Vertebral Compression Fractures in Osteoporotic and Pathologic Bone: A Clinical Guide to Diagnosis and Management

Vertebral Compression Fractures in Osteoporotic and Pathologic Bone: A Clinical Guide to Diagnosis and Management

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Vertebral compression fractures (VCFs) are the most common type of fracture secondary to osteoporosis. These fractures are associated with significant rates of morbidity and mortality and annual direct medical expenditures of more than $1 billion in the United States. This book presents a concise review of the diagnosis, management and treatment of vertebral compression fractures, discussing best practices for evaluation and radiographic diagnosis of vertebral compression fractures, as well as both non-operative and operative treatment options, including cement augmentation.

Opening chapters discuss both normal bone physiology as well as the pathophysiology of osteoporotic bone, and the evaluation and biomechanics of VCF, both osteoporotic and pathologic. Examination, radiography and long-term sequelae of VCF are then presented. The bulk of the remainder of the book focuses on medical, non-operative and operative management strategies, including vertebroplasty and kyphoplasty cement augmentation, management of spinal deformity, VCF adjacent to previous spinal fusion, and sacral insufficiency fractures. A final chapter on future treatment strategies rounds out the presentation. Spinal Compression Fractures in Osteoporotic and Pathologic Bone is ideal for orthopaedic trauma, spine, and neurosurgeons. The book is also intended for endocrinologists, rheumatologists, interventional radiologists, physiatrists, anesthesiologists, primary care physicians, and other practitioners who manage and treat patients with osteoporosis.

Ossified chronic subdural hematoma

Ossified chronic subdural hematoma

Calcified chronic subdural hematoma or ossified chronic subdural hematoma (CSDH), characterized by slowly progressing neurological symptoms, is a rarely seen entity that may remain asymptomatic for many years.

Incidence of calcified or ossified CSDH is high in certain countries, including the USAJapan and Turkey, with a steady increase in recent years 1).

They should be considered in the differential diagnosis at the time when we encounter because of its infrequency and variable clinical manifestation, following shunting in children or head trauma in adults 2).

Differential diagnosis

Calcified epidural hematoma, calcified empyema, meningioma, calcified arachnoid cyst, and calcified convexity of the dura mater with acute epidural hematoma should be considered for the differential diagnosis 3).

Treatment

Management of CSDH has improved dramatically in recent years thanks to advances in diagnostic tools, but there is still some controversy regarding the optimal treatment strategy.

Systematic reviews

In a systematic review, PRISMA guidelines were followed to query existing online databases between January 1930 and December 2018. We found a total of 88 articles containing 114 cases of calcified or ossified CSDH, 83 patients operated and 31 ones not operated.

There were 78 males and 29 females (7 with unreported gender) from 25 countries, ages ranging from 4 months to 86 years (mean 33.7 years), with etiologies of head trauma in 33.3%, shunting for hydrocephalus in 27.2%, or following cranial surgery in 4.4%. The duration of symptoms ranged from acute onset to 20 years, with a mean of 24.1 months. Imaging techniques such as X-ray, computed tomography, and magnetic resonance imaging were used with pathological confirmation of CSDH and complete recovery in 56.4% of patients.

Incidence of calcified or ossified CSDH is high in certain countries, including the USAJapan and Turkey, with a steady increase in recent years. Therapy of choice is surgery in these patients and it should be considered in the differential diagnosis at the time when we encounter because of its infrequency and variable clinical manifestation, following shunting in children or head trauma in adults 4).


Yang X, Qian Z, Qiu Y, Li X. Diagnosis and Management of Ossified Chronic Subdural Hematoma. J Craniofac Surg. 2015 Sep;26(6):e550-1. doi: 10.1097/SCS.0000000000002025. PubMed PMID: 26352368.

Case reports

A 59-year-old man presented with epileptic seizures interpreted as episodic syncope in the past 3 years and the patient had a history of head trauma about 4 years ago. Computed tomography revealed an ossified chronic subdural hematoma involving the right frontotemporoparietal region, which was totally resected using microsurgical technique. Postoperatively, weakness developed in the right arm and magnetic resonance imaging revealed a bilateral tension pneumocephalus, which was immediately treated by a left frontal burr hole trepanation, and the patient was discharged uneventfully 5).


