Zero-profile implant versus integrated cage-plate implant in treatment of single level cervical disc disease.

The aim of this retrospective study is to evaluate and compare the clinical and radiological results of the use of Zero-P implant and the integrated cage-plate implant in surgical treatment of single level cervical disc disease. It includes 54 consecutive patients who underwent single level anterior cervical discectomy and fusion. The patients were divided into 2 groups. Group (A) including 28 patients operated with zero- profile implant and group (B) including 26 patients operated with integrated cage-plate implant. Mean operative time, blood loss, incidence of dysphagia and any other complications related to the procedure were recorded and compared. Patients were assessed radiologically by measuring cervical lordosis using the Cobb angle and the segmental angle. Patients were assessed clinically by the Japanese orthopedic association score and the neck disability index. These values were also compared. The mean age of the patients in group (A) was 49.5±11 years, and in group (B) it was 49.8±11.6 years. Mean blood loss and operative time in group (A) were 77.3±9.4 ml and 72.1±7.9 minutes, while in group B, they were 80.7±9.5 ml and 74.8±8.4 minutes with no statistically significant difference between both groups. There were also no statistically significant difference between both groups as regards incidence of dysphagia, clinical scores nor radiological parameters. In conclusion, both zero-profile implant and integrated cage-plate implant have comparable satisfactory clinical and radiological results in treatment of single level cervical disc diseases with little complications.

Pars interarticularis repair using pedicle screws and laminar hooks fixation technique in patients with symptomatic lumbar spondylolysis.

STUDY DESIGN: Prospective case series. PURPOSE: To assess the outcomes of pars repair surgery using pedicle screws and laminar hooks. METHODS: This study was conducted on 22 patients with symptomatic lumbar spondylolysis. Curettage of the fibrocartilage in the defect and drilling of the sclerotic bone ends were done, followed by impaction of cancellous bone graft. Pedicle screws were inserted bilaterally in the corresponding pedicles and connected to a laminar hook via rods (screw-rod-hook fixation). The intensity of back pain and the functional outcome were assessed using the visual analog scale (VAS) and the Oswestry disability index (ODI). Plain radiographs were performed immediately postoperatively and after 3 and 6 months. CT scan was done at the final follow-up to assess pars healing. The mean follow-up period was 27 months. RESULTS: The mean preoperative VAS and ODI were 7.4 ± 0.8 and 64.8 ± 6.7, which improved to 2.4 ± 0.8 and 20 ± 6 respectively at the final follow-up (P < 0.001). Healing of the defect was found in 19 patients at the final follow-up. Non-fusion with graft resorption was noticed in the remaining 3 cases (13.6%). However, postoperative VAS and ODI values improved even in the radiologically non-fused patients. LEVEL OF EVIDENCE: Therapeutic study, Level IV. CONCLUSION: Pars repair using pedicle screws and laminar hooks is a relatively simple yet effective procedure.

Solving the enigma of posterolateral tibial plateau fractures, the clue protocol.

The study aim is to evaluate functional and radio- logical outcomes following a suggested protocol based on the four-column classification for management of posterolateral column tibial plateau fractures. A prospective cohort study was performed in level I academic center on 42 patients with mean age of 36 years (22-59). Eleven patients had isolated posterolateral column fractures whereas 31 patients had associated columns fractures. According to the suggested protocol, all cases of isolated posterolateral column fracture started treatment via arthroscopic evaluation of soft tissue injuries (menisci and liga- ments), arthroscopically assisted reduction and inter- nal fixation by rafting screws followed by ORIF if plating was needed. If associated with other columns fractures, columns were fixed sequentially in an anti-clockwise direction starting from anteromedial column. Average follow up was 26 months. Mean time to union was 16.3 (12-22) weeks. No radiological evidence of loss of coronal or sagittal alignment was detected at final follow up. Five patients had an average depression of 5 millimeters that did not need further intervention at this short-term follow up. Mean KOOS was 81 (72- 88). The average knee range of motion was (0° - 127°). One patient had temporary common peroneal nerve injury, one patient had deep infection and two had superficial wound infection. implementing the suggested protocol gives good to excellent radiological and functional results as regard posterolateral tibial plateau fracture. A larger study group with longer follow up is needed.

Interbody fusion versus posterolateral fusion in treatment of low grade lytic spondylolisthesis.

