[Intra-operative myelography in treatment of fractures of thoracolumbar spine]. / Peroperacná perimyelografia pri liecbe zlomenín torakolumbálnej chrbtice.

PURPOSE OF THE STUDY: The aim of this retrospective study was to evaluate the results of intra-operative myelography as the method used to assess the reduction of bone fragments from the posterior margin of the vertebral body. MATERIAL AND METHODS: Forty patients with 42 comminuted fractures of the thoracolumbar spine were included in the study. The pre-operative spinal stenosis caused by bone fragments from the posterior margin of the vertebral body, as detected by CT scanning, ranged from 25 % to 85 %. Neurological deficit was due to injury in 19 patients and in one it developed post-operatively after the patient stood and walked. After ligamentotaxis and internal fixation, intra-operative myelography was used to show decompression of the spinal canal. A spinal block or severe constriction of contrast flow was an indication for hemilaminectomy (laminectomy) and direct decompression of the spinal canal. In the patients with neurological deficit and severe spinal stenosis persisting after ligamentotaxis and detectable by skiascopy, hemilaminectomy (laminectomy) and direct spinal decompression followed by intra-operative myelography were carried out. RESULTS: Intra-operative myelography was used 46 -times (20-times in 20 patients free from neurological deficit and 26-times in 20 patients with neurological deficit). In 38 cases (82.6 %) dural sac compression was not present (patients with neurological deficit, 13-times after ligamentotaxis, eight-times after ligamentotaxis and hemilaminectomy with direct decompression, twi- ce at repeat surgeryúúú patients without neurological deficit, 15-times). On two occasions (4.4 %) the contrast agent injected into the dural sac did not make the interior body part visible, on three occasions (6.5 %) contrast medium was injected extradurally, and dural sac compression following ligamentotaxis requiring hemilaminectomy (laminectomy) and direct decompression occurred in three cases (6.5 %). In the patients without neurological deficit, dural sac compression was not recorded. No serious complications associated with contrast medium injection in the dural sac were present, and there was no deterioration of neurological symptoms due to a dural tap. In three cases (6.5 %) a false negative finding was recorded, showing free flow of contrast medium with no areas of constriction or obstruction and signs of post-operative nerve irritation ( radicular syndrome associated with L3 fracture with a fragment placed laterally in two patients and hyperalgesia of the thigh after T12 fracture in one patient). Repeat surgery and additional decompression (hemilaminectomy and foraminotomy, laminectomy) resulted in immediate resolution of neurological symptoms. DISCUSSION: The success rate, complications and disadvantages of intra-operative myelography have not been reported. At present, ionic water-soluble contrast agents used for intrathecal administration are associated with only a low number of serious complications. Neurological deficit due to dural tap is rare. Extradural administration is not effective. A disadvantage reported here involves a failure to visualize the area because of a low amount of contrast agent administered to avoid spinal cord injury. A possibility of false negative findings arising from only one lateral view of the contrast agent flowing round fragments is the major disadvantage. In contrast to the previous reports, we relate the false negative findings to neurological findings. CONCLUSIONS: Intra-operative myelography is still a currently used method. Its advantages include a simple procedure without removal of posterior column structures, and the possibility of objective recording and continuous observation of the dural sac. The free flow of contrast medium makes obstruction of the spinal canal impossible. The consequences of a false negative finding can be successfully treated at the second stage.

[Current trends of the treatment of the femoral neck fractures in seniors]. / Súcasný trend lie'cby zlomenín krcka stehnovej kosti u seniorov.

INTRODUCTION: Proximal femur fracture of the seniors is often "omen" for their life. These fractures are the most frequent cause of acute hospitalization of the aged and on the contrary to previous years the procedures are considered as emergent - life saving. OBJECTIVE: The aim of the study was to find out which of the contemporary used surgical procedures for the treatment of unstable femoral neck fractures at the Department of Trauma Surgery in Kosice yield in the lowest number of failures and postoperative complications. Subsequently we have analyzed changes in surgical treatment of these fractures in two time periods (1999-2001) and (2002-2004) respectively. According to review of the literature and our knowledge we tried to suppose algorithm of their treatment. MATERIAL AND METHODS: There were 563 patients over 65 years were assigned to the retrospective clinical trial. They underwent the internal fixation or arthroplasty for unstable femoral neck fractures between January 1999 and December 2004 and were registered at least one year after the surgery. RESULTS AND CONCLUSION: The results from the clinical trial show that it is more suitable to use internal fixation for biologically younger seniors with fractures of proximal femur. Hemiarthroplasty is indicated for the patients with assumed short-term life expectancy and total hip arthroplasty remains the method of choice for the treatment of the failure of the other surgical procedures. There is decrease of number of implanted hemiarthroplasties in comparison of two analyzed time periods. Moreover, number of treated patients in the later period has increased.

Plasma fibrinogen level and the risk of major cardiovascular diseases and nonvascular mortality: an individual participant meta-analysis.

CONTEXT: Plasma fibrinogen levels may be associated with the risk of coronary heart disease (CHD) and stroke. OBJECTIVE: To assess the relationships of fibrinogen levels with risk of major vascular and with risk of nonvascular outcomes based on individual participant data. DATA SOURCES: Relevant studies were identified by computer-assisted searches, hand searches of reference lists, and personal communication with relevant investigators. STUDY SELECTION: All identified prospective studies were included with information available on baseline fibrinogen levels and details of subsequent major vascular morbidity and/or cause-specific mortality during at least 1 year of follow-up. Studies were excluded if they recruited participants on the basis of having had a previous history of cardiovascular disease; participants with known preexisting CHD or stroke were excluded. DATA EXTRACTION: Individual records were provided on each of 154,211 participants in 31 prospective studies. During 1.38 million person-years of follow-up, there were 6944 first nonfatal myocardial infarctions or stroke events and 13,210 deaths. Cause-specific mortality was generally available. Analyses involved proportional hazards modeling with adjustment for confounding by known cardiovascular risk factors and for regression dilution bias. DATA SYNTHESIS: Within each age group considered (40-59, 60-69, and > or =70 years), there was an approximately log-linear association with usual fibrinogen level for the risk of any CHD, any stroke, other vascular (eg, non-CHD, nonstroke) mortality, and nonvascular mortality. There was no evidence of a threshold within the range of usual fibrinogen level studied at any age. The age- and sex- adjusted hazard ratio per 1-g/L increase in usual fibrinogen level for CHD was 2.42 (95% confidence interval [CI], 2.24-2.60); stroke, 2.06 (95% CI, 1.83-2.33); other vascular mortality, 2.76 (95% CI, 2.28-3.35); and nonvascular mortality, 2.03 (95% CI, 1.90-2.18). The hazard ratios for CHD and stroke were reduced to about 1.8 after further adjustment for measured values of several established vascular risk factors. In a subset of 7011 participants with available C-reactive protein values, the findings for CHD were essentially unchanged following additional adjustment for C-reactive protein. The associations of fibrinogen level with CHD or stroke did not differ substantially according to sex, smoking, blood pressure, blood lipid levels, or several features of study design. CONCLUSIONS: In this large individual participant meta-analysis, moderately strong associations were found between usual plasma fibrinogen level and the risks of CHD, stroke, other vascular mortality, and nonvascular mortality in a wide range of circumstances in healthy middle-aged adults. Assessment of any causal relevance of elevated fibrinogen levels to disease requires additional research.