A 46-year-old man with a history of alcohol abuse and a right frontotemporoparietal and left frontal ossified CSH that was diagnosed 2 years previously presented with headache and memory loss over 6 days. The patient was being followed with serial imaging, which showed the static state of the mass and no other lesions 7 months before admission. He underwent right frontotemporoparietal craniectomy to remove the ossified CSH and tumor. When the bone was lifted and the thin dura was opened, a hard, thick, ossified capsule was observed. No apparent tumor invasion was noted in the skull or epidural space. Despite refusing further chemotherapy and radiation therapy, the patient has been disease-free and working for 5 years.

Based on reported cases and relevant literature, large B-cell lymphoma may be associated with ossified CSH 6).


A 81-year-old woman with calcified chronic subdural hematoma. The patient underwent an osteoplastic left craniotomy, evacuation of chronic subdural mass with careful dissection and successful removal of the inner and outer membrane. Postoperative CT scan showed removal of subdural hematoma, a decrease of the left shift of median line and good brain re-expansion. The postoperative period was without any serious complications.

The subdural hematoma was successfully removed, resulting in a good recovery with complete resolution of patient’s symptoms. They highly recommend surgical treatment in cases of chronic symptomatic calcified subdural hematomas 7).


A Giant Ossified Chronic Subdural Hematoma 8).


Fang et al. reported a case of ossified chronic subdural hematoma in a 7-year-old female child, with a literature review 9).


Siddiqui et al. reported one case with diabetes insipidus 10).


A young girl affected by a syndromal hydrocephalus who developed a bilateral ossified chronic subdural hematoma with the typical radiological appearance of “the armored brain”. Bilateral calcified chronic subdural hematoma is a rare complication of ventriculoperitoneal shunt. There is controversy in the treatment, but most published literature discourages a surgical intervention to remove the calcifications 11).


Turgut et al. published one Ossified chronic subdural hematoma 12).


A 22-year-old male who had presented with severe headache consequent to brain compression caused by bifronto-parieto-temporal ossified subdural hematoma. We evaluated our method and surgical intervention in the light of the literature. The question whether the ossified membrane should be excised or not excised in these cases is a matter of controversy. They think that an ossified membrane causing an armored brain appearance should be excised in symptomatic, young patients with prominent cerebral compression. During this dissection, the relatively thickened arachnoid mater provides a safe border 13).


A 67-year-old man presented with headache, dysphasia, and left-sided hemiparesis. Routine skull x-ray showed a huge calcification extending from the frontal to the parietal regions in the right side. CT and MRI scan revealed a huge ossified SDH covering the right hemisphere. Right frontoparietal craniotomy was performed and the ossified SDH was completely removed. Severe adhesion was noticed between the pia mater and the inner surface of the ossified mass. The subdural mass had ossified hard outer and inner rims and a soft central part. The postoperative course was uneventful and 3 months after the operation, the patient was neurologically intact. The authors report the successful treatment of a patient with a huge ossified SDH covering the right hemisphere. Careful dissection and total removal are needed in such symptomatic cases to avoid cortical injury and to improve results 14).


A 24-year-old man with a history of tonic-clonic convulsions since 7 months of age was admitted because of increasing frequency and duration of seizures. Computed tomography and magnetic resonance imaging demonstrated a fusiform extra-axial lesion just above the tentorium and adjacent to the cerebral falx. A calcified and ossified chronic subdural hematoma was noted and was almost completely removed by craniotomy. Better seizure control was achieved by the removal of the calcified chronic subdural hematoma. Calcified subdural hematoma, calcified epidural hematoma, calcified empyema, meningioma, calcified arachnoid cyst, and calcified convexity of the dura mater with acute epidural hematoma should be considered for the differential diagnosis of an extra-axial calcified lesion 15).


Turgut et al. reported the successful removal of an ossified crust-like chronic subdural hematoma (SDH) covering the hemisphere in a 16-year-old boy. In this article, the importance of the surgical approach is stressed, and the rarity of this condition in the neurosurgical literature is also outlined 16).


A case of ossified chronic subdural hematoma is presented in a 13-year-old male in whom the mass was surgically removed. His neurological deficits continued afterward but were less severe 17).

