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PubMed2003

Optimizing patient selection in percutaneous vertebroplasty.

Percutaneous vertebroplasty has emerged as an effective technique for treatment of painful vertebral compression fractures (VCFs) caused by osteoporosis, malignancy, and some benign bone tumors. In selecting appropriate patients for vertebroplasty, it is important to distinguish the pain caused by VCF from other numerous causes of back pain. Careful adherence to clinical and imaging selection criteria is crucial to procedural success.

Back Pain↗

PubMed2003

Percutaneous vertebroplasty: technical considerations.

Percutaneous vertebroplasty has now been in use in the United States for 10 years. Standards of practice are available from the American College of Radiology. The performance of this procedure is becoming routine for most interventional practices, and it has become the general standard of care for pain associated with vertebral compression fractures of the spine. This article describes routine procedural technique and considerations and is intended to review the authors' knowledge of the procedure and provide reliable methods for good outcomes and complication avoidance.

Analgesia↗

PubMed2004

Peripheral high-flow arteriovenous vascular malformations: a single-center experience.

PURPOSE: To assess the long-term outcomes of patients with high-flow arteriovenous malformations (HFAVMs) of the extremities. MATERIALS AND METHODS: A retrospective review was performed to identify patients with HFAVMs referred for possible intervention between 1988 and 2003. Sixteen patients with upper-limb HFAVMs and 15 patients with lower-limb HFAVMs were identified (18 men, 13 women; mean age, 36.8 years; range, 21.1-72.2 years). Arteriography, duplex imaging studies, or magnetic resonance imaging were performed in all patients. RESULTS: Follow-up was completed in 30 patients (mean duration, 3.3 years; range, 0.2-13 years), with one patient lost to follow-up. Nineteen had symptoms that warranted endovascular treatment: 13 underwent embolotherapy and six were considered unsuitable because of challenging anatomy that rendered embolization unsafe or impossible. Eleven patients' symptomatology did not warrant treatment and these patients were treated conservatively. The 13 patients treated with embolotherapy underwent a total of 27 treatment sessions (mean, 2.1 sessions per patient; range, 1-5). N-butyl cyanoacrylate and polyvinyl alcohol were used as the embolic agent in 11 and two patients, respectively. Three patients had complete resolution of HFAVM clinically and angiographically, and five patients' symptoms were controlled despite persistence of the HFAVM angiographically. Five patients had no improvement after treatment. Two major complications occurred (7.4% per session or 15.4% per patient): one patient developed a tibial plateau compression fracture and one patient had temporary L5 neuropathy after embolization of the pelvis and thigh. Of the six patients who were considered unsuitable for embolotherapy, one patient died of hepatocellular carcinoma, two had significant progression of symptoms, and the remaining three patients' symptomatology was unchanged. Only one of the nine patients with mild symptoms at presentation had symptom progression during follow-up. CONCLUSIONS: Peripheral HFAVM is a rare and therapeutically challenging condition. Patients with minimal symptoms at presentation do well with conservative treatment, and symptomatic progression is infrequent. Only patients with significant symptomatology should undergo embolization therapy, which invariably requires multiple sessions and must be aimed at eradication of the nidus.

Adult↗

PubMed2005

Does vertebral height restoration achieved at vertebroplasty matter?

