Vertebral Augmentation Compared to Conservative Treatment of Vertebra Plana and High-Degree Osteoporotic Vertebral Fractures: A Review of 110 Fractures in 100 Patients.

This is a retrospective study that evaluated surgical versus non-surgical treatment of 100 patients followed for up to six years diagnosed with severe osteoporotic vertebral compression fractures (VCF). Fractures were classified by percent collapse of vertebral body height as "high-degree fractures" (HDF) (>50%) or vertebra plana (VP) (>70%). A total of 310 patients with VCF were reviewed, identifying 110 severe fractures in 100 patients.

Re-expansion and Stabilization of Vertebra Plana Fractures Using Bilateral SpineJack® Implants.

The surgical treatment of osteoporotic vertebral fractures with greater than 70% collapse, known as "Vertebra Plana (VP)" has been controversial. Originally VP was a considered a contraindication to vertebroplasty or kyphoplasty because of presumed difficulty of entering the collapsed vertebra as well as obtaining significant re-expansion or correct associated sagittal kyphosis. In some cases, multilevel pedicle screw fixation with or without attempts to correct the collapse is still performed to correct the kyphosis or prevent progression.

The Use of SpineJack Intravertebral Implant for the Correction of Recurrent Vertebral Fracture After Kyphoplasty.

This report presents a case of short-term symptomatic failure with continued vertebral collapse after a T12 kyphoplasty for an acute fracture in a severely osteoporotic elderly patient. The original trajectory of the unilateral balloon and subsequently injected bone cement failed to fill the fracture, allowing further vertebral collapse that resulted in a rapid return of pain. Within 30 days, a titanium intravertebral body implant, SpineJack® (Stryker Corp, Kalamazoo, MI), combined with injection of polymethylmethacrylate (PMMA) bone cement, was placed in the collapsed area.

The Role of Minimally Invasive Spinal Surgical Procedures in the Elderly Patient: An Analysis of 49 Patients Between 75 and 95 Years of Age.

As the population gets older, yet remains active, the number of patients presenting with symptomatic spinal disease over the age of 75 increases. These include pain from osteoporotic spinal fractures, lumbar degenerative disease, as well as radiculopathy or neurogenic claudication from stenosis over the age of 75 and older increases. While some of these patients are very healthy, taking minimal medication, many are not good candidates for more invasive surgical procedures under general anesthesia because of medical co-morbidities such as insulin-dependent diabetes and medication use such as anti-coagulants.

Cauda Equina Syndrome in a Patient with Intradural Schwannoma at the Same Level as an Acute L2 Compression Fracture.

Intradural tumors are found often as either incidental findings or during evaluation during magnetic resonance imaging (MRI) for lumbar and/or radicular pain. This patient presented with an acute L2 compression fracture, however, the initial MRI identified a large spinal mass separate from the fracture but at the same level. The patient had acute upper lumbar pain after a fall but the neurologic examination also revealed findings of early cauda equina syndrome with muscle weakness, asymmetric leg numbness, and urinary incontinence.

The Use of Vertiflex® Interspinous Spacer Device in Patients With Lumbar Spinal Stenosis and Concurrent Medical Comorbidities.

The use of the Vertiflex® interspinous spacer is a recent minimal invasive procedure useful in the treatment of lumbar spinal stenosis (LSS). It is used mostly by interventional pain physicians who can also perform the minimally invasive lumbar decompression (MILD procedure). Previously when a patient had clinical symptomatic neurogenic claudication (NC) and radiologic findings of lumbar stenosis and had failed conservative treatment, the options were decompressive laminectomy, laminectomy with pedicle fixation at one or more levels or laminotomy combined with interlaminar stabilization (Coflex® implant).

Treatment of a High-risk Thoracolumbar Compression Fracture Using Bilateral Expandable Titanium SpineJack Implants.

In this case, an 80-year-old active patient developed an acute osteoporotic fracture after a fall at L1 above a previous interlaminar implant at L4-5 for stenosis with neurogenic claudication. Radiologic studies found both intra-discal and intra-vertebral vacuum clefts that are highly correlated with instability and progressive kyphosis. Long-term experience with kyphoplasty has shown that acute and subacute fractures can often be re-expanded; however, over three months to one year, the correction is frequently lost and the vertebral height continues to decrease leading to increased risk of both continued deformity and especially adjacent level fractures.

Re-expansion of Osteoporotic Compression Fractures Using Bilateral SpineJack Implants: Early Clinical Experience and Biomechanical Considerations.

