Sagittal plane configuration of the sacrum in spondylolisthesis.

STUDY DESIGN: A radiographic study of the sagittal sacral deformity in spondylolisthesis. OBJECTIVES: To characterize and classify the pathoanatomy of sagittal sacral deformation in spondylolisthesis. SUMMARY OF BACKGROUND DATA: Spondylolisthesis has been extensively described and reviewed in the literature. Deformity of the entire sacrum in spondylolisthesis potentially could affect the natural history, treatment options, and outcome. The sagittal contour of the entire human sacrum has never been quantitatively studied in spondylolisthesis. METHODS: A literature search was performed and data was gathered retrospectively on patients with spondylolisthesis at the authors' institution. Cases of degenerative spondylolisthesis were excluded. Specifically those patients with L5-S1 spondylolisthesis were studied. The authors studied standing lateral radiographs and performed statistical analysis to understand morphologic relations. RESULTS: A broad range of global sacral kyphosis (37-188 degrees ) exists in spondylolisthesis. Increasing sacral kyphosis is significantly associated with increasing percent slip, sacral horizontal angle, Neuman's classification, lumbar lordosis, and lumbar index. A simple classification of the spectrum of sacral deformity in the sagittal plane is presented. CONCLUSION: The entire sacrum in spondylolisthesis can develop a significant kyphotic deformity in the sagittal plane, and this is associated with other abnormalities found in the lumbosacral spine. Sacral deformity is a significant factor in the assessment of the sagittal contour of the patient with L5-S1 spondylolisthesis.

An open, minimally invasive approach to the lumbar spine.

A minimum 2-year follow-up retrospective review was undertaken to assess our experience with an anterior paramedian muscle-sparing approach to the lumbar spine for anterior spinal fusion (ASF). The records of 28 patients (November 1991 through January 1996) undergoing ASF via a left lower quadrant transverse skin incision (6-10 cm) with a paramedian anterior rectus fascial Z-plasty retroperitoneal approach were reviewed. Diagnosis, number, and level of lumbar interspaces fused, types of fusion, estimated blood loss, length of procedure, length of hospital stay, and complications were analyzed. All cases were completed as either a same-day anterior/posterior (24 of 28) or as a staged procedure at least 1 week after posterior fusion (4 of 28). The General Surgery service performed the muscle-sparing approach, whereas the Orthopedic Spine service performed the ASF. There were 14 men and 14 women, with a mean age of 35.5 years (range, 11-52 years). Diagnoses included spondylolisthesis in 20 cases (including four grade III or IV slips), segmental instability (degenerative or postsurgical) in 7, and 1 flatback deformity. A single level was fused in 20 cases (L4/5 in 4 and L5/S1 in 16), two levels were fused in 5 cases (L4/5 and L5/S1) and three levels were fused in 2 cases (L3/4, L4/5, and L5/S1). The mean length of stay was 7.4 days (range, 5-12 days). The mean estimated blood loss was 300 mL for the anterior procedure alone and 700 ml for both anterior/posterior procedures on the same day. The mean length of operating room time for the anterior approach and fusion was 117 minutes (range, 60-330 minutes). Posterior instrumentation was used in all cases. Anterior interbody struts used included 19 autogenous tricortical grafts, 4 fresh-frozen allografts (2 femoral rings and 2 iliac crests), 3 carbon fiber cages packed with autogenous bone, and a Harms titanium cage with autograft. There was one L5 corpectomy for which a large tricortical allograft strut was utilized. There were no vascular, visceral, or urinary tract injuries. In three cases a mild ileus developed, which resolved spontaneously. We conclude that the anterior paramedian muscle-sparing retroperitoneal approach is safe, uses a small skin incision, avoids cutting abdominal wall musculature, and allows for multiple-level anterior spinal fusions by a variety of interbody fusion techniques. This approach does not require transperitoneal violation or added endoscopic instrumentation, nor does it limit fusion level and technique of fusion, as is the case with the recently popularized laparoscopic approach to the lumbar spine.

An evaluation of spinal deformity in metastatic breast cancer.

Between October 1984 and January 1988 31 magnetic resonance (MR) imaging studies were performed on 27 patients with metastatic vertebral breast cancer (MVBC). The MR images were reviewed to determine the extent and type of sagittal spinal deformity, and whether spinal canal compromise was present. Adjunct studies were compared to determine the pathogenesis of spinal deformity and the etiology of spinal canal compromise. An analysis of the data revealed that a consistent pattern of sagittal spinal deformity exists with MVBC, and a classification system was developed to describe the stages of vertebral deformity. Criteria are suggested for identifying metastatic spinal instability. A protocol is presented for treating patients with metastatic spinal involvement. By understanding the natural history of metastatic spinal deformity, instability and spinal canal compromise can be recognized and treated early, before the onset of progressive deformity and neurologic sequelae.

The pattern of vertebral involvement in metastatic vertebral breast cancer.

The spine is a common site of bony metastasis. To date, studies have not identified the initial site and pattern of vertebral metastasis in a homogeneous group of patients. Twenty-seven magnetic resonance imaging studies performed on 25 patients with metastatic vertebral breast cancer were reviewed retrospectively. The location and extent of metastatic vertebral involvement were determined. The vertebral body is the most frequent initial site of metastatic seeding. Although radiographically an absent pedicle is often the first sign of metastatic disease, involvement of the pedicle is by direct extension from either the vertebral body or the posterior elements and is therefore a late occurrence in the disease process.

Extracorporeal hemolysis in orthopedic patients. Report of two cases.

Two patients who had extracorporeal hemolysis of their blood transfusions are reported. In both cases, accidental overheating and hemolysis of the transfused blood caused a gross hemoglobinuria. Because the etiology of the hemolysis was not readily apparent at the time, both patients were managed as though they had had an acute hemolytic transfusion reaction. Because there was no activation of the complement cascade by antigen-antibody complexes, both patients suffered no ill effects. Differentiation of extracorporeal hemolysis from hemolytic transfusion reactions requires a careful inspection of all blood administration equipment, as well as an analysis of the untransfused blood in both bag and tubing. Patients undergoing orthopedic procedures account for 15% of all blood transfused in the United States. Awareness of adverse effects of transfusion is therefore important to orthopedic surgeons.

Zielke instrumentation.

Zielke modified Dwyer's anterior spinal instrumentation to produce the Ventral Derotational Spondylodesis (VDS) System. The primary indication for VDS instrumentation is the treatment of progressive, single, major lumbar or thoracolumbar curves in idiopathic scoliosis. The surgical technique, including selection of appropriate curvatures and levels of instrumentation, is described. A group of 25 consecutive patients undergoing VDS instrumentation for lumbar or thoracolumbar curvatures was reviewed. The average correction of the major curve was 76%. The minor curvature was corrected with an average of 47%. A significant complication was a 20% incidence of pseudarthrosis and rod breakage. The implications of these problems are discussed. Zielke instrumentation is a powerful technique for the correction of selected curves. The system provides greater correction of the major curve, improved frontal and sagittal alignment, and preservation of distal motion segments.

Luque rod stabilization for metastatic disease of the spine.

Instability of the spine caused by metastatic spread of primary tumors represents a serious risk for spinal cord or nerve root compression. In order to restore stability and relieve neural compression, a variety of surgical techniques originally used for reduction of nonpathologic spinal fractures have been applied to the problem of spinal metastases. Recently, we have utilized a technique developed primarily for correction of scoliosis to the treatment of metastatic spinal fractures. Six patients with spinal instability and neural compression secondary to metastatic tumors had segmental spinal stabilization with Luque rods, sublaminar wiring, and methyl methacrylate. Restoration of stability was successful in all cases with alleviation of preoperative pain and return to full activity. No evidence of instability occurred in this group of patients. As demonstrated by this experience and that of a few other small series, Luque rod stabilization provides a valuable addition to the techniques available for stabilization of metastatic fractures of the spine. Although the precise role of Luque rod segmental spinal stabilization in treatment of metastatic disease of the spine continues to be defined, thus far it has proved beneficial for cases of multiple vertebral body involvement or instability beyond one vertebral level.

Reconstructive spinal surgery as palliation for metastatic malignancies of the spine.

Metastatic tumors of the spine often cause severe pain and paralysis because of deformity and neural encroachment. As oncology now extends the life expectancies of these patients, spinal decompression and stabilization is necessary. We consider that prophylactic stabilization of the spine is analogous to prophylactic nailing of a femur with a pathologic lesion. Both the femur and spine are weight-bearing structures. The advent of segmental instrumentation makes this a feasible accomplishment with minimal morbidity. Seventeen patients with metastatic disease of the spine at Rush-Presbyterian-St. Luke's Medical Center, Chicago, were reviewed. All maintained spinal stability postoperatively. Eleven of the 17 had significant pain relief for 3 months or more. Five of 11 paralyzed patients had significant neural recovery. A classification for treatment purposes regardless of tissue type was developed. Once classified, the surgical goals for these patients were to decrease pain, to preserve or to improve neurologic function and to mobilize the patient without external orthosis.

Burst fractures of the thoracic and lumbar spine.

A burst fracture may be defined as an unstable compression fracture of the posterior wall of the vertebral body that allows fragments to be retropulsed into the spinal canal. Computerized axial tomography evaluation of these injuries often reveals posterior element fracture heretofore not stressed in the literature. In surgical treatment for these injuries four important considerations must be met; (1) the coronal and sagittal alignment of the spine; (2) patency of the neural canal; (3) the two-column concept of spinal stability; and (4) bony vertebral body reconstitution. An algorithm for treatment may be developed with the aid of these principles. Distraction and the creation of spinal lordosis are necessary for reduction.

Associated practice: a case for professional collaboration.

The establishment of a successful nurse-physician associated practice requires planning, patience, and a willingness to take calculated risks. The nurse executive can lend credibility and support to the nurse in associated practice by understanding the concept, providing a climate for acceptance of such practices, and by clarifying the role of the nurse associate in relation to other professionals in the organization. In this article the authors describe models for associated practice, as well as the measures necessary to ensure peer and patient acceptance and effective health care delivery.

The treatment of severe scoliosis in osteogenesis imperfecta. Case report.

Surgical stabilization of the scoliotic spine in osteogenesis imperfecta (OI) is technically difficult owing to the mechanical weakness of the bone. Brittle bone makes instrumentation of the spine a procedure all too often associated with complications. Combining the instrumentation of the OI spine, both anteriorly and posteriorly, with the use of methylmethacrylate to augment the fixation may prove valuable as a surgical technique. This usage of methylmethacrylate in correcting severe scoliosis in OI has not been previously reported.

Methylmethacrylate reconstruction of large iliac crest bone graft donor sites.

Often full-thickness iliac crest grafts are necessary for various reconstructive procedures. Sometimes large defects remain in the donor ilium subsequent to their removal. Several complications have occurred as a result of these bony defects. Although several reports have been published regarding the repair of iliac herniae, little has been written about procedures to prevent these complications. A technique was devised to reconstruct the ilium with methylmethacrylate. After preparation of the defect, malleable retractors are bent to conform to the contour of the iliac crest. Methylmethacrylate is then packed into the mold made by the retractors. After hardening, the methylmethacrylate casting of the defect is trimmed and routine soft tissue closure is performed. This technique has been used in eight patients without any complications. The appearance of the waist and crests has been excellent; there have been no fractures or displacements of the mass of cement and there have been no infections. All these reconstructions have been mechanically stressed as all patients had well molded postoperative casts and/or braces. Reconstruction of the ilium with methylmethacrylate after removal of full-thickness grafts appears to be a reliable, safe, and easy technique based on a short-term follow-up of up to three years.

Severe lumbosacral spondylolisthesis in adolescents and children. Reduction and staged circumferential fusion.

Using a new surgical regimen, fourteen patients with lumbosacral spondylolisthesis and more than 50 per cent slipping were treated by reduction of the slip with two Harrington distraction rods extending from the first lumbar laminae to the sacral alae and bilateral posterolateral fusion from the fourth lumbar to the second sacral segment. Then, at a second procedure, thirteen had an anterior lumbosacral fusion using two bicortical wedge-shaped iliac grafts. The distraction rods were removed six to twelve months later. At follow-up, correction of the slips ranged from 70 to 100 per cent. In four of the thirteen patients the reduction was improved by 10 to 13 per cent during the anterior procedure. In one patient, a twenty-one-year-old women with a slip of more than 100 per cent, a cauda equina syndrome developed after the reduction and posterolateral fusion, and this necessitated removal of th rods and cancellation of the anterior fusion. This patient recovered completely and her final result was a solid posterolateral fusion in situ, with her abnormal posture and gait unchanged. The other thirteen patients, after follow-up ranging from two years to six years and seven months, had solid fusion, normal spinal alignment, normal anatomy of the spinal canal, and normal posture and gait. Only one patient had loss of correction during follow-up, which amounted to 7 per cent. We concluded that correction of severe spondylolisthesis (50 per cent or more) in properly selected patients can be accomplished by this two-stage procedure without risk of further slipping, pseudarthrosis, persistent deformity, or recurrence of the slip due to late remodeling.

Anterior and posterior spinal fusion for paralytic scoliosis.

Twenty-three patients with paralytic scoliosis were treated with a combination of anterior and posterior spinal instrumentation and fusion. The sequence was anterior surgery first in 19 patients and posterior surgery first in 4. The average age was 14.4 years. Preoperative correction with a halo-hoop apparatus was performed in 12 patients. The average preoperative curve for the group measured 100 degrees, and the average postoperative curve at a mean follow-up time of 21 months was 37 degrees. The mean loss of correction was 8 degrees. Although superior hook dislodgment occurred in 5 patients, no pseudarthrosis or beinding of the fusion mass was documented.

Simultaneous anterior and posterior surgical approach to the thoracic and lumbar spine.

A technique for the simultaneous anterior and posterior surgical approach to the thoracic and lumbar spine is presented. No intraoperative repositioning of the patient is required. The procedure requires a surgical team of two spinal surgeons and two assistant surgeons, as well as an anesthesiologist familiar with hypotensive techniques. The procedure as utilized in 14 cases has proven to be safe and expeditious. The simultaneous anteroposterior approach has proven to be especially useful in cases with combined anterior and posterior instability. The technique described provides the experienced spinal surgeon with the best solution to certain complex spinal problems.

Harrington rod distraction instrumentation: its effect on vertebral rotation and thoracic compensation.

The effects of Harrington rod distraction instrumentation on vertebral rotation and thoracic decompensation were investigated radiographically both pre- and post-operatively. A method for semiquantitatively evaluating thoracic decompensation is introduced to serve as an adjunct to the evaluation of spinal deformity. Although little derotation of the vertebrae occurs with lateral correction, thoracic decompensation should be significantly improved.