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Iwate Medical University Morioka 020-8505, Japan
I read with interest the paper on the transoral approach to vertebroplasty in the November 2000 issue of AJR [1]. Although the report deals with only a single case, it contains an important piece of information in the treatment of a potentially difficult lesion in the body of the axis.
However, I think that the possibility of infection is still not excluded in this patient. The authors followed up for 6 months and found no sign of infection [1], but a 6-month follow-up is too short to comment on the possibility of infection. In the experience in the orthopedic literature of hip arthroplasty, an indolent delayed infection becomes evident from 3 months to 2 years after the procedure [2]. In the case of this patient, if an infection occurs, it may become evident later than usual because an antibiotic (tobramycin) was added to the methylmethacrylate cement.
Some journals (e.g., Journal of Bone and Joint Surgery) strongly encourage researchers to follow up for more than 2 years before submitting the manuscript for publication. I am afraid that this report was published a little early to comment on the possibility of the most worrisome complication of the transoral approach to vertebroplasty.
References
Emory University Atlanta, GA 30322
Dr. Ehara raises an interesting point regarding the risk of delayed infection after vertebroplasty via the transoral route as described in our article [1]. This was also our greatest concern while planning our approach to this case. To our knowledge, the overall risk of infection after traditional percutaneous vertebroplasty has never been published in the peer-reviewed literature, but it is thought to be well below 1%. We believe the infection risk of transoral vertebroplasty to be no higher than the risk of 0-2% for wound infection after transoral surgery, as listed in the article.
As Dr. Ehara has written, delayed infection is a possibility that can be further masked by the addition of tobramycin to the methylmethacrylate cement. Previously published data suggest that the addition of tobramycin can decrease the risk of cement infection after common orthopedic procedures [2, 3]. Addition of tobramycin to methylmethacrylate results in the binding of the cement to the antibiotic, which is released locally over several months. Accordingly, the classification system for postoperative hip replacement infection described in the author's letter includes a 3-month to 2-year period of potential delayed infection after surgery [4]. However, this article also states that these infected patients are never entirely free of pain in the postoperative period. Whether a patient with infected vertebroplasty cement would show symptoms of pain is not known.
In our case, the patient has not manifested symptoms to suggest delayed infection through what is now a 2-year period of follow-up [1]. Specifically, there have been no symptoms of upper cervical spine instability, pain, drainage, or associated fever to suggest indolent infection. Therefore, we remain confident that the transorally placed methylmethacrylate remains free of infection. Future evaluation of both routine percutaneous vertebroplasty and the transoral approach to vertebroplasty will help to quantify the overall infection risks.
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