Thoraco-lumbar osteoporotic compression fractures have a higher incidence of continued collapse with development of deformity and progression to vertebra plana when untreated and even after vertebral augmentation (VA) or balloon kyphoplasty (BKP). Even when there is the restoration of height and improvement in angulation, multiple long-term follow-up series have repeatedly documented that over time, many patients lose the initial height correction and in a smaller group the vertebral body re-collapses leading to the development of progressive deformity with an increased risk for adjacent level fractures. At first, larger balloons and more cement were used to try and avoid these problems, but it did not reduce the risk of adjacent fractures.

An Unusual Vertical T12 Fracture Extending into the T12-L1 Disc in a Patient with Diffuse Idiopathic Spondylotic Hyperostosis: A Case Study Using Vertebroplasty to Stabilize the Fracture.

Osteoporotic spinal fractures are seen above previous spinal instrumentation and also found in patients with diffuse idiopathic spondylotic hyperostosis (DISH). In both situations, there is marked spinal rigidity with a limited mobile spinal section that is vulnerable to motion and subsequent fracture with no or minimal trauma especially when there is concurrent osteoporosis. This is an unusual case where the patient developed a vertical anterior avulsion type fracture of T12 through a large bridging spondylotic ventral spur of bone, resulting in severe positional pain above a previous lumbar instrumented fusion.

Radiologic Evaluation Of Lumbar Spinal Stenosis: The Integration Of Sagittal And Axial Views In Decision Making For Minimally Invasive Surgical Procedures.

Radiologic findings in combination with clinical symptoms are critical in the diagnosis and evaluation of the severity of lumbar spinal stenosis (LSS) as well as the need for surgical treatment. Dynamic radiographs, computerized tomography (CT), and magnetic resonance imaging (MRI) each provide different but interrelated pieces of information in the patient with lumbar spinal stenosis. Making a treatment decision based only on one of the radiographic studies may negatively affect the treatment outcome.

The Association of Iliac and Sacral Insufficiency Fractures and Implications for Treatment: The Role of Bone Scans in Three Different Cases.

Iliac wing fractures are under-diagnosed fractures often associated with sacral insufficiency fractures in osteoporotic patients. They are rarely seen alone. Insufficiency fractures of the iliac bone can often be missed on computerized tomography (CT) and magnetic resonance imaging (MRI) yet identified on radioisotope bone scans.

Two Cases with Incidental Finding of Large Asymptomatic Intradural Lumbar Tumors.

Benign lumbar intradural tumors are statistically uncommon and usually present with complaints of back pain with or without radicular neurological complaints. This report involves two separate patients that were found incidentally to have large intradural tumors without any neurologic complaints. In both cases the tumors were discovered when having magnetic resonance imaging (MRI) after minor auto accidents.

Radiologic Evaluation of Chronic Vertebral Compression Fractures and Role of Vertebral Augmentation.

The literature has classified chronic vertebral compression fractures (VCF) as those still "symptomatic" four or more months after onset. Pain is regarded as the predominant chronic symptom; however, radiologic changes are important in evaluating fracture progression. This review examines a series of patients with chronic fractures and both persistence of spinal pain combined with radiologic changes, such as worsening collapse, spinal angulation, the development of vertebral edema and clefts, as well as the development of new fractures at adjacent spinal levels.

Evaluation of CyberKnife Radiosurgery for Recurrent Trigeminal Neuralgia.

Stereotactic radiosurgery (SRS) has evolved as an accepted treatment for medication resistant trigeminal neuralgia. Initial results are very good but follow-up over three to five years shows a gradual return of pain in up to 50% of treated patients, often requiring further treatment. The results with repeat SRS using the isocentric Gamma Knife (GK) (Elekta, Stockholm, Sweden), especially in patients having initially good results, are very similar to the outcomes after the initial treatment although there is an increased risk of residual facial numbness secondary to the additional radiation dose to the trigeminal nerve.

Direct Posterior Bipolar Cervical Facet Radiofrequency Rhizotomy: A Simpler and Safer Approach to Denervate the Facet Capsule.

Radiofrequency cervical rhizotomy has been shown to be effective for the relief of chronic neck pain, whether it be due to soft tissue injury, cervical spondylosis, or post-cervical spine surgery. The target and technique have traditionally been taught using an oblique approach to the anterior lateral capsule of the cervical facet joint. The goal is to position the electrode at the proximal location of the recurrent branch after it leaves the exiting nerve root and loops back to the cervical facet joint.

Selection of Tubular and Endoscopic Transforaminal Disc Procedures Based on Disc Size, Location, and Characteristics.

The clinical effectiveness of percutaneous and transforaminal endoscopic discectomy procedures has been evaluated by the system used or compared to open laminectomy or micro-discectomy but are not evaluated based on the location and characteristics of the abnormal disc. This review proposes that outcomes are primarily related to disc size, biomechanics, location, and associated segmental fibrotic and bone changes as well as the surgeon's skill in using various systems rather than the specific system used. In these cases, the surgeon needs to decide if the goal of the procedure is simply internal decompression of an abnormal but contained herniated disc or release of the entrapped nerve root by a large contained disc, extruded and migrated disc fragment, or coexistent foraminal stenosis.