References

1) , 2) , 4)

Turgut M, Akhaddar A, Turgut AT. Calcified or Ossified Chronic Subdural Hematoma: A Systematic Review of 114 Cases Reported during Last Century with a Demonstrative Case Report. World Neurosurg. 2019 Nov 1. pii: S1878-8750(19)32791-3. doi: 10.1016/j.wneu.2019.10.153. [Epub ahead of print] Review. PubMed PMID: 31682989.
3) , 15)

Yan HJ, Lin KE, Lee ST, Tzaan WC. Calcified chronic subdural hematoma: case report. Changgeng Yi Xue Za Zhi. 1998 Dec;21(4):521-5. PubMed PMID: 10074745.
5)

Turgut M, Yay MÖ. A Rare Case of Ossified Chronic Subdural Hematoma Complicated with Tension Pneumocephalus. J Neurol Surg Rep. 2019 Oct;80(4):e44-e45. doi: 10.1055/s-0039-1694738. Epub 2019 Dec 31. PubMed PMID: 31908905; PubMed Central PMCID: PMC6938459.
6)

Liu X, Zhou J, Shen B, Sun D, Zhang Z, Li H, Zhang J. Ossified Chronic Subdural Hematoma and Subsequent Epstein-Barr Virus-Positive Large B-Cell Lymphoma: Case Report and Literature Review. World Neurosurg. 2019 Oct;130:165-169. doi: 10.1016/j.wneu.2019.07.011. Epub 2019 Jul 9. PubMed PMID: 31299306.
7)

Snopko P, Kolarovszki B, Opsenak R, Hanko M, Benco M. Chronic calcified subdural hematoma – case report of a rare diagnosis. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2019 Sep 26. doi: 10.5507/bp.2019.041. [Epub ahead of print] PubMed PMID: 31558846.
8)

Tian W, Meng X, Zou J. A Giant Ossified Chronic Subdural Hematoma. J Coll Physicians Surg Pak. 2019 Sep;29(9):905. doi: 10.29271/jcpsp.2019.09.905. PubMed PMID: 31455496.
9)

Fang J, Liu Y, Jiang X. Ossified Chronic Subdural Hematoma in Children: Case Report and Review of Literature. World Neurosurg. 2019 Jun;126:613-615. doi: 10.1016/j.wneu.2019.03.144. Epub 2019 Mar 27. PubMed PMID: 30926556.
10)

Siddiqui SA, Singh PK, Sawarkar D, Singh M, Sharma BS. Bilateral Ossified Chronic Subdural Hematoma Presenting as Diabetes Insipidus-Case Report and Literature Review. World Neurosurg. 2017 Feb;98:520-524. doi: 10.1016/j.wneu.2016.11.031. Epub 2016 Nov 17. Review. PubMed PMID: 27867130.
11)

Viozzi I, van Baarsen K, Grotenhuis A. Armored brain in a young girl with a syndromal hydrocephalus. Acta Neurochir (Wien). 2017 Jan;159(1):81-83. doi: 10.1007/s00701-016-2991-1. Epub 2016 Oct 25. PubMed PMID: 27778104; PubMed Central PMCID: PMC5177664.
12)

Turgut M, Samancoğlu H, Ozsunar Y, Erkuş M. Ossified chronic subdural hematoma. Cent Eur Neurosurg. 2010 Aug;71(3):146-8. doi: 10.1055/s-0030-1253346. Epub 2010 May 3. PubMed PMID: 20440672.
13)

Kaplan M, Akgün B, Seçer HI. Ossified chronic subdural hematoma with armored brain. Turk Neurosurg. 2008 Oct;18(4):420-4. PubMed PMID: 19107693.
14)

Moon HG, Shin HS, Kim TH, Hwang YS, Park SK. Ossified chronic subdural hematoma. Yonsei Med J. 2003 Oct 30;44(5):915-8. PubMed PMID: 14584111.
16)

Turgut M, Palaoğlu S, Sağlam S. Huge ossified crust-like subdural hematoma covering the hemisphere and causing acute signs of increased intracranial pressure. Childs Nerv Syst. 1997 Jul;13(7):415-7. PubMed PMID: 9298279.
17)

Iplikçioğlu AC, Akkaş O, Sungur R. Ossified chronic subdural hematoma: case report. J Trauma. 1991 Feb;31(2):272-5. PubMed PMID: 1994092.

Intrathecal morphine for Restless Legs Syndrome

Intrathecal morphine for Restless Legs Syndrome

For those who suffer from a medically refractory Restless Legs Syndrome (RLS), intrathecal morphine treatment has been shown to be effective. The aim of a retrospective study of Steensland et al. was to investigate efficacy, complications and side effects in patients treated over several years with an implantable pump. A comparison was done to a group of patients treated with a similar pump system due to spasticity.

The charts of ten patients with severe or very severe RLS have been reviewed. These patients have received an intrathecal drug delivery system during 2000 -2016. To compare the rate of complications, a control group of 20 patients treated with intrathecal baclofen due to spasticity was included in the study. Their time of treatment corresponded to the RLS patients’.

The severity of symptoms related to RLS decreased significantly after treatment. Doses required ranged from 68 to 140 µg/day. Two cases of side effects were detected; one case with nausea and dizziness and one case with headache and fatigue. The rate of mechanical-, infectious- and other complications were similar between the two groups.

