In percutaneous vertebroplasty, clinically significant complications occur predominantly in patients with spinal metastases. This higher rate of complication may be associated with increased pressurization that has been reported due to the presence of lytic tissue during vertebroplasty. To date, there has been no research investigating techniques aimed at reducing this pressurization. This study investigated the potential of tumour volume reduction using laser induced thermo therapy ablation within the metastatic spine. This novel technique proved to be capable of efficient tissue shrinkage (average 60%) with little or no pressurization (average 1.3mmHg) and moderate levels of temperature elevation (average increase of 15.1°C).

This study aims to investigate the potential of minimally invasive tumour volume reduction using laser induced thermo therapy ablation within the metastatic spine.

Volume reduction of tumour tissue prior to cement injection may provide a method to reduce pressurization, reduce the likelihood of tumour extravasation and improve cement fill during percutaneous vertebroplasty.

In percutaneous vertebroplasty, clinically significant complications occur predominantly in patients with spinal metastases (10%).

Laser-induced thermo therapy condensed and coagulated the simulated tumour. Volume shrinkage of the tumour tissue averaged 60%. Pressures generated within the vertebral body only rose an average of 1.3mmHg during the procedure. Maximum temperatures on the posterior body wall increased by 15.1°C, with average temperatures 6.8°C above the baseline.

A simulated lytic defect created using breast tissue was introduced into the vertebral body of a calf spine to model a metastatically involved vertebra. A pre-charred surgical fibre coupled to a diode laser delivering 1750J of energy was inserted through an eleven-guage needle into the centre of the tumour using an intrapedicular technique. During treatment, the temperature at the posterior body wall and intravertebral pressure were measured. Following ablation, the volume of the remaining tissue was measured.

The results suggest that this novel technique is capable of reproducible, uniform, and effective tissue destruction with little to no pressurization and moderate levels of temperature elevation. Both pressures and temperatures generated during our study were lower than reported values during percutaneous vertebroplasty and suggest little risk of complications.

Vertebroplasty (VP) is currently used to improve spinal stability in patients with vertebral metastases. This study assessed the effects of Laser Induced Thermo Therapy (LITT), a minimally invasive technique used to ablate tumor tissue prior to vertebroplasty. Load-induced canal narrowing (LICN) was measured pre and post-vertebroplasty in twelve paired spinal motion segments with simulated lytic metastases. LICN improved post-vertebroplasty for all specimens treated with LITT. In all specimens, cement location was an important factor in post-vertebroplasty stability. Reduction of the tumor volume pre-vertebroplasty resulted in more reliable defect filling.

To investigate the effect of tumor ablation using Laser Induced Thermo Therapy (LITT) prior to vertebroplasty (VP) on cement distribution and vertebral stability.

Tumor volume reduction using LITT prior to cement injection improves defect filling and consistently reduces Load Induced Canal Narrowing (LICN).

A simple, minimally invasive procedure providing accurate tissue destruction pre-vertebroplasty may result in more reliable cement fill, reduce cement extravasation and improve post-vertebroplasty stability.

Following verebroplasty, LICN improved in all specimens treated with LITT and in those VP alone specimens with cement located posterior to the tumor tissue (33%). LITT treated vertebrae exhibited a trend toward reduced posterior wall motion post-vertebroplasty (LICN=29.7±27.1%) versus specimens treated with VP alone (LICN=248.7±253%). In the LITT+VP group, cement was fully contained within the vertebral body while cement extravasation into the canal was noted in 33% of the specimens treated without LITT.

Twelve paired cadaveric thoracolumbar spinal motion segments with simulated lytic metastases were randomized for treatment with VP alone or LITT+VP. In the LITT+VP group, a laser fibre inserted through a transpedicular approach was used to ablate the tumor tissue prior to cement injection. The specimens were axially loaded to 800N pre and post-treatment. LICN was used as a measure of vertebral stability. Cement location was assessed post-testing through axial sectioning. Location of cement is an important factor in determining post-VP stability. Vertebroplasty is effective in decreasing LICN if the tumor is ablated or surrounded posteriorly with cement.

