Ricardo Díaz-Romero Paz

Background Osteoporosis (OP) represents a great challenge for the spine surgeon. Despite having effective pharmacological treatments for OP and surgical technical innovations, the awareness of spine surgeons regarding OP seems low. The purpose of this research was to assess practice patterns on the diagnosis and treatment of spine surgeons regarding OP. Methods An electronic survey of ten multiple-choice questions was administered to members of the European Association of Neurosurgical Societies (EANS). The survey asked about the specialty, the workplace, and practice patterns and attitudes regarding OP and spine fusion surgery, pseudoarthrosis, and vertebral compression fractures (VCF). Results A total of 122 surgeons completed the survey. In patients with suspected OP, 31.4% of surgeons would refer the patient to the OP specialist before surgery and 21.5% chose to perform the surgery without additional studies. A 66.4% of respondents would modify the surgical strategy in the case of OP. The most popular surgical techniques elected were cemented augmented screws (77.9%) and long-segment instrumentation (45.1%). Regarding pseudoarthrosis, 29.5% of surgeons opted to refer to the OP specialist, and 23.8% didn9t consider any additional studies Concerning VCF management, 41.32% of respondents would refer the patient for treatment of OP, and the most common therapeutic strategy was conservatively treatment for 4 to 6 weeks and vertebroplasty or kyphoplasty if no improvement (55.74%). There was a higher proportion of surgeons that would not consider preoperative studies or referring patients with suspected OP for spine surgery (χ² = 4.48, p =0.03) and pseudoarthrosis (χ ²= 9.5, p =0.002) compared to VCF. Conclusions There was a greater awareness regarding optimizing OP management in VCF compared to patients with suspected OP for spine arthrodesis or pseudoarthrosis. There still opportunities for improvement for the timely diagnosis and treatment of OP in spine surgery patients.

Study Design: A cross-sectional study. Objectives: To investigate the prevalence of poor bone quality in patients requiring spine surgery through comprehensive evaluation with bone mass density (BMD), trabecular bone score (TBS), FRAX, and vitamin D status. Methods: we prospectively recruited patients of > 50 years old candidates for lumbar or cervical spine fusion surgery at our institution. Recorded data were: demographic, body mass index (BMI), risk factors for osteoporosis, daily calcium intake, FRAX score, disability index for lumbar and cervical spine, and VAS for pain. Serum 25 OH vitamin D, BMD using DXA, and TBS was also evaluated. Results: A total of 104 patients were recruited, osteoporosis by BMD was detected in 9.6%, and osteopenia in 34.6% of patients. 69.4% of patients with osteopenia had a degraded or partially degraded bone microarchitecture by TBS. Low levels of vitamin D were detected in 79.8% of patients. Increased pain was associated with low BMD levels. Adding TBS to BMD for the determination of bone strength resulted in 33.7% of patients with poor bone quality. Lastly, the combination of BMD, TBS, and FRAX revealed 37,5% of patients with poor bone quality. Conclusions: Poor bone quality and low vitamin D levels are quite common among patients aged ≥ 50 years undergoing spine surgery. DXA alone seems not enough for preoperative identification of impaired bone quality cases. FRAX is useful for identifying high-risk patients and TBS is a valuable complement to DXA by adding the dimension of bone quality.

La prevalencia de osteoporosis en pacientes sometidos a cirugía de raquis se ha estimado en el 50% de las mujeres de más de 50 años, cifra superior a la de la población en general ajustada por edad. Consecuentemente, muchos autores recomiendan la evaluación sistemática y el tratamiento oportuno de la osteoporosis en la mayoría de pacientes que se van a someter a una cirugía de artrodesis. La disminución de la densidad mineral ósea (DMO) es el principal factor de riesgo independiente relacionado con el fracaso de la instrumentación en las cirugías de fusión lumbar. Las complicaciones derivadas de la cirugía de fusión vertebral son más frecuentes en pacientes mayores de 65 años y osteoporóticos. Las complicaciones tempranas más frecuentes son el pullout o arrancamiento de los tornillos pediculares, la fractura pedicular y la fractura por mecanismo de compresión en el segmento vertebral adyacente. Después de los 3 meses, las complicaciones más frecuentes son la pseudoartrosis, la fractura o la movilización de las barras, la subsidencia de cajas intersomáticas vertebral y la cifosis de la unión proximal. Existen algunos ensayos clínicos de cirugía de artrodesis de columna con tratamiento perioperatorio con alendronato, ácido zoledrónico, o teriparatida que han demostrado ser efectivos en la mejoría clínica y el incremento de las tasas de fusión. Existen diversas modificaciones en el arsenal quirúrgico que pueden mejorar las tasas de fusión y disminuir las complicaciones quirúrgicas, a destacar la artrodesis con tornillos pediculares cementados y tornillos expansibles. Finalmente existen ensayos clínicos aleatorizados que han demostrado que los tratamientos de refuerzo vertebral en fracturas vertebrales osteoporóticas son claramente beneficiosos a corto y a largo plazo.

The vast majority of melanomas of the CNS appear as a result of metastases. The primary spinal melanoma is a very rare entity with only 60 cases reported in the literature. A case of 41-year-old man with acute cauda equina syndrome is presented. The MRI reveals an intradural lesion from T12 to L3 on T1-weighted was heterogeneous hyperintense and homogeneous hypointense on T2, The differential diagnosis included spinal subdural hematoma and intradural pigmented tumor. An urgent thoracolumbar laminectomy from T11 to L3 was performed, an extensive dark tumor mixed with hemorrhage from T12 to L3 was found, due to an infiltrative dissemination of the tumor a subtotal resection was achieved. In the postoperative period the patient improved of cauda equina syndrome, the histologic analysis confirmed the diagnosis of a malignant melanoma. The patient underwent fractioned radiotherapy and chemotherapy, nevertheless 4 months later suffered from multiple cerebellar metastases with a fatal outcome. There are three reports of primary spinal melanoma located at cauda equina, none with a complete cauda equina syndrome neither with such rapid clinical deterioration and extension as the present case had. The primary spinal melanoma is a very rare entity, radiologic features on MRI may vary due to paramagnetic susceptibility effect of the melanin and intratumoral hemorrhage what makes pathological examination essential for diagnosis. Complete surgical excision should be attempted whenever is possible, in most cases radiotherapy and chemotherapy are indicated and the prognosis is variable probably influenced by the grade of dissemination of the tumor at the time of the diagnosis.

The principal objective of this study was to evaluate the incidence of adjacent-segment degeneration (ASD) in patients who underwent cervical disc arthroplasty (CDA) as compared with anterior cervical discectomy and fusion (ACDF). It is a prospective cohort study of patients with a single-level cervical degenerative disc disease from C3 to C7 who underwent CDA or ACDF between January 2004 and December 2006, with a minimum follow-up of 3 years. The patients were evaluated pre- and postoperatively with the visual analog scale (VAS), the neck disability index (NDI), and a complete neurological examination. Plain radiographic assessments included sagittal-plane angulation, range of motion (ROM), and radiological signs of ASD. One hundred and five patients underwent ACDF and 85 were treated with CDA. The postoperative VAS and NDI were equivalent in both groups. The ROM was preserved in the CDA group but with a small decreased tendency within the time. Radiographic evidence of ASD was found in 11 (10.5%) patients in the ACDF group and in 7 (8.8%) subjects in the CDA group. The Kaplan–Meier survival analysis for the ASD occurrence did not reach statistically significant differences (log rank, P = 0.72). Preservation of motion in the CDA patients was not associated with a reduction of the incidence of symptomatic adjacent-segment disease and there may be other factors that influence ASD.