In light of the decrease in symptom severity and the low rate of side effects, intrathecal morphine can be considered an adequate treatment for those suffering from medically refractory RLS. The occurrence of complications did not differ between subjects with RLS and spasticity 1).

Case reports

Three patients with medically refractory RLS received an implanted pump for delivery of intrathecal morphine. Severity of RLS and self-assessed health were rated using the International Restless Legs Syndrome Study Group (IRLSSG) rating scale and the Short Form health survey (SF-36). Assessments were made preoperatively and after 6 months of follow-up.

Preoperatively two patients had very severe RLS, scoring 35 and 36 on the IRLSSG rating scale, and one patient had severe RLS (score, 26). All three patients were free of symptoms of RLS post-operatively and also at the 6-month follow-up. The daily doses of intrathecal morphine ranged from 73 to 199 µg. Results from the SF-36 health survey showed that all three patients had a better physical health compared to before surgery.

Intrathecal morphine may be efficient in the treatment for medically refractory RLS. All three patients became completely free of symptoms, and there was also improvement in self-perceived overall health 2)


In 2012 case reports of 4 patients documented excellent results with short-term use of intrathecal opioids also in RLS 3).


In 2008 Ross et al. reported the successful use of low-dose intrathecal morphine in a severe case of restless legs syndrome refractory to medication.

The surgery was complicated by extreme restlessness in the recovery room resulting in withdrawal or breakage of the catheter on multiple occasions. Relief of symptoms was lost with each catheter malfunction. They describes the possible origin of this complication and a solution to the problem resulting in the successful control of symptoms for 7 months since the last surgery. 4).

They are, however, wrong in their statement that this is the third published case of this particular treatment. In an article in the Swedish medical journal Lakartidningen 5), Lindvall et al. previously accounted for 7 patients with refractory restless legs syndrome who were successfully treated with intrathecal morphine. An abstract in English is available through the official web site of this journal, and the article is indexed by PubMed. The 7 patients were treated at 3 hospitals in the northern region of Sweden, which is covered by the neurosurgical department of Umeå University Hospital 6).


In 2002 two patients with incapacitating symptoms from restless legs syndrome, not adequately responding to conventional treatment with dopaminergic drugs, were implanted with a pump device (Isomed) for intrathecal delivery of morphine and bupivacaine. The treatment resulted in total resolution of all symptoms with few side effects 7).

References

1)

Steensland I, Koskinen LD, Lindvall P. Treatment of Restless legs with a pump; efficacy and complications. Acta Neurol Scand. 2019 Dec 28. doi: 10.1111/ane.13213. [Epub ahead of print] PubMed PMID: 31883387.
2)

Lindvall P, Hariz GM, Blomstedt P. Overall self-perceived health in Restless legs treated with intrathecal morphine. Acta Neurol Scand. 2013 Apr;127(4):268-73. doi: 10.1111/j.1600-0404.2012.01707.x. Epub 2012 Aug 9. PubMed PMID: 22881705.
3)

Hornyak M, Kaube H. Long-Term treatment of a patient with severe restless legs syndrome using intrathecal morphine. Neurology. 2012 Dec 11;79(24):2361-2. doi: 10.1212/WNL.0b013e318278b5e7. Epub 2012 Nov 28. PubMed PMID: 23197746.
4)

Ross DA, Narus MS, Nutt JG. Control of medically refractory restless legs syndrome with intrathecal morphine: case report. Neurosurgery. 2008 Jan;62(1):E263; discussion E263. doi: 10.1227/01.NEU.0000311089.04014.91. PubMed PMID: 18300885.
5)

Lindvall PK, Ruuth K, Jakobsson B, Nilsson SK. [Intrathecal morphine infusion a possible treatment in restless legs]. Lakartidningen. 2007 Aug 8-21;104(32-33):2250-2. Swedish. PubMed PMID: 17822205.
6)

Lindvall P, Ruuth K, Jakobsson B, Nilsson S. Intrathecal morphine as a treatment for refractory restless legs syndrome. Neurosurgery. 2008 Dec;63(6):E1209; author reply E1209. doi: 10.1227/01.NEU.0000325674.02282.CC. PubMed PMID: 19057291.
7)

Jakobsson B, Ruuth K. Successful treatment of restless legs syndrome with an implanted pump for intrathecal drug delivery. Acta Anaesthesiol Scand. 2002 Jan;46(1):114-7. PubMed PMID: 11903084.
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