complications and analyse the factors influencing their occurrence. The records of 145 patients treated between 1982 and 1991 for metastatic disease of the spine were retrospectively reviewed for intra- and postoperative complications. Other factors such as radiation therapy, emergent nature of surgery, and neurologic deficits were analysed for potential correlations with the frequency of complications. Twenty-seven (18.6%) patients developed postoperative complications. Wound dehiscence and infection (11%) were the most frequent complications. Statistical analysis showed a significant influence of three factors: preoperative radiation therapy, paraplegia before surgery, and surgery under emergency conditions. The rate of complications in this surgery is lower than might be expected and can be significantly reduced. Surgery should be performed before radiation therapy and before appearance of substantial neurologic deficits.
Combined Modality Therapy↗
[Radiotherapy of spinal metastases in breast cancer. Apropos of a series of 108 patients].
PURPOSE: Retrospective analysis of analgesic, decompressive and remineralization effects of radiation therapy for spinal metastases in breast cancer. PATIENTS AND METHODS: From January 1990 to December 1992, 108 patients with breast cancer were treated by irradiation at the Bergonié Institute for a first spinal metastasis. Three patients had undergone previous surgery (laminectomy and Doves' frame). The indication of radiation therapy was analgesic (102 patients) or decompressive (six patients). The usual irradiation scheme was 30 Gy/10 fractions/2 weeks. RESULTS: The analgesic effect was considered as 'complete' or 'almost complete' (83%), 'moderate' (13%) or absent (4%). The mean time to the maximum analgesic response was 35 days. The duration of both the analgesic response and remineralization effects could not be retrospectively assessed due to lack of data. Decompressive effects were complete in five cases and absent in one case. A second spinal radiation therapy was necessary 78 times (eight times in junction field within 6 months following the first treatment). Spinal cord compression occurred either out of (three cases) or within (one case) the irradiated field. CONCLUSION: Radiation therapy for spinal metastases in breast cancer remains a palliative analgesic treatment. Indication for decompression is rare. However, assessment of compressive 'risk' leads to discussion of radiological staging (contribution of magnetic resonance imaging) and possible previous treatment (vertebroplasty or osteosynthesis).
Adult↗
Asymptomatic cervical haemangioma treated by percutaneous vertebroplasty.
We report a 17-year-old asymptomatic patient with a partially collapsed seventh cervical vertebra due to a haemangioma revealed by conventional radiographs performed for army enrollment. Given radiological evidence of aggressiveness, percutaneous vertebroplasty by injection of methyl methacrylate cement was performed to prevent complications. CT a year later showed no progression of the lesion. The patient remains asymptomatic.
Adolescent↗
[Spontaneous vertebral pseudarthrosis in ankylosing spondylitis. Apropos of 3 cases].
PURPOSE OF THE STUDY: The authors describe the surgical treatment of three cases of vertebral pseudarthrosis in two patients suffering from rheumatoid spondylitis for an average of 20 years. MATERIAL: Two pseudarthrosis involved the thoracic level (T9-T10 and T10-T11), after an insignificant trauma. In the other case, the lesion was a secondary localization (L5-S1) arising spontaneously two years after the treatment of a T10-T11 lesion. Initial conservative treatment was unsuccessful in all three cases. Anterior surgery was performed in all three cases. In two out of the three, posterior surgery was associated with the anterior approach. RESULTS: After surgery, the three lesions healed. DISCUSSION: Extensive discovertebral lesions during the course of rheumatoid spondylitis are well known. The authors discuss the pathophysiological mechanisms, the diagnostic difficulties of such lesions in patients referred for chronic spinal pain, and the choice of treatment. CONCLUSION: Surgical treatment was considered necessary in view of the mechanical solicitations of the mobile segment. A double approach, both anterior and posterior, gave good results and is advocated by the authors.
Adult↗
[Surgery of bone metastases. Techniques and indications].
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Adult↗
Anterior discectomy without interbody fusion for cervical disc herniation.