This is a prospective randomized study to compare the outcome of two widely used fusion methods ; posterior lumbar interbody fusion (PLIF) and posterolateral fusion (PLF) in treatment of adult low grade lytic spondylolisthesis to know which is ideal. 40 consecutive patients with single level lytic spondylolisthesis were randomly divided into two treatment groups when undergoing surgery. Blood loss and operative time were recorded. Patients were postoperatively assessed using JOA score. Union rate was assessed. They were followed up for a minimum of 2 years. No differences were found between both groups as regards operative time and blood loss. At 2 years follow up, statistically significant improvement in JOA scores were found in both fusion groups. However, no difference could be found between the groups. Both groups showed solid fusion with no evidence of non-union in all cases. Both methods appear to be equally effective in treatment of the condition.

Bifocal Compression-Distraction for Combined Bone and Soft-Tissue Defects in Post-traumatic Tibial Nonunion.

OBJECTIVE: To compare 2 distraction osteogenesis techniques in post-traumatic tibial nonunion patients with composite bone and soft-tissue defects. DESIGN: Nonrandomized prospective, case series, single-center study. SETTING: Department of Orthopaedics and Traumatology, Limb Reconstruction Unit, El-Helal hospital, Cairo, Egypt. PARTICIPANTS: Fifty post-traumatic tibial nonunion patients with composite bone and soft-tissue defects. INTERVENTION: Twenty-five patients were treated using bone transport (BT) technique, and 25 patients were treated using acute shortening (AS) and distraction technique. OUTCOME MEASUREMENTS: The external fixation index (EFI); functional and bone results; and complication rates. RESULTS: All patients were followed for a minimum of 18 months after removal of their Ilizarov frame. AS and BT groups were followed up for a mean of 19.7 and 20.3 months, respectively. The mean bone gap after resection and debridement was 4 cm in AS group and 5.9 cm in BT group (P = 0.06). The mean EFI was statistically significant and lower in the AS group compared with BT group (P = 0.03). There were no other statistically significant differences between either intervention groups. CONCLUSIONS: Both techniques achieved comparable good to excellent results, and the differences in number of complications and ASAMI scores for bone or function were not statistically significant. Yet, it appears that the AS technique may be superior because it has a significantly lower EFI. This may not be feasible in all cases, however, because the AS technique is limited by the defect size and the condition of the surrounding soft tissues. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Plate augmentation combined with bone grafting for aseptic non-union of femoral shaft fractures following interlocking nails.

TThe aim of this study was to evaluate plate augmentation over previously inserted interlocking nails, combined with iliac bone grafting in treating aseptic femoral shaft non-unions. The research was conducted prospectively on 34 patients. A narrow dynamic compression plate was placed while the nail was retained. All the screws were directed posterior to the nail. There were 25 males and 9 females with mean age of 36.6 years old. The mean operative time was 95 minutes with 320ml blood loss. 28 patients showed solid healing by 6 months postoperatively (82%). By 8 months, all patients showed solid union (mean 6.3 months). Full range was regained in both hips and knees and all patients could walk bearing full weight without supportive devices by 8 months. Where non-union occurs over an interlocking nail, augmenting it with a plate and bone grafting appears to be an effective treatment method to obtain solid union.

Volumetric change in interbody bone graft after posterior lumbar interbody fusion (PLIF): a prospective study.

PURPOSE: The purpose of this study is to quantify the change in the volume of the interbody bone graft after the PLIF and monitor the change over time for subsequent analysis. METHODS: The 114 cases were selected as the subjects of this study. The observation period was for 5 years following the surgery. The volume of the bone graft in the interbody space was calculated by summing up the cross-sectional area of the bone graft on each axial image multiplied by the height (2 mm) (the volume of the two cages was excluded). The volume ratio (%) = (bone graft volume)/(total volume of the interbody space - cage volume) was used for the purpose of evaluation. RESULTS: The volumetric change of the bone graft was 51 % (3 months), 53 % (6 months), 54 % (1 year), 55 % (2 years), 59 % (3 years), 62 % (4 years), and 72 % (5 years), indicating a continued increase up to the 5-year mark. In particular, a significant increase was observed from the second year as compared with the previous years' result. Additionally, the volumetric increase from the second year to the fifth year was significantly higher than that before the second year. CONCLUSIONS: The post-PLIF volumes of interbody bone grafts exhibited increases particularly from the second to fifth years after the procedure. Even the elderly and those with poor bone qualities can expect to have volumetric increases over time. Sufficient interbody space should be secured for accommodating bone grafts by intraoperative reduction, wherever possible.

A new criterion for the alarm point for compound muscle action potentials.

