Combined anterior and posterior fusion for spine TB in children

In this study, anterior debridement, grafting and posterior pedicular plating with small DCP with cortical screws 3.5 mm were used in 12 children with tuberculosis of the dorsal and dorsolumbar spine. All of them were in different grades of paraplegia. The affected level was D6-7 in 3 patients, D8-9 in 3 patients, D12-L1 in 5 patients and L2-3 in 1 child. The patients were operated upon anteriorly by thoracotomy in six patients and thoracolumbar approach in the remaining six cases. A second posterior step was done one week later. Postoperative plaster jacket was done for four months at least. A follow up was done for each patient at 1.5, 3, 6 and 12 months including clinical and radiological assessment. The follow up duration ranged from 1-3 years with an average of 18 months. There was fusion for all patients after 4-6 months. A neurological improvement was reported for all patients [2 Frankel grades at least]. Kyphotic deformity was corrected from 33 to 10 degree postoperatively and increased to 18 degree on the late follow up. Antituberculous drugs were continued for nine months at least according to the recommended doses

Modified Scott's operation for management of lumbar spondylolysis and minimal degree spondylolithesis

Thirty-two patients complaining of low back pain and diagnosed as spondylolysis were included in this study. All of them had spondylolysis of the lumbar spine at different levels. The affected level was L5 [n = 16], L4 [n = 10] and multiple-levels lysis [n = 6]. Twenty-two patients had associated grade I spondylolithesis in association with the lysis. The other 11 patients had spondylolysis only. These patients were managed surgically in this study by the modified Scotts technique using pedicular screws and washers as anchorage point instead of wiring around the transverse process. The defect was filled by iliac grafts either paste or tricortical one. Minimal decompression through limited fenestration was done in three patients. The patients were followed up for one year at least. The follow up duration ranged between 12 and 30 months with an average 18 months. The study concluded that this modified technique is a safe and easy technique, avoiding the complications of wire breakage and transverse process fracture of the traditional Scotts technique. It can be applied to multiple level lysis with the preservation of a good back motion

Treatment of fracture shaft femur in children using either plating or elastic rod, A comparative study

Sixty patients were included in this study and classified in two groups: The first group included 25 patients who were managed by elastic rod and the second group included 35 patients who were operated upon using AO narrow DC plating. All patients were presented with fresh fractures, except six patients with malunited fractures treated by plating. The follow up included both clinical and radiological assessment at 1.5, 3, 6 and 12 months. The assessment included union, angular deformities, hip and knee motion, leg length discrepancy, rotational asymmetry and gait return to school and normal activities. The general assessment was done using Thoreson et. al. score [1984] and Neer's functional score [1957]. It was concluded that the use of minimal invasive elastic rods as a line of treatment of fracture femur in children is more reliable, having an early return to school, shorter hospital stay and earlier bony union when compared with plating. There is no need for blood transfusion. The use of plating is more complicated that needs blood transfusion with more trauma to the muscles. The only pitfall in elastic rod is the need for intraoperative image and the rotational instability in some cases

Arthrodesis hip using broad DCP

In this study, 34 patients were assessed. The mean age was 22 with a range from 16-36 years. All of them were not candidates for total hip replacement. In all patients, the other entire hip was normal. All of them were complaining of stiff arthritic hip for different causes. All of them were operated upon using the direct lateral approach exposing the hip joint and the iliac bone. Internal fixation was achieved using contoured broad DCP instead of the traditional cobra plate, to put the limp in the ideal position of arthrodesis. The greater trochanter was osteotomized with the preservation of abductor muscle attachment for easier THR. The plate was fixed to iliac bone with cancellous screws 6.5 mm and to the femur using cortical screws 4.5 mm. The mean operative time was 90 minutes. Each patient needed one unit of blood transfusion intraoperatively. A good bony union was reported in all patients. One patient of minimal infection was reported due to a general poor condition. A good postoperative lower limp function was reported in all patients. The pain completely disappeared after good bony union, except in one patient with minimal infection

Late follow-up of 190 patients with dorso-lumbar spinal fractures treated by transpedicular screw and plates

Between 1989 and 1995, at the Department of Orthopaedic Surgery, Assiut University Hospital, 190 patients with thoracolumbar frctures underwent surgical treatment. There were 115 males and 75 females; the average age was 27.7 years [range, 17 to 65 years]. The affected level was D-10 in 16 patients [8.4%]; D-11 in 13 [6.8%]; D-12 in 60 [31.5%]; L1 in 50 [26.3%]; L2 in 28 [14.7] L3 in 23 [12.1%]. According to the Magert and Harms classification [1988], 70 patients [36.8%] had flexion compression fractures, 89 [46.8%] had flexion distraction fractures and 31 [16.4%] had torsional injury. On admission and according to Frankel classification 55 patients [28.9%] were grade A, 30 [15.9%] grade B, 45 [23.7%] grade C, 40 [2 1%] grade D and 20 patients [10.5%] grade E. The mean operative time totaled 2 hours. Spinal plates were used in 45 patients [23.8%] and NDCP in 145 patients [76.2%]. Decompression was carried out in 125 patients [65.8%] with neurological compromise. In the earlier cases, 22 [11.6%] patients underwent fusion in combination with instrumentation. 86 patients had their implants removed for different indications. The metal was removed in 34 patients after screw failure, 6 with severe back pain without loosening of the implant and in 46 patients according to their demand. At the final follow-up which ranged from 3 to 7 years [average 4.5 years], fifty patients [26.3%] with incomplete paraplegia returned to normal; no improvement occured in patients with complete paraplegia. No neurological deterioration was reported. Compared to the preoperative status, our follow-up examinations demonstrated improvement in the neurology and function. 50 patients [26.3%] with incomplete paraplegia showed neurological improvement by one or two grades at least. The back pain was excellent and good in 79%; the range of motion was excellent and good in 85%. The radiographic assessment in the lateral plan [Cobb technique] demonstrated a significant [P < 0.001] mean restoration from an initial angle of 23.5° to 7° with gradual loss of reduction of about 2° after metal removal. There was a mean gain of regional kyphotic angle 16.3°. The mean gain of the vertebral height was 46% and the mean loss was 9%. The mean gain of the retropulsion was 8mm and the mean loss was one mm only. The preoperative wedge angle of the verebral body correlated significantly with the postoprative loss of reduction. The implant removal did not lead to increase in the range of back motion. It did not change the neurological state or lead to improvement in the back pain except in those with pain due to implant failure. The complications related to the instrumentation were screw malposition in 15 patients [7.8%], screw loosening or breakage in 34 patients [17.9%], with no metal breakage

Management of iatrogenic dural tears in the lumbar spine surgery

Thirty two patients with iatrogenic dural tears were reported out of 260 patients of lumbar spine surgery [12.3 percent] who were operated upon at Orthopedic Department, Assiut University Hospitals from 1990 to 1997. The operation was done for spinal canal stenosis in 120 patients [46.2 percent], 80 were recurrent disc prolapse or post laminectomy syndrome [30.8 percent], and 25 were single or multiple level fresh disc herniation [9.6 percent] and 35 patients with Spondylolithesis [13.5 percent]. The tear was posterior in 21 patients [65.6 percent] and posterolateral in 9 [28.1 percent] and ventral in 2 patients [6.2 percent] The tear was repaired primarily in 27 patients [84.4 percent], covered by fascial flap and gelfoam layer due to inaccessible tear in 5 patients [15.6 percent]. Postoperative complete bed rest in prone position was obligatory in all patients in a position depending on the site of tear. The patients were followed up for one year at least. 17 were males [53.1 percent] and 15 were females [46.9 percent]. Twenty seven patients [84.4 percent] showed excellent results, 4 patients [12.5 percent] showed fair results [one patient with closed pseudomeningocele, three with persistent CSF leakage, where two of them were treated by re-operation and the third improved after a longer duration of complete bed rest]. One patient [3.1 percent] with poor result [severe meningitis and neurological deterioration]. All the patients with fair or poor results were not repaired by direct primary repair. We conclude that primary repair is obligatory in all patients with iatrogenic dural tears. The incidence of dural tears is higher in recurrent patient than in any other lumbar spine surgery