Oral Squamous Cell Carcinoma Found Inline with the Fields of Repeat Stereotactic Radiosurgery for Recurrent Trigeminal Neuralgia.

A case of an extremely healthy, active, 96-year-old patient, nonsmoker, is reviewed. He was initially treated for left V1, V2, and V3 trigeminal neuralgia in 2001, at age 80, with stereotactic radiosurgery (SRS) with a dose of 80 Gy to the left retrogasserian trigeminal nerve. He remained asymptomatic for nine years until his trigeminal pain recurred in 2010.

Multilevel Contiguous Osteoporotic Lumbar Compression Fractures: The Relationship of Scoliosis to the Development of Cascading Fractures.

Osteoporotic patients can present with either single or multiple fractures secondary to repeated falls and progressive osteoporosis. Multiple fractures often lead to additional spinal deformity and are a sign of more severe osteoporosis. In the thoracic spine, multiple fractures are associated with the development of gradual thoracic kyphosis but neurologic deficits are uncommon.

Use of Spinal Cord Stimulation in Elderly Patients with Multi-Factorial Chronic Lumbar and Non-Radicular Lower Extremity Pain.

Spinal cord stimulation (SCS) is an effective treatment for chronic back and limb pain. The criteria for use of SCS for specific problems such as failed back surgery syndrome (FBSS), peripheral neuropathic pain and residual pain after joint replacement is well established. With an aging population, there are more patients presenting with a combination of various multi-factorial chronic pain problems rather than from a single clear cause.

Bilateral Peripheral Nerve Field Stimulation for Intractable Coccygeal Pain: A Case Study Using Dual Lead Intercommunication.

Coccygeal pain is a difficult chronic pain problem with mixed response to various treatments. This is a report of a case of coccygeal pain that after failing various conservative and interventional procedures over five years was evaluated with a temporary peripheral sacral fascial lead followed by implantation of bilateral sacral paramedian leads for peripheral nerve field stimulation (PNFS). This resulted in marked pain control and resumption of full activity.

Progression of Vertebral Compression Fractures After Previous Vertebral Augmentation: Technical Reasons for Recurrent Fractures in a Previously Treated Vertebra.

It is well recognized that patients can develop additional vertebral compression fractures (VCF) in an adjacent vertebra or at another vertebral level after successful vertebral augmentation. Factors such as the patient's bone mineral density, post procedure activity, and chronic corticosteroid use contribute to an increased risk of re-fracture or development of new fractures in the first three months after the initial procedure. However, there is a very small subgroup of patients that have unchanged or worse pain after the vertebral augmentation that may indicate continued progression of the treated compression fracture or a recurrent fracture at the previously treated level.

Vertebral Compression Fractures after Lumbar Instrumentation.

Lumbar spinal stenosis (LSS) is primarily found in an older population. This is a similar demographic group that develops both osteoporosis and vertebral compression fractures (VCF). This report reviewed a series of patients treated for VCF that had previous lumbar surgery for symptomatic spinal stenosis.

Bipolar Radiofrequency Facet Ablation of the Lumbar Facet Capsule: An Adjunct to Conventional Radiofrequency Ablation for Pain Management.

Radiofrequency facet ablation (RFA) has been performed using the same technique for over 50 years. Except for variations in electrode size, tip shape, and change in radiofrequency (RF) stimulation parameters, using standard, pulsed, and cooled RF wavelengths, the target points have remained absolutely unchanged from the original work describing RFA for lumbar pain control. Degenerative changes in the facet joint and capsule are the primary location for the majority of lumbar segmental pathology and pain.

Delayed Development of Trigeminal Neuralgia after Radiosurgical Treatment of a Tentorial Meningioma.

Trigeminal neuralgia is a known symptom of the tumors and aberrant vessels near the trigeminal nerve and the tentorial notch. There are very few reports of delayed development of trigeminal neuralgia after radiosurgical treatment of a tumor in these areas. This is a case report of a patient treated with radiosurgery for radiation induced meningiomas, 30 years after childhood whole brain radiation.

Baastrup's Disease, Interspinal Bursitis, and Dorsal Epidural Cysts: Radiologic Evaluation and Impact on Treatment Options.

Baastrup's disease or "kissing spines syndrome" was first described as a cause of lumbar pain before computerized tomography (CT) and magnetic resonance imaging (MRI) scanning existed. The diagnosis was based on x-ray studies, which showed that the spinous processes, especially in the lower lumbar spine, became approximated to each other and this was a generator of positional back pain. Biomechanically, the interspinous and supraspinous ligaments that are degenerated in Baastrup's disease normally contribute significantly to sagittal alignment.