PURPOSE: Altered vertebral and spinal configuration after osteoporotic vertebral compression fracture (VCF) is believed to contribute to postfracture morbidity. The objective of this study was to determine whether patients in whom partial vertebral height restoration (VHR) was achieved at percutaneous vertebroplasty had greater pain relief or improved quality of life compared with patients in whom no anatomic restoration was achieved. MATERIALS AND METHODS: Consecutive subjects undergoing percutaneous vertebroplasty for painful osteoporotic VCFs completed the Osteoporosis Quality of Life Questionnaire (OQLQ) a validated, disease specific instrument that measures health related quality of life in women with osteoporosis with back pain caused by VCF. At postoperative week 2, month 2, and month 6, all subjects completed the mini-OQLQ, a validated extraction of OQLQ. Pain was rated with a standard visual analogue scale (VAS). Radiographs were manually digitized and evaluated for the presence of dynamic mobility and VHR. The relationship between VHR achieved at percutaneous vertebroplasty and postoperative pain relief and quality of life outcome was examined by multivariate analysis. RESULTS: Forty-six subjects (32 women) underwent 49 percutaneous vertebroplasty procedures to treat 66 painful VCFs. Mean patient age was 74.3 years+/-10.9. Mean fracture age was 2.5 months+/-2.1. Pain rating fell from 7.7+/-1.8 to 2.8+/-1.8 within 1 day of percutaneous vertebroplasty and remained improved through month 6 (P<.001). All OQLQ domains improved substantially at week 2 (P<.02) and remained improved through month 6 (P<or=.007). Preoperative dynamic mobility ranged -2.9 to 19.9 mm (average, 5.5 mm). Postoperative VHR in mobile VCFs ranged -2.1 to 9.6 mm (average, 2.9 mm). At all postoperative time points up to 6 months, pain and OQLQ domain scores were similar in patients who achieved partial VHR at percutaneous vertebroplasty compared with those in whom no VHR was achieved. CONCLUSION: Partial vertebral height restoration achieved at percutaneous vertebroplasty did not result in additional pain relief or improved quality of life beyond cement fixation alone.

Aged↗

PubMed2005

Unilateral humeral lengthening in children and adolescents.

This study evaluates our early experience with unilateral humeral lengthening in children and adolescents. From 1995 till 2001, 16 cases with unilateral humeral shortening ranging from 5.5 to 15 cm were referred to our center. The cause was Erb's palsy in eight cases, epiphyseal injury in five cases and infection in three cases. The average age at operation was 13 years (range 8.5-17 years). Hybrid fixation using wires and half pins were applied to all cases to minimize the risk of operative neurovascular complications. Osteotomy was performed in the middle third of the humerus through a posterior approach. After a latent period of 5-7 days lengthening started at a rate of 0.33 mm every 8 h. At an average follow up of 3 years and 2 months (range 1 year and 4 months to 5 years and 6 months) there were 10 excellent and six good results. The average healing index was 28 days/cm. Complications included pin tract infection in all cases; radial nerve palsy in one patient whose humerus overlengthened by 2 cm but improved completely after compression; fracture of the regenerate in two cases.

Adolescent↗

PubMed1993

Effect of promethazine on lumbar vertebral bone mass in postmenopausal women.

OBJECTIVES: Work in mice suggests that the age-related loss of bone mineral noted in that species is caused by an intrinsic defect in a haematopoietic cell population which results directly or indirectly in increased bone resorption. This age-related loss of bone mineral is prevented or reversed by well-tolerated doses of promethazine HCL. The present study was undertaken to determine if promethazine would retard or reverse bone loss in postmenopausal women. DESIGN: Postmenopausal women whose spine (L2 to L4) bone mineral content (BMC) was two standard deviations below young normal values were assigned randomly to receive calcium or promethazine and calcium daily. Subjects who had been taking oral oestrogen for more than 4 years also were assigned randomly but independently to the calcium or promethazine groups. SETTING: All subjects were seen in the out-patient clinic of the Department of Medicine, School of Medicine, University of California, Los Angeles. SUBJECTS: Healthy, ambulatory postmenopausal females were recruited by word of mouth and by advertisement from the local community. Fifty-four subjects completed the first 6 months of the study and 43 completed 30 months. INTERVENTIONS: The subjects were assigned randomly to receive 1000 mg calcium daily or promethazine 50 mg and calcium 1000 mg daily throughout the period of the study. MAIN OUTCOME MEASURES: Bone mineral content of the lumbar vertebrae (L2 to L4) was determined by dual photon densitometry every 6 months. Dorsolumbar spine X-rays were obtained yearly and at the completion of the study to detect new compression fractures. RESULTS: In the groups not taking oestrogen, BMC decreased at the rate of 1.53% year-1 in the group given only calcium; in contrast, BMC increased at 3.22% year-1 in the group given promethazine and calcium (P < 0.001). Among the women taking oestrogen, increases in mean BMC were noted in both groups, but those taking promethazine and calcium had a greater rate of increase than observed in the group taking only calcium (5.62% vs. 1.97% per year-1, P < 0.001). CONCLUSIONS: These results suggest that promethazine can induce a modest increase in vertebral BMC in postmenopausal women who are not taking oestrogen and greater increases in those who are.

Absorptiometry, Photon↗

PubMed2005

Surgical management of spinal disease in renal recipients.

