Avoidable causes in pedicle instrumentation failure

The authors reviewed factors related to the surgical techniques attributed to surgeon-errors which result in failures of the construct of the internal fixation of thoracolumbar fractures through transpedicular screws systems, and how these could be avoided. The authors reviewed 280 consecutive patients with traumatic thoracolumbar fractures who underwent spinal surgical fixation with short segment transpedicular screw instrumentation at two institutions, between January 1997 and June 2005. All patients in this series were victims of high-force trauma. Among this series, 30 patients had a construct failure attributed to surgeon-related errors. Clinical evaluation of the patients was performed on admission and at postoperative period using ASIA scale. All patients were radiologically investigated by plane x-rays and computerized tomographic scan spine on admission and occasionally MRI and 3D CT scan of the spine when required. We used McAfee classification of thoracolumbar injuries. Surgical treatment was indicated in cases of biomechanical instability of the spine and/or if a neurologic deficit was imminent or already present, the patients were followed-up as regard to clinical and radiological evidence of construct failure. Thirty patients out of 280 patients with post-traumatic thoracolumbar injuries had construct failures. Main clinical presentation of construct failure was severe pain and inability to walk at postoperative period. Radiologically there was progressive spinal deformity with and without implant failures. The locations of the fractures in order of frequency were as follows: L1 in 18 cases, L2 in 7 cases, T12 in 5 cases. The construct failure was in the form of screw binding in 6 patients, screw breakage in 12 patients, screw/rod dislodgement in 3 patients, progressive kyphosis in 5 patients, disengaged screw's cup in 2 patients, and broken rods in 2 patients. Successful use of transpedicular screws in traumatic thoracolumbar fractures is predicated on understanding of biomechanical properties of both the spine and implants. Great attention must be directed to maintain the sagittal and coronal balances of the spine over the sacrum through reconstruction of comminuted anterior vertebral column and appropriate distraction of the construct. In spite of routine use of pedicle, screw has not been free of complications; the majority of construct failures is not actually device failures but instead is surgeon-related errors

Vertebroplasty in combination with pedicle screw instrumentation: a new trend in traumatic thoracolumbar fractures

The purpose of the present study was to demonstrate the feasibility and effectiveness of vertebroplasty with polymethyl methacrylate [PMMA], in combination with posterior short-segment reduction and fixation in patients with traumatic thoracolumbar fractures especially with failure of the anterior spinal column to reduce the incidence of construct failure and avoid supplementary anterior approach. Selected fifteen patients with unstable traumatic thoracolumbar fractures with incomplete neurologic deficits were included in this prospective study. They had undergone a surgery for posterior short-segment instrumentation combined with conventional transpedicular vertebroplasty. Polymethyl methacrylate was used to restore the height of anterior column. For vertebroplasty simple instruments were used. The pre and postoperative clinical assessment of the patients in this study was according to Frankel clinical grading. In all patients computed tomography [CT] spine with 3D reconstructions and occasionally magnetic resonance imaging studies were used for initial and follow-up radiological assessment beside the plain X-ray films. The mean follow-up period was one year. The postoperative radiographs and CT scans with 3D reconstruction demonstrated a good reduction of the fractures and restoration of the anterior height of the vertebral body in all patients. The anterior height of the vertebral body could be restored up to 70 - 90% of the estimated intact height. No patients showed construct failure during the follow-up period. Complications included, cement leakage in eleven cases; one patient developed additional neurological deficit. Transpedicular conventional vertebroplasty is a suitable technique to maintain the restored height of collapsed anterior column, when used in combination with posterior instrumentation; it can be effective and sufficient in management of traumatic thoracolumbar fractures to reduce the construct failure resulting from compromised anterior column

Surgical vs medical treatment of SSICH

To study and compare the effectiveness and outcome of the surgical treatment versus medical management of patients with spontaneous supratentorial intracerebral haemorrhage [SSICH]. A comprehensive review of 35 patients with spontaneous supratentorial ICH was carried out at Banha University Hospital and King Fahd General Hospital from March 1999 to September 2001. Twenty patients had surgery for clot evacuation through open craniotomy and 15 received medical management. Inclusion criteria was Glasgow Coma Score [GCS]> 5 at the time of enrollment, with focal neurological deficits and ICH volume > 20 cc on the initial brain computed tomography scan. The follow-up period was 3 months. Outcome was defined using the Glasgow Outcome Scale [GOS]. A good outcome was defined as GOS score > 3 at 3 months. Overall, the results of management of spontaneous supratentorial ICH either surgically or medically is inconclusive. Forty-six percent of the patients died [GOS 1], 34% remained severely disabled [GOS 3] and 20% became independent with moderate disability [GOS 4]. The likelihood of a good outcome [GOS>3] for the surgical treatment group differs from the medical treatment group [25% vs 13%]. There was no significant difference in mortality at 3 months [45% vs 46.6%]. At the end of the follow-up period, the median GOS score showed a nonsignificant trend towards a better outcome in the surgical treatment group against the conservative medical treatment group [56% vs 53%]. Craniotomy with clot evacuation for spontaneous supratentorial ICH may result in functional independence in approximately 25% of patients [5 out 20]. Despite this, there is no clear indication from this study for the optimal treatment of these patients, either through aggressive surgical intervention or conservative medical management

Lumbosacral perineural cysts

The treatment of lumbosacral nerve root cysts is both difficult and challenging because it produces manifestations of nerve root compression which may result from many other sources of pain such as facet joints, discs, and canal stenosis. Different surgical procedures to manage perineural cysts are being used, but a consensus on which methods are best has not been reached. We analysed surgical results for 11 patients, whom we treated between 1997 and 2002 to determine the efficacy of the procedures and factors that influence the outcome. Eleven patients with one or more lumbosacral perineural cysts presented with intractable radicular pain in one or both lower limbs, [which were not responding to medical treatment] underwent surgical decompression and marsupalisation of the cyst. The patients' data was analysed for preoperative clinical and radiological findings. All patients were examined daily, 1-week postoperatively and followed-up for 3 to 60 months to assess the surgical outcome. All patients in this study presented with clinical findings similar to those associated with other spinal epidural lesions at the same locations. Both computed tomography and magnetic resonance imaging aided in an accurate diagnosis of perineural cysts. Surgical results were excellent in 8 patients, and good in 3. There were no major intraoperative complications or new postoperative neurological deficits. Perineural cysts are rare intraspinal epidural cysts filled with CSF, and have inconsistent relation to nerve roots, without communicating with subarachnoid spaces. Surgical excision of the wall of perineural cysts usually results in considerable improvement in the patient's condition

Management of spontaneous supratentorial intracerebral hemorrhage a comparative study between surgical and medical treatment

To study and compare the effectiveness and outcome of the surgical treatment versus medical management of patients with spontaneous supratentorial intracerebral hemorrhage [ICH]. A comprehensive review of 35 patients with spontaneous supratentorial ICH is preformed at Benha university hospital and King Fahd general hospital from March 1999 to September 2001. Twenty patients had surgery for clot evacuation through open craniotomy and fifteen received medical management. Inclusion criteria were Glasgow Coma Score> 5 at the time of enrollment, with focal neurological deficits, ICH volume> 20 cc on the initial brain CT scan. The follow up period was three months. Outcome was defined using the Glasgow Outcome Scale [GOS]. A good outcome was defined as GOS score> 3 at 3 months. Overall the results of management of spontaneous supratentorial ICH either by surgical or medical treatment is potentially confounded and inconclusive. Fourty six percent of the patients died [GOS 1], 34% remained severely disabled [GOS 3] and 20% became independent with moderate disability [GOS 4]. The likelihood of a good outcome [GOS >3] for the surgical treatment group differ from the medical treatment group [25% vs 13%]. There was no significant difference in mortality at 3 months [45% vs. 46.6%]. At the end of the follow up period, the median GOS score showed a nonsignificant trend towards a better outcome in the surgical treatment group against the medical treatment group [56% vs. 53%]. Craniotomy with clot evacuation for spontaneous supratentorial ICH may result in functional independence in approximately a quarter of patients [5 out 20]. Despite this, there is no clear indication from this study for the optimal treatment of these patients either through aggressive surgical intervention or conservative medical management