Giant cell arteritis and polymyalgia rheumatica: two different but often overlapping conditions.

Genetic markers of disease susceptibility and severity in giant cell arteritis and polymyalgia rheumatica.

Osteoporosis is the most common contributing factor of spinal fractures, which characteristically are not generally known to produce spinal cord compression symptoms. Recently, an increasing number of medical reports have implicated osteoporotic fractures as a cause of serious neurological deficit and painful disabling spinal deformities. This has been corroborated by the present authors as well. These complications are only amenable to surgical management, requiring instrumentation. Instrumenting an osteoporotic spine, although a challenging task, can be accomplished if certain guidelines for surgical techniques are respected. Neurological deficits respond equally well to an anterior or posterior decompression, provided this is coupled with multisegmental fixation of the construct. With the steady increase in the elderly population, it is anticipated that the spine surgeon will face serious complications of osteoporotic spines more frequently. With regard to surgery, however, excellent correction of deformities can be achieved, by combining anterior and posterior approaches. Paget's disease of bone (PD) is a non-hormonal osteometabolic disorder and the spine is the second most commonly affected site. About one-third of patients with spinal involvement exhibit symptoms of clinical stenosis. In only 12–24% of patients with PD of the spine is back pain attributed solely to PD, while in the majority of patients, back pain is either arthritic in nature or a combination of a pagetic process and coexisting arthritis. In this context, one must be certain before attributing low back pain to PD exclusively, and antipagetic medical treatment alone may be ineffective. Neural element dysfunction may be attributed to compressive myelopathy by pagetic bone overgrowth, pagetic intraspinal soft tissue overgrowth, ossification of epidural fat, platybasia, spontaneous bleeding, sarcomatous degeneration and vertebral fracture or subluxation. Neural dysfunction can also result from spinal ischemia when blood is diverted by the so-called "arterial steal syndrome". Because the effectiveness of pharmacologic treatment for pagetic spinal stenosis has been clearly demonstrated, surgical decompression should only be instituted after failure of antipagetic medical treatment. Surgery is indicated as a primary treatment when neural compression is secondary to pathologic fractures, dislocations, spontaneous epidural hematoma, syringomyelia, platybasia, or sarcomatous transformation. Five classes of drugs are available for the treatment of PD. Bisphosphonates are the most popular antipagetic drug and several forms have been investigated.

Principles of management of osteometabolic disorders affecting the aging spine.

Introduction This paper describes surgical options for Osteoporotic vertebral compression fracture (OVCF) with acute flexible or chronic rigid kyphosis, and pseudarthrosis complicated with pain and neurologic deficit. Methods This study has two components. a) A prospective clinical study of surgical treatment of 31 patients (age: 69 ± 11 years) with either acute flexible or progressive pseudarthrotic kyphosis manifested with severe pain or neurological deficit between 2010 and 2014. Eleven patients exhibited neurocompression (Frankel B, C, D). Surgery consisted in indirect reduction, kyphoplasty, and short posterior instrumentation in 28 patients and multilevel instrumentation in three. b) The second component involved a literature search of OVCF complicated with acute or painful chronic deformities and neurologic deficit, managed with open surgical approach. Results Indirect reduction, kyphoplasty and short posterior stabilization can restore satisfactory anatomic alignment and neurological deficit. Multilevel instrumentation was used for rigid long kyphosis. Complications were related to a) screw pull out and junctional kyphosis (4 patients) one of the patients also developed anterior migration of cement, b) cement leakage (4 patients). L5 radiculopathy occurred in one patient. The others remained asymptomatic. The literature review concluded that corpectomy with anterior, posterior or combined instrumentations is indicated for burst fractures, or rigid kyphosis with neurocompression. Prompt decompression with anatomical alignment may restore paraplegia. Complications were germane to osteoporotic bone predisposing to hardware loosening or cut out and dislodgement of instrumentation. Discussion Neurologic deficit associated with fractures or progressive pseudarthrotic kyphosis effectively may respond to indirect postural reduction, kyphoplasty and posterior percutaneous short segment transpedicle instrumentation. For burst fractures and rigid chronic kyphosis corpectomy reconstructed with cages and anterior, or posterior or combined instrumentations can restore and maintain normal anatomy. The following guidelines for optimal surgical instrumentation have been established: To prevent screw loosening and junctional kyphosis the instrumentation should not end within the kyphotic segment. Screws for anterior instrumentation should penetrate the contralateral cortex. Multiple site of fixation or combined anterior and posterior instrumentations dissipate stresses at any one site. Augmentation of transpedicle screw fixation with cement is a sound technical principle. Cement should inserted in a doughy state with minimal pressure to prevent cement complications.