OBJECT AND BACKGROUND: The survival of renal recipients improved dramatically and long-term survival of renal graft patients is common, which in turn increases the chance of these patients requiring spinal surgery. However, there are few appropriate reports about the results of spine surgery on renal recipients. This study was undertaken to analyze the authors' experience of spine surgery after renal transplantation. METHODS: Thirty-two renal recipients who underwent spine surgery with regular follow-up of more than 24 months were included in this study. The patients' medical records and the radiological reports were reviewed retrospectively and their postoperative conditions were evaluated during their regular visits or by telephone. RESULTS: The mean duration from the renal transplantation to spinal surgery was 6 +/- 1.2 yr. Among spinal diseases of renal recipients, there were 23 cases of degenerative spinal diseases, seven cases of vertebral compression fracture, and two spinal cord tumors. The operation methods were conventional spine surgery with or without bone fusion (27 cases), percutaneous vertebroplasty (three cases) and tumor resection (two cases). The mean values of the Prolo scale in the preoperative (4.5 +/- 0.3) and postoperative (7.4 +/- 0.4) period showed significant clinical improvement after the operation. Postoperative renal function was not deteriorated in any patients and there were no major complications. CONCLUSION: Spine surgery can be performed with acceptable clinical results and without major complications in renal recipients. Spine surgery has no aggravating effect on the patients' renal function. Surgery is a valuable, safe option for the treatment of spinal disease in this rare distinct group of patients.

Female↗

PubMed1996

Metabolic bone disease of liver cirrhosis: is it parallel to the clinical severity of cirrhosis?

Metabolic bone disease has long been recognized in chronic liver disease, especially cholestatic or alcoholic liver diseases. The aim of the present study was to investigate the prevalence and severity of osteodystrophy in cirrhotic men and the correlation of its incidence with the clinical severity of cirrhosis in an endemic area of post-necrotic hepatitis. We measured serum levels of osteocalcin, 25-hydroxyvitamin D, parathyroid hormone mid-molecule, calcium and testosterone in 74 cirrhotic men (Child-Pugh's classification grade A n = 30, B n = 21 and C n = 23) and 16 healthy controls. Standard X-rays and bone mineral densities of lumbar spine were performed in 30 patients with post-necrotic cirrhosis and 10 healthy controls. Serum levels of osteocalcin, parathyroid hormone and testosterone were significantly lower in patients with cirrhosis than in controls. Changes paralleling an increased severity of cirrhosis were found in serum levels of 25-hydroxyvitamin D and testosterone, but not in the serum levels of osteocalcin and parathyroid hormone. The lumbar bone mineral density was significantly lower in patients with post-necrotic cirrhosis than in controls (0.97 +/- 0.13) vs 1.07 +/- 0.12 g/cm2, P < 0.05) and was correlated with serum 25-hydroxyvitamin D levels (r = 0.467; P < 0.005). There was no correlation between the bone mineral density and serum osteocalcin or the clinical severity of cirrhosis. The prevalence of spinal osteoporosis, as defined by a lumbar bone mineral density greater than two standard deviations below the mean value of the controls, was 20% in cirrhotic patients compared with 10% in controls. Two (6.7%) patients (both grade C) had spinal compression fractures compared with none in the control group. In conclusion, serum osteocalcin and lumbar bone mineral density were significantly lower in cirrhotic men than in controls. However, they were not correlated with each other or the clinical severity of cirrhosis.

Aged↗

PubMed1990

Osteopenia in pregnancy during long-term heparin treatment: a radiological study post partum.

Osteopenia, sometimes with compression fractures of the spine, is a side-effect of long-term heparin treatment. The frequency is unknown. In this study, 70 women were given subcutaneous heparin as therapy for, or prophylaxis against, thromboembolism during pregnancy. All, except two, were examined by X-ray of the spine and hip first week post partum. The duration of treatment and the dosage of heparin varied. There were 12 (17%) with obvious osteopenia, including two women with multiple fractures of the spine (3%). Re-examination 6-12 months post partum showed that the changes were reversible in most cases. Another 18 women were examined about three years after heparin treatment during pregnancy. No obvious osteopenia was found among them or in a control group of 30 women examined in the first week post partum. The degree of osteopenia was not correlated with either the heparin dose or the duration of treatment. Women treated with heparin in consecutive pregnancies do not seem to have an increased risk of osteopenia.