OBJECT: The purpose of this study was to review the present criteria for the compound muscle action potential (CMAP) alert and for safe spinal surgery. METHODS: The authors conducted a retrospective study of 295 patients in whom spinal cord monitoring had been performed during spinal surgery. The waveforms observed during spinal surgery were divided into the following 4 grades: Grade 0, normal; Grade 1, amplitude decrease of 50% or more and latency delay of 10% or more; Grade 2, multiphase pattern; and Grade 3, loss of amplitude. Waveform grading, its relationship with postoperative motor deficit, and CMAP sensitivity and specificity were analyzed. Whenever any wave abnormality occurred, the surgeon was notified and the surgical procedures were temporarily suspended. If no improvements were seen, the surgery was terminated. RESULTS: Compound muscle action potential wave changes occurred in 38.6% of cases. With Grade 1 or 2 changes, no paresis was detected. Postoperative motor deficits were seen in 8 patients, all with Grade 3 waveform changes. Among the 287 patients without postoperative motor deficits, CMAP changes were not seen in 181, with a specificity of 63%. The false-positive rate was 37% (106 of 287). However, when a Grade 2 change was set as the alarm point, sensitivity was 100% and specificity was 79.4%. The false-positive rate was 20% (59 of 295). CONCLUSIONS: Neither the Grade 1 nor the Grade 2 groups included patients who demonstrated a motor deficit. All pareses occurred in cases showing a Grade 3 change. Therefore, the authors propose a Grade 2 change (multiphasic waveform) as a new alarm point. With the application of this criterion, the false-positive rate can be reduced to 20%.

Posterior approach for cervical fracture-dislocations with traumatic disc herniation.

In the treatment algorithm for cervical spine fracture-dislocations, the recommended approach for treatment if there is a disc fragment in the canal is the anterior approach. The posterior approach is not common because of the disadvantage of potential neurological deterioration during reduction in traumatic cervical herniation patients. However, reports about the frequency of this deterioration and the behavior of disc fragments after reduction are scarce. Forty patients with traumatic disc herniation were observed. They represented 29.2% of 137 consecutive patients with subaxial cervical spine fracture-dislocations. Surgical planning was performed according to our two-stage algorithm. In the first stage, they were treated with posterior open reduction and posterior spine arthrodesis. In the second stage, anterior surgery was added for cases where neurological deterioration attributed to non-reduced disc fragments on postoperative magnetic resonance imaging (MRI). Neurological deterioration after posterior open reduction was not observed. Furthermore, 25% of total cases and 75% of incomplete paralysis cases improved postoperatively by ≥ 1 grade in the American Spinal Injury Association impairment scale. Reduction or reversal of disc herniation was observed in all cases undergoing postoperative MRI. For local sagittal alignment, preoperative 9.4° kyphosis was corrected to 6.9° lordosis postoperatively. The disc height ratio was 72.4% preoperatively and 106.3% postoperatively. The second stage of our plan was not required after the posterior approach in this series. The incidence of neurological deterioration after posterior open reduction was zero, even in cases with traumatic cervical disc herniation. Favorable clinical and radiological outcomes could be obtained by the first stage alone. Although preparations for prompt anterior surgery should always be made to cover any contingency, the need for them is minimal.

Cervical spine osteolysis in a case of undifferentiated spondyloarthropathy with features mimicking neoplasm or infection.

STUDY DESIGN: Case Report. OBJECTIVE: To present a case of undifferentiated spondyloarthropathy with sternocostoclavicular arthro-osteitis and osteolyis of cervical body requiring surgical reconstruction of the spine and describing the findings which resembled multiple metastases or infection. SUMMARY OF BACKGROUND DATA: Sternocostoclavicular arthro-osteitis is not infrequent in Japan. It has been reported in patients with seronegative spondyloarthropathies as psoriatic arthropathy or its variant, palmoplantar pustulosis. Cervical spine involvement in the seronegative spondyloarthropathy is usually in the form of syndesmophytes, subluxations, or facet erosions/ fusions. To the best of our knowledge, this is the first report on severe osteolytic cervical spondylitis associating anterior chest wall disease, to the extent that surgical reconstruction is needed. METHODS: A 64 year-old woman presented with neck pain. Cervical spine imaging revealed osteolysis and crumbling of C5 vertebral body. Computed tomography of the thorax showed multiple erosions of the anterior chest wall. Multiple hot spots were detected by bone scan. Biopsies were obtained to exclude neoplasm and infection. Surgical reconstruction via combined anterior-posterior approach was performed to achieve solid spine arthrodesis. RESULTS: Neoplasm and infection were excluded. Careful reassessment alerted to the diagnosis of undifferentiated spondyloarthropathy. Solid arthrodesis and pain relief could be obtained by surgery together with medical control of the disease.