Surgical options for osteoporotic vertebral compression fractures complicated with spinal deformity and neurologic deficit

Vertebral compression fractures are among the most common forms of manifestations of osteoporosis. Conservative treatment comprises adequate analgesia, osteoporosis medication and individualized physiotherapy or braces. Nevertheless, vertebral compression fractures frequently lead to persisting pain and decrease daily activity and quality of life. In these cases, kyphoplasty and vertebroplasty can be efficient treatment options. Vertebroplasty is a minimally invasive procedure, in which bone cement is filled into the vertebral body under fluoroscopic control. In most cases, this internal stabilization leads to a rapid reduction in pain. Kyphoplasty additionally aims to correct the kyphotic deformation of the broken vertebra via introducing and inflating a balloon catheter. There is broad clinical experience with both procedures. For kyphoplasty, randomized controlled trials showed significant improvements in pain and quality of life in patients undergoing kyphoplasty. However, cement leakages lead to rare but severe complications such as pulmonary embolism and nerve palsies.

Vertebral fractures due to osteoporosis. Kyphoplasty and vertebroplasty vs conservative treatment

Resume La pathogenie de la pseudopolyarthrite rhizomelique (PPR) et de la maladie de Horton (MH) est probablement multifactorielle, ce qui explique en particulier la diversite des resultats des etudes du genotype HLA DR. Toutefois, ces facteurs genetiques pourraient rendre compte de la diversite des formes cliniques d'une meme maladie comme la PPR par rapport a la Symptomatologie d'arterite temporale au cours de la MH. But de l'etude Etude comparative des antigenes HLA DRB1 au cours de la PPR et de la MH. Malades et methodes

Étude du polymorphisme HLA DRB1 au cours de la pseudopolyarthrite rhizomélique et de la maladie de Horton

Osteoporotic vertebral crush fractures with neurologic complications are rarely reported in the literature. We report six new cases particularly severe in which death occurred in two cases. The study group included four women and two men with a mean age of 75 years (range: 72-79). Vertebral collapse causing neurological deficit was T5, T9, T11 in two cases, L1 and L3. The mean number of vertebral collapses was three per patient (range: 1-9). Back pain appeared without traumatism 6 weeks before admission (range: 1-24). Neurological complications appeared 2.5 weeks after back pain (range: 1-8). One patient suffered from a paraplegia, three from a paraparesia with bladder dysfunction (n = 1). In one case there was a severe weakness of the levator muscles of the foot and in another a L3 femoral neuralgia with severe bowel and bladder dysfunction. X-rays demonstrated backwards displacement of the posterior cortex in three cases, an intravertebral vacuum phenomenon in two cases and a heterogeneous appearance suggesting a malignancy in two cases. Computed tomography, performed in four patients and tomography in one patient, demonstrated fragmentation of the vertebral body in all the cases and vacuum phenomenon in four cases. Magnetic resonance imaging performed in four cases has confirmed the absence of epiduritis and a compression due to bony structures in two cases. A vertebral biopsy was performed in three cases. Osteoporosis was observed in all the cases and in two cases there was also an osteonecrosis. Surgical treatment was performed in three cases and conservative medical treatment in the other cases. After surgical treatment we have observed an absence of improvement of neurological complications in one case, an improvement in another and finally a full recovery in the last case. After conservative treatment we have noted in two cases an absence of improvement of neurological complications and in one case an improvement of neurological deficit. Two patients died (one after medical treatment and another after surgical treatment).

Tassements vertébraux ostéoporotiques avec complications neurologiques sévères. À propos de six observations

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Étude du polymorphisme HLA DRB1 au cours de la pseudopolyarthrite rhizomélique et de la maladie de Horton

Tassements vertébraux ostéoporotiques avec complications neurologiques sévères. À propos de six observations