Adult↗

PubMed1977

Symposium on arthritis in older persons. Section III. Osteoarthritis and back pain. Examination of the back in the geriatric patient.

Older people often complain of back pain, but it usually is not a major complaint except in the presence of serious disease such as malignancy, compression fractures from osteoporosis, or disc-space infections. When back pain is a serious symptom in the elderly patient, the physician should look beyond the obvious evidences of degenerative joint disease for these other more serious conditions. Satisfactory examination of the back does not require an undue amount of time. It is important that it be done systematically. Simple, rapid, and adequate procedures are described.

Aged↗

PubMed1998

The morbidity of bone disease in thalassemia.

As thalassemia patients age, bone disease becomes a serious cause of morbidity. The frequency and type of bone disease is affected by the underlying type of thalassemia and its treatment. Problems include rickets, scoliosis, spinal deformities, nerve compression, fractures and severe osteoporosis. In early stages, patients may be asymptomatic but can present with back pain, a limp, dyspnea, neurological emergencies, or sudden fractures. The etiologies are often multifactorial, culminating with increased bone resorption and remodeling. They include hormonal deficiency, bone marrow expansion, nutritional deficiency, or desferal toxicity. Particular risk factors include older patients, low baseline hemoglobin, delayed puberty, hormonal failure, and high iron stores. Nutritional deficiencies may further compound the patient's risk for bone disease. Increasing evidence suggests that these complications and their associated long-term morbidity can be prevented if an annual screening is done, followed by long-term intervention. Patients treated with amino biphosphonates inhibit bone resorption and may demonstrate rapid healing. Intra-nasal calcitonin has also been successful in treating osteopenia. Early use of estrogen and testosterone appears to markedly lower the risk for selective patients. Both transfused and non-transfused patients should be educated about risk factors and early symptoms. All patients should be screened annually for bone disease. Once adolescence occurs, annual testing in selected cases should include bone density studies with X-ray absorptiometry.

Adolescent↗

PubMed2006

Intravenous pamidronate treatment of infants with severe osteogenesis imperfecta.

OBJECTIVE: Children with the severe forms of osteogenesis imperfecta have in several studies been treated with intravenous pamidronate, but there are only few reports of the effect of early treatment. AIM: To evaluate the effect of treatment started in infancy. METHODS: In a prospective observational study, with a historic control group, intravenous disodium pamidronate (APD) was given as monthly infusions to 11 children with osteogenesis imperfecta aged 3-13 (median 3.6) months, who had severe osteogenesis imperfecta with congenital bowing of the femora and vertebral compression fractures. RESULTS: During treatment of children aged between 3 and 6 (median 4.5) years, dual-energy x ray absorptiometry measurements of the lumbar spine showed a gradual increase in bone density. Bone metabolism parameters in serum (alkaline phosphatase, osteocalcin, procollagen 1 carboxy-terminal peptide, collagen 1 teleopeptide) and in urine (deoxypyridinoline) indicated a decrease in bone turnover. An improvement of mobility was seen and at the latest recording, at the age of 3.3-6.5 (median 4.8) years, the children could all walk. Vertebral remodelling was seen, with increased vertebral height, and no child developed scoliosis, kyphosis or basilar impression. All children required femoral intramedullar rods for fractures, and five needed tibial rodding for extreme curvatures that prevented functional standing and walking. No adverse effects were seen on growth, fracture healing or blood chemistry. CONCLUSIONS: APD is an efficient symptomatic treatment for infants with severe osteogenesis imperfecta, but additional orthopaedic surgery is often needed. Early treatment may prevent scoliosis and basilar impression. Long-term follow-up is important.

Absorptiometry, Photon↗

PubMed2000

Intravenous pamidronate in juvenile osteoporosis.

AIMS: To investigate the use of the aminobisphosphonate, disodium pamidronate, in children with vertebral osteoporosis. METHODS: Five children (aged 10-15 years) with vertebral osteoporosis who developed compression fractures in the thoracic and/or lumbar spine as a consequence of five different conditions, received treatment with intravenous disodium pamidronate in doses ranging from 0.5 to 12 mg/kg/y. RESULTS: Each child had rapid pain relief following the first treatment, followed by large increments in lumbar spine bone density over one year; the change in bone density standard deviation score ranged from 0.5 to 2.5 with percentage increments of 26% to 54%. CONCLUSION: Intravenous pamidronate appears to be a useful therapeutic option in childhood osteoporosis, but its use in children must still be regarded as experimental and therefore closely monitored.