Funding: USAMRMC DAMD 17–00–1–0693

Over 5 years we gave 84 patients epidural cortisone (80 mg depomedrol and local anaesthesia) for back and/or leg pain due to degenerative disease of the spine.

The mean age of the 35 men and 49 women was 65.2 years (37 to 86). All patients had back pain and 77% had neurogenic leg pain. Spinal radiographs demonstrated degenerative changes, including intervertebral disc space narrowing and/or facet joint arthritis, in 84%. MRI, performed in 80 patients (95%), confirmed degenerative disease of the lumbar spine and demonstrated neural compression in 78 of the 80 (97%). Five patients received a second epidural injection and one a third. Complete resolution of back and/or leg pain occurred in 32 patients (38%), and 34 (40%) had relief for between 1 and 12 months. There was no change in the symptoms of 18 patients (21%). Surgery was undertaken in 17 patients (20%), with seven undergoing spinal decompression alone and 10 decompression and a fusion. After surgery, four of the seven patients who did not have a fusion still had back pain. All 10 of the patients who underwent decompression and fusion had a good outcome. One patient developed an epidural haematoma following the epidural injection.

Epidural steroid injection had a favourable outcome in 78% of our patients, with a low incidence of complications. Patients who failed to respond to the epidural injection did poorly with spinal decompression alone.

Clinical features and radiographic findings of three patients with dysplasia epiphysealis hemimelica (Trevor disease) are reviewed. In all patients the osteochondromatous lesions grow out from the epiphysis of the ankle joint with single lower extremity involved. The clinical symptoms, localization and roentgenogram are most important factors for confirming diagnosis. One patient presented with ankle varus deformity was found associated partial arrest of the distal tibial growth plate, surgical treatment including three arthrotomy with excision intraarthicular osteochondromatous lesions procedures, and one combined Langenskoid physeal bar excision procedure. Symptoms relieved and ankle function improvement were found in all three patients. MRI can provide further information such as: joint congruous, separation plane between the epiphysis and accessory osteochondromatous lesion; physeal plate growth disturbance conditions, and enabling precise localization and surgical treatment.

Background: Reconstruction nail had developed since 1985. General indications reviewed from literatures are 1. Ipsilateral femoral neck-shaft fracture (nondisplaced), 2. Russell-Type IB subtrochanteric fracturtes (intact piriformis fossa, fractured less trochanter). Many authors did not recommend that application of reconstruction nail in displaced ipsilateral femoral neck-shaft fractures. The reason is that unpredictable femoral neck-shaft reduction and over-distraction of shaft fracture. We developed one new method for overcoming such technical puzzle to achieve one-step reduction for displaced ipsilateral femoral neck-shaft fractures.

Material: There are 24 consecutive cases were treated by reconstruction nail by the same operator in Chi-Mei Foundation Hospital from February, 1999 to June, 2000. Five of them were diagnosed as displaced ipsilateral femoral neck-shaft fractures and treating new surgical technique in reconstruction nailing. Initial radiographic assessment revealed displaced neck fracture can be classified as Garden III, the fracture morphology is vertical (Pauwell III). Average age of these five patients is 37.6 y/o. The sex distribution is M:F=3:2

Method: Provisional proximal fixation of femur is mandatory. First, we use two 5.0mm drillpit transfixed trochanter region after assure of femoral anteversion. Second, release of traction and distal locking for reduction and fixation of shaft fracture part. Third, remove application handle and use Internal rotation or other remote maneuver for restoration of neck-shaft angle. Finally, complete drilling through neck and sequent proximal cephalomedullary locking was performed by free-hand method.

Result: Initial reduction result was acceptable. There was no significant coxa-varus or coxa-brevis. Two of them had removed of implants and clinical result was satisfied. No avascular necrosis was noted in our following up.

Discussion: How to treat displaced ipsilateral femoral neck-shaft fractures in one-step was obstacle in our orthopedic practice. Abandonment of reconstruction nail just due to technique demanding purpose is very pity. We developed such technique to make patient with displaced ipsilateral femoral neck-shaft fractures treat by closed and one-step method and gained more satisfaction.