Sudden death caused by spinal cord injury associated with vertebral fractures and fetlock failure in a Thoroughbred racehorse

The most prevalent causes of death in racehorses are musculoskeletal injuries, causing ~83% of deaths within the racing industry in California and elsewhere. The vast majority of these injuries have preexisting lesions that predispose to fatal injury. A 4-y-old Thoroughbred colt suffered an acute suspensory apparatus failure, including biaxial proximal sesamoid bone fractures of the right front fetlock, causing loss of support of the fetlock joint and consequent fall with fractures of the cervical and sacral spine. Cervical fracture caused spinal cord damage that resulted in sudden death. A preexisting lesion in the medial proximal sesamoid bone likely predisposed to complete fracture of this bone and fetlock breakdown. Interestingly, a comparable osteopenic lesion was present in the intact medial proximal sesamoid bone of the left forelimb, which is consistent with bilateral repetitive overuse injury in racehorses. The morphologic features of the cervical and sacral spine fractures were compatible with acute injury; no evidence of preexisting lesions was seen. Most likely, these acute vertebral fractures occurred as a result of the horse falling. This case emphasizes the importance of performing a detailed autopsy in horses that suffer an appendicular musculoskeletal injury, particularly in fatal cases when the horse dies following a leg injury.

Comparison of Ray Tracing and Monte Carlo Calculation Algorithms for Spine Lesions Treated with CyberKnife

Purpose: This study attempts to evaluate Ray Tracing (RT) and Monte Carlo (MC) algorithm for CyberKnife treatments of spine lesions and determine whether MC algorithm is necessary for all spine treatment and analyze which sites of spine lesion for which RT algorithm is comparable to MC algorithm. Methods: The CyberKnife is used for stereotactic body radiotherapy for lesions in the cervical spine (30), thoracic spine (50), lumbar spine (30) and sacral spine (15). Dose was calculated using RT and MC algorithms for patients planned with the same beam angles and monitor units. Dose-volume histograms of the target and selected critical structures are evaluated. Results: The average target coverage of prescribed dose with MC algorithms was 94.80%, 88.47%, 92.52% and 93.41% respectively in cervical, thoracic, lumbar and sacral spine. For thoracic spine, RT algorithm significantly overestimates the percentage volume of target covered by the prescribed dose, as well as overestimates doses to organs at risk in most cases, including lung, spinal cord and esophagus. For cervical, lumbar and sacral spine, the differences of the target coverage of prescription dose were generally less than 3% between the RT and MC algorithms. The differences of doses to organs at risk varied with lesion sites and surrounding organs. Conclusions: In the thoracic spine lesions with beams through air cavities, RT algorithm should be limited and verified with MC algorithm, but the RT algorithm is adequate for treatment of cervical, lumbar and sacral spine lesions without or small amount of beams passing through the lungs.

Incidence of pressure ulcer in patients using an alternating pressure mattress overlay: the ACTIVE study

Objective: The primary objective was to determine the clinical benefit of using a specific alternating-pressure mattress overlay (APMO) in the prevention of pressure ulcer (PU) in patients at medium to high risk. Method: This prospective study was conducted in five rehabilitation centres and three nursing homes. Patients at medium to high risk of PU, but without PU at baseline, and lying between 15 and 20 hours per day on a specific APMO were included. The primary endpoint was the percentage of patients who developed a sacral, spine, heel or trochanteric PU (supine support areas) of at least category II, at day 35. All patients were included in the analysis. Results: A total of 89 patients were included; of whom six patients (6.7%) dropped out of the study (average (±standard deviation) follow-up 32±5.4 days). No sacral, spine, heel or trochanteric PU of at least category II was reported (i.e., an incidence of 0% [95% Confidence Interval: 0–4.1%] according to the exact Clopper–Pearson method]. Patients were ‘satisfied’ or ‘very satisfied’ with the comfort and stability of the APMO. The caregivers assessed as ‘very easy’ or ‘easy’ the implementation, maintenance and use of the APMO (turning over, moving to a sitting position). Conclusion: In combination with the usual measures to prevent PU, the results of our study showed a low incidence of PU in high-risk patients lying for between 15 and 20 hours a day on an APMO, use of which is therefore recommended in these patients.

Long-term outcome after combined kyphoplasty and intraoperative radiotherapy (Kypho-IORT) for vertebral tumors

Introduction The spine represents the site which is most frequently affected by bone metastases in patients with systemic cancer. Of all local treatment options, combined kyphoplasty and intraoperative radiotherapy (Kypho-IORT) provides both, instantaneous stabilization and immediate pain relief. We here report on the long-term outcomes of the largest cohort treated with Kypho-IORT to date. Methods Between 2009 and 2019 a total of 104 patients underwent Kypho-IORT to vertebral tumors in the thoracic, lumbar, or sacral spine with transpedicular kyphoplasty and intraoperative irradiation with a needle-shaped electronic brachytherapy source at our center. Patients were treated either on trial, within the prospective Kypho-IORT studies (NCT01280032 and NCT02773966), or, after completion of the study, off trial but compliant with the study protocol. Follow-up and imaging with computed tomography (CT) or magnetic resonance imaging was scheduled after 3 and 6 months and then bi-annually. Results A total of 143 vertebrae (89 thoracic spine, 53 lumbar spine, and 1 sacral spine) were treated in 104 patients. The median follow-up was 14.5 months (range 0.4–109). Local progression occurred in 10 patients (10 vertebrae) after a median time of 22.3 months (range 1.5–73) resulting in local control rates of 97.1, 95.9, and 94.2% at 6, 12, and 24 months, respectively. Overall survival was 74.6, 61.7, and 50.3% at 6, 12, and 24 months, respectively. A single serious adverse event was reported. Conclusion In addition to immediate pain reduction and stabilization, Kypho-IORT shows excellent long-term local control with minimal side effects.