Absorptiometry, Photon↗

PubMed1980

Heparin-induced osteopenia in pregnancy.

Multiple vertebral compression fractures occurred in a pregnant woman receiving heparin over nine months. This phenomenon may be more common than is clinically recognised and warrants careful re-examination of the indications and method of administration of anti-coagulants during pregnancy.

Adult↗

PubMed1968

Seat-belt injuries.

The drivers and passengers of two cars which collided head-on all wore lap and diagonal seat-belts. Three of the four suffered ruptured viscera and two incurred flexion-compression fractures of the neck.A victim of a traffic accident who was wearing a seat-belt and who has superficial bruising or pain presents a difficult diagnostic problem. Visceral injury should be suspected in such cases.

Abdominal Injuries↗

PubMed2004

Stabilisation of scoliosis in two koi (Cyprinus carpio).

Two koi (Cyprinus carpio) from the same pond developed similar lesions of scoliosis. Radiographic examinations showed that their spines had become malaligned as a result of vertebral compression fractures involving T14 to T16. The vertebrae in both fish were stabilised with screws, k-wire and polymethylmethacrylate. They both appeared to improve after surgery, but they began to decline and died within three months. A postmortem examination revealed multi-organ inflammation that was not associated with the surgical implants.

Animals↗

PubMed1989

Non-neoplastic lesions of vertebral bodies: findings in magnetic resonance imaging.

This paper presents examples of non-neoplastic lesions of the spine that produce focal or diffuse signal alterations on MR images, and that may, therefore, be confused with metastases or primary neoplasms. Examples include endplate changes associated with degenerative disk disease, hemispherical spondylosclerosis, osteoporotic compression fractures, Paget's disease, focal and diffuse fatty infiltration, osteomyelitis, and changes associated with various arthritides. Distinguishing signal intensity characteristics on T1 and T2 weighted images and distinctive morphology are emphasized.

Fractures, Bone↗

PubMed2004

Primary vertebral osteosarcoma: imaging findings.

PURPOSE: To evaluate patient age and sex and location and imaging appearances of primary vertebral osteosarcoma (PVOS) compared with histologic subtypes. MATERIALS AND METHODS: Retrospective review (1915-2001) of imaging findings in patients with histologically proved primary osteosarcoma of vertebral column was performed. Two radiologists in consensus reviewed findings for location, origin site, matrix pattern, and spinal canal invasion and compared them with histologic subtypes. Radiation-induced, Paget, metastatic, and multifocal osteosarcoma were excluded. RESULTS: Of 4,887 osteosarcoma cases, 198 (4%) were PVOS arising from vertebral column. There were 103 female and 95 male patients (age range, 8-80 years; median age, 34.5 years). Involvement included cervical (27 patients), thoracic (66 patients), lumbar (64 patients), and sacral (41 patients) spine. Adequate imaging findings were available in 69 patients, and involvement of two levels was seen in 12 (17%). In nonsacral spine, most tumors (44 cases) arose from posterior elements, with partial involvement of vertebral body. Lesions confined to vertebral body were less frequent (12 cases). Sacral tumors involved body and sacral ala. The most common histologic subtypes were osteoblastic (47 patients), chondroblastic (12 patients), telangiectatic (four patients), fibroblastic (four patients), small cell (one patient), and epithelioid (one patient). The majority (55 cases) demonstrated osteoid matrix mineralization; 17 showed marked mineralization. Five cases with marked mineralization were confined to vertebral body, with "ivory vertebra" appearance. Purely lytic pattern was seen in 14 (20%) cases. Lytic pattern was seen in four (100%) telangiectatic, three (75%) fibroblastic, three (25%) chondroblastic, three (6%) conventional osteoblastic, and one (100%) small-cell subtypes. Invasion of spinal canal was common (84% of cases). Appearance simulating osteoblastoma without soft-tissue mass was present (seven cases). Pathologic compression fractures were identified (seven patients). CONCLUSION: This study provides age and sex distribution and location and imaging features in a large series of PVOS.

Adolescent↗