Between 1985 and 1990, 68 patients with cervical radiculopathy due to soft disc herniation were treated by anterior cervical discectomy without interbody fusion. Eleven patients were unavailable for follow-up examination. The mean follow-up was 23 months (range 12-54 months). Both clinical and radiographic follow-ups were done, and 92% of the patients was found to have excellent or good clinical results. Radiographic follow-up revealed that 34% had fused spontaneously and 66% developed fibrous healing of the disc space with an average range of mobility of 2.07 deg. All patients were shown to be stable on flexion-extension films. Complications included two transient CSF leaks. No neurologic deficits arose. One patient was reoperated and fused for intractable residual neck pain. We conclude that anterior cervical discectomy without interbody fusion is a simple, safe and effective procedure for patients with soft disc herniation.
Adult↗
Odontoid fractures. Review of 150 cases and practical application for treatment.
A total of 150 odontoid fractures was treated over a 12-year period, 43 by anterior screw fixation. The rate of pseudarthrosis dropped from 20% to 5% in type II unstable fractures. Thus, anterior screw fixation seems to be safe and efficient, and may be more widely used to treat all type II and some type III fractures. Odontoid pseudarthrosis is usually tolerated quite well and therefore requires no correction. If necessary, anterior grafting with fixation can be proposed as an alternative for posterior fusion.
Bone Screws↗
Long-term results of cervical epidural steroid injection with and without morphine in chronic cervical radicular pain.
To evaluate the long-term effectiveness of a single cervical epidural steroid injection (CESI) performed with or without morphine, 24 patients, without need of surgery, but suffering for more than 12 months from cervical radicular pain, were included in a prospective and randomised study. The cervical epidural space was injected (C7-D1; 18-ga needle) with an increasing volume (10 ml maximum) of isotonic saline solution to exacerbate the patient's radicular pain. The patients were then randomly allocated to 2 groups: the steroid group (group S, n = 14) received an equivalent volume of 0.5% lidocaine plus triamcinolone acetonide (10 mg/ml) and the steroid plus morphine group (group S + M, n = 10) received the same combination plus 2.5 mg of morphine sulphate. Pain relief was assessed as the percentage of pain decrease on a visual analogue scale on day 1 and at months 1, 3, 6, 8 and 12 after CESI, up to 48 months. Anthropometric data between the 2 groups were similar. The mean volume injected in the epidural space was: 6.6 +/- 2.1 and 6.3 +/- 1.9 ml in groups S and S + M, respectively, and this volume exacerbated pain in 21 of 24 patients. Despite observing a better transient improvement the day after CESI in the S + M group, long-term results did not differ. The success rate was 78.5% in group S and 80% in group S + M providing pain relief of 86.8 +/- 14.7% and 86.9 +/- 17.9%, respectively. Pain relief remained stable with time (mean follow-up: 43 +/- 18.1 months).(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
[Imaging of scoliosis].
The majority of scoliosis (80%) and especially the idiopathic scoliosis are simply investigated by plain films of the entire spine with erect frontal and lateral views, and supine frontal view at the initial examination. Repeated erect frontal views are sufficient for the follow-up. The important radiation dose (average of 1.2 mG for the frontal view and 2.2 mG for the lateral views) imposes to reduce the frequency of these radiographs. This radiological study allows: to separate non structural and structural curves; the identification and the measurement of a structural curve, discussion for its etiology, appraisal of its progressiveness, discussion of the operative or non operative treatment, and radiological follow-up. Modern imaging (C.T, C.T myelography, MRI) is indicated only in very particular cases: idiopathic scoliosis with neurological symptoms, congenital scoliosis with structural vertebral abnormalities, especially these with posterior arch abnormalities, and progressive scoliosis in spinal dysplasiae. Painful scoliosis are unusual. If pain is present consideration should be given for diagnosis of an underlying lesion. In this case a relevant strategy using modern imaging becomes useful and will be discussed.
Humans↗
[A rare etiology of spinal cord compression: Gaucher disease].
Gaucher's disease is a sphingolipidosis transmitted as an autosomal trait. Bone lesions are frequent in type 1 of the disease (i.e. the adult type without neurological manifestation). We report the case of a 70-year old woman suffering from spinal lesions with vertebral collapse and spinal cord compression. Our diagnosis was based on the finding in bone samples of Gaucher cells looking like large macrophages, and on the enzymatic assay of glucocerebrosidase. New treatments, such as replacement of the deficient enzyme by placental glucocerebrosidase, are currently being evaluated.
Aged↗