Kyphosis - A risk factor for positioning brachial plexopathy during spinal surgeries.

OBJECTIVE: The aim of this study was to evaluate the differences in transcranial electric motor-evoked potentials - TceMEP on upper limbs and the incidences of postoperative brachial plexopathy between patients with kyphotic and scoliotic trunk shapes. METHODS: In the period of January 2011-January 2017, 61 consecutive patients (mean age: 18.4 years ± 4.4 years (range: 10-32)) with pediatric spinal deformity underwent surgery in our Department. Eight of them had a kyphotic trunk deformity (Scheuermann kyphosis, neurofibromatosis, posterior thoracic hemivertebra), and the rest of the 53 patients had a scoliotic trunk deformity (mostly adolescent idiopathic scoliosis - AIS, lateral hemivertebra). The TceMEP recordings in all four limbs were analyzed every 30 min, or upon the surgeon's command. Upper limb TceMEP recordings were used as a control of systemic and anesthetic related changes, and as the indicator of positioning brachial plexopathy. RESULTS: Four out of 8 patients (50.0%) from the kyphotic group experienced noteworthy decreases in TceMEP amplitude (≥65%) in one or both arms, and only 2 out of 53 patients (3.8%) from the scoliotic group, confirming significant statistical difference (Chi-square 16.75, p < 0.05). Two out of 8 patients with decreases in TceMEP amplitude suffered from transitory postoperative brachial plexopathy, and both of them were from the kyphotic group. CONCLUSION: It seems that kyphotic trunks have a higher risk for positioning-related brachial plexopathy, probably due to distribution of trunk's weight onto only four points (two iliac bones and two shoulders), compared to the scoliotic trunks that have wider weight-bearing areas. We emphasize the importance of proper patient positioning and close intraoperative neuro-monitoring of all four limbs in more than one channel per limb. LEVEL OF EVIDENCE: Level IV Therapeutic Study.

Postoperative infections after posterior spondylodesis of thoracic and lumbal spine. Surgical spine infections.

BACKGROUND: Postoperative infection after posterior spondylodesis of thoracic and lumbal spine is the most common complication, and a reason for revision surgery. Aim of this work is to analyze rate of postoperative spine infections at our institution, and to determine eventual risk factors. SUBJECTS AND METHODS: In our paper we analyze incidence of deep surgical infections after posterior spondylodesis, performed on our Spine department during last 5 years (September 1, 2008 - September 1, 2013). Including criteria were: posterior spondylodesis with transpedicular screws from Th1 to S2 due to different spine indications (injuries, degenerations, deformities, tumors), absence of local or general infection prior the index surgery, surgery performed by the same surgeon (MB). Excluding criteria were: needle procedures (kypho/vertebro-plasties, nerve root and faset blocades), anterior spine surgeries, cervical spine surgeries, and decompresive surgeries. RESULTS: One hundred sixty five patients with 183 surgeries have been included in this study. Early surgical infection (within a month after the surgery) has appeared at five patients (2.7%). There have been no late surgical infections. Analyzing patients' charts, we have found that Meticillin-susceptible Staphylococcus aureus (MSSA) and Methicillin-resistant Staphylococcus aureus (MRSA) have caused infections in two patients, while Clebisiela pneumoniae ESBL has caused infection in one patient. Those five patients with infections have had further risk factors: long preoperative hospitalization at four patients, polytrauma, diabetes and advanced age at one patient, each. Three patients with postoperative infection had completely non-titanium surface of implants, and other two had about 20% of non-titanium implant surface, although vast majority of surgeries have been performed by implants whose surface was completely titanium alloy. Infections have appeared between 10-30 postoperative days. In two patients where revision surgeries (debridement, drainage, antibiotic according the species) had been performed in two weeks after appearance of infection, infections have been cured. In three patients where revisions had been postponed for longer than two weeks, additional surgeries (removal of implants) were necessary for curing the infections. CONCLUSIONS: This study presented that rate of infection, microbiological species and risk factors are similar to the other orthopedics procedures and other institutions. Early revision is preferable, since it effectively avoids implant removal.

The radiological estimation of vertebral body volumes on the thoracic and lumbal spine.

The aim of this work is to radiologicaly estimate the width, height and depth of bodies of thoracic and lumbal vertebras. Charts of one hundred and seventeen patients with implanted internal fixateur on the thoracic and lumbal spine, between 01.01.2008. and 31.3.2010. at the Department of Orthopedics and Traumatology - Clinical Centre Sarajevo, were retrieved, and only 14 patients, with totally 46 vetrtebras have meet including criteria (clearly visible measured structures on X-ray and CT scans, and data about implants dimensions). Digitalized anteroposterior and laterolateral X-ray, and transversal and sagital CT scans were basic inputs for measurement of height, width and depth of the vertebral body--CH, CW, CD. The correction of enlargement on X-ray pictures was performed according to known dimensions of implants and the length scale on CT scans. Enlargement of those parameters, from T1 to L5 spine level was from 60 to 100%, except the stagnation in the mid-thoracic region, and decreasing of corporal depth on the L5 vertebra (CD/L5), in comparison to the fourth vertebra (CD/L4). The clinical importance of this work is in estimation and comparison of dimensions of vertebral bodies measured on X-ray and CT scans, as the basic inputs during surgical procedures of vertebroplasty and anterior spondilodesis.

Motor evoked potentials in 43 high risk spine deformities.

INTRODUCTION: Correction of pediatric spine deformities is challenging surgical procedures. This fragile group of patients has many risk factors, therefore prevention of most fearing complication-paraplegia is extremely important. Monitoring of transmission of neurophysiological impulses through motor and sensor pathways of spinal cord gives us an insight into cord's function, and predicts postoperative neurological status. GOAL: Aim of this work is to present our experiences in monitoring of spinal cord motor function - MEP during surgical corrections of the hardest pediatric spine deformities, pointing on the most dangerous aspects. MATERIAL AND METHODS: We analyzed incidence of MEP changes and postoperative neurological status in patients who had major spine correcting surgery in period April '11- April '14 on our Spine department. RESULTS: Two of 43 patients or 4.6% in our group experienced significant MEP changes during their major spine reconstructive surgeries. We promptly reduced distractive forces, and MEP normalized, and there were no neurological deficit. Neuromonitoring is reliable method which allows us to "catch" early signs of neurological deