Spinal Tumor Resection with Intraoperative Computed Tomography Navigation in Tumor-Induced Osteomalacia: A Case Report

This is the first report using intraoperative CT navigation for Tumor-induced Osteomalacia (TIO) lesions of the spine. TIO is a rare paraneoplastic disorder caused by tumors secret Fibroblast growth factor 23 secreted by tumor tissue. Surgical resection of the main tumor is the only definitive treatment. However, the tumor is usually small, and it hard to find it, and it tends to be seen when the recurrence is caused by the difficulty of whole tumor resection. A 57-year-old woman presented with a rare case of TIO located in T10 vertebra body. Using the intraoperative CT navigation, we resected the tumor in the T10 vertebral body very effective for accurate localization of the tumor and helpful for guidance of resection area and confirmation for excision of tumor. As a treatment for TIO, we report a tumor resection with intraoperative computed tomography navigation that made it possible to resect tumor in T10 vertebrae precisely and safely, which is small and difficult and dangerous access.

New formulas to predict the length of a peripherally inserted central catheter based on anteroposterior chest radiographs

Purpose: To develop formulas that predict the optimal length of a peripherally inserted central catheter (PICC) from variables measured on anteroposterior (AP) chest radiography (CXR). Materials and methods: A total of 134 patients who underwent PICC insertion at the angiography suites were included. Clinical information such as patient height, weight, sex, age, cubital crease to inferior carina border length (CCL), and approach side were recorded. The following variables via measurement on AP-CXR were also collected: (1) distance from the T1 to T12 vertebra (DTV), (2) maximal horizontal thoracic diameter (MHTD), and (3) clavicle length (CL). Results: Significant correlations between CCL and the following variables were identified in linear regression analyses: approach side, height, weight, sex, DTV, MHTD, and CL. Multiple regression results motivated the following two formulas: (1) with height data, estimated CCL (cm) = 12.429 + 0.113 × Height + 0.377 × MHTD (if left side, add 2.933 cm, if female, subtract 0.723 cm); (2) without height data, estimated CCL = 19.409 + 0.424 × MHTD + 0.287 × CL + 0.203 × DTV (if left side, add 3.063 cm, if female, subtract 0.997 cm). Estimated final PICC length can be calculated as (Estimated CCL, cm) + 4.0 (distance from inferior carina border to about 2.0 vertebra body unit, cm) − (distance from set cubital crease to designated puncture point, cm). Conclusion: This study suggests new formulas to predict the appropriate PICC length for bedside insertion using previous AP-CXRs. With this formula, ideal positioning of the catheter’s tip can be achieved in the clinical practice, avoiding or minimalizing the exposed catheter out of skin. These formulas may be helpful for patients who cannot undergo intra-hospital transport due to hemodynamic instability or who are concerned about isolation precautions due to any infectious-related contamination.

Bone Marrow Dosimetric Analysis of Lymphopenia in Patients With Esophageal Squamous Cell Carcinoma Treated With Chemoradiotherapy

Background: Lymphocytes as a marker of immune function are essential to the immune response. Sternum and vertebra bone marrow (BM) exposed to radiation may affect lymphocytes during radiotherapy (RT) for esophageal carcinoma (EC). We analyzed the relationship among peripheral blood lymphocytes, exposed sternum and vertebra body BM, and overall survival (OS) to find BM dosimetric parameters of lymphopenia during chemoradiotherapy (CRT) for patients with esophageal squamous cell carcinoma (ESCC). Methods: We examined 476 ESCC patients from January 2012 to January 2015, all of whom received concurrent or sequential CRT. Absolute lymphocyte counts (ALC) during RT of each patient were collected from the routine workup at the following RT times: pretreatment ALC (ALC0), at 1–5, 6–10, 11–15, 16–20, and 21–25, and more than 26 sessions (called ALC1–6, respectively). The sternum and vertebral body BM were delineated in accordance with uniform standards, and the irradiated volumes were calculated by dose-volume histograms (DVH). The Kaplan–Meier method and Cox proportional hazards regression were used to analyze the survival of the patients. Comparisons of DVH were performed using the Mann–Whitney U test or two-sample t-test where appropriate. Results: A relative volume of sternum BM irradiated by more than 20 Gy could clearly affect the peripheral blood lymphocytes. The V20 of sternum BM and V50 of vertebra body BM were related to the OS of the patients, and the level of ALC2(at 6–10 times of RT) could predict the patients’ outcomes. The Cox regression analyses showed that the 218 patients with ALC2 ≥ 0.8×109/L had a significantly longer OS (47.0 vs. 30.9, p<0.0001) than the 258 patients with ALC2 < 0.8×109/L. Conclusion: In patients with ESCC, the relative volume of sternum BM irradiated by more than 20 Gy was associated with lymphocyte. The V20 of the sternum BM and the V50 of the vertebra body BM were related to the OS of the patients. The level of ALC2 is a significant prognostic factor in esophageal carcinoma patients.

Multilevel Anterior Cervical Corpectomy and Fusion for Ossification of the Posterior Longitudinal Ligament

Background Cervical ossification of the posterior longitudinal ligament (OPLL) is a kind of spinal disorder widely spared in Asia. In dealing with multilevel cervical OPLL, the ideal surgical approach is still under debate. Here we introduce our findings of multilevel anterior cervical corpectomy and fusion (ACCF) in treating multilevel cervical OPLLMethods 79 patients with multilevel cervical OPLL who had ACOR on C4-C5 or C5-C6 were retrospectively reviewed. Patients’ Japanese Orthopedic Association (JOA) Score, the improvement rate of JOA Scores (RIS), sagittal cervical mobility (SCM) and the distance between the lower endplate of the vertebra body above the titanium mesh and the superior endplate of the vertebra body below the titanium mesh ( L ) were analyzed and subjected into paired-t test. Radiographic features and complications were described as well.Results p<0.001 in all paired-t tests of JOA Scores, SCM and L at 1day, 6months, 1year and 2year follow-ups compared with preoperative ones. Patients’ RIS continued to increase in 2 years. 6 (7.59%) patients’ L at the 2 years follow-up shortened more than 10mm than their postoperative L. 1 (1.27%) patient had severe titanium mesh canting.Conclusions Multilevel ACCF procedure has positive outcomes in treating multilevel cervical OPLL. Postoperative complications like titanium subsidence and dislocation can happen after this procedure. Follow-ups should be conducted regularly and thoroughly with this kind of patients.

The problem of mismatches between CT scan and DXA results

Background. It is reported that radiodensity measured in Hounsfield units becomes more and more popular in bone property assessment, however also mismatch with DXA results is observed.Purpose. The aim of this study is to evaluate the relationships between the results of DXA and CT with a focus on explanations for observed discrepancies.Material and methods. This is a cross-sectional study; forty patients were enrolled, all patients underwent DXA and CT. A bone mineral density BMD (g/cm2 ) was calculated for each vertebra of a lumbar spine (L1-L4 inclusive), neck, upper neck, shaft, Wards triangle and trochanter of hip. Bone radiodensity in HU was taken from each vertebral body in the sagittal, axial and coronal planes. A total vertebra body radiodensity including cortical bone and radiodensity of only cancellous bone were calculated. To assess a potential impact on DXA and CT data agreement a mean radiodensity and square of the right and left vertebral pedicles and facet joints were measured for each vertebra.Results. A strong correlation between BMD measured using DXA and CT data was estimated with a multiply r accounting for 0,84169, p<0,0001, however the most contributing parameters were those calculated for facet joints. It has been detected that both radiodensity of only a cancellous bone and total have a weak correlation with matching BMD measurements of a proximal femur.Conclusion. The results of DXA could be strongly influenced by hypertrophic changes of facet joints. Both CT and DXA measurements taken from a lumbar spine may have a mismatch with figures taken from hip.

Anterior stabilization of C1–C4 vertebrae after transoral removal of a giant cell tumor of C2–C3 vertebrae

A clinical case of a single-step transoral removal of C2 and C3 vertebral bodies with subsequent stabilization of the C1–C4 spinal segment through the same approach (with additional submandibular approach to insert screws into the C4 vertebra body) without dissection of the mandible and tongue is presented. The first experience of anterior stabilization of the C1–C4 spinal segment using a custom-made instrumentation system demonstrated its effectiveness. It was shown that, taking into account the length of the cervical spine resection, the anterior stabilization with a custom-made plate should be combined with standard methods of posterior fixation. Innovative surgical technologies allow optimizing the surgical technique of cervical spine stabilization and provide earlier rehabilitation of a patient.

Fusion of axis with third cervical vertebra: a case report

Introduction: Fusion of one or more contiguous vertebral segments is usually the result of embryological failure of normal spinal segmentation. It may be associated with syndromes such as Klippel-Feil. Fused cervical vertebrae (FCV) may also be acquired or pathologic. FCV is generally associated with disease like tuberculosis, other infections, juvenile rheumatoid arthritis and trauma. The commonest site of involvement is C2-C3. In condition of fusion the two vertebrae appear not only structurally as one but also function as one. This anomaly may be asymptomatic; however, it may also manifest in the form of serious clinical features such as myelopathy, limitation of the neck movement, muscular weakness, atrophy or neurological sensory loss. Case report: We observed the fusion of axis with 3rd cervical vertebra. Body, laminae and spines of C2 and C3 were completely fused on both anterior and posterior aspects, whereas the pedicles and transverse processes were not fused. Foramen transversarium was present on both the vertebrae bilaterally. Conclusion: This variation is noteworthy to neurosurgeons and radiologists in studying computed tomography (CT) and magnetic resonance imaging (MRI) scans.

Modern Synthetic Substitute of Bone Tissue

Potentialities of synthetic bone substitutes application in vertebrology, especially in cervical spine surgery is demonstrated. From 2010 to 2011 thirty seven patients (21 — 70 years) with spine injuries and degenerative diseases were operated on. During surgical intervention subtotal resection of cervical vertebra body was performed. BoneMedik-S block of appropriate size was inserted into the defect. In all cases the final step of operation was stable fixation of segment by metal plate and screws. It was shown that modern synthetic biomaterials for substitution of bone tissue defects enabled to shorten the volume of surgical intervention and contributed to the formation of natural spongy human bone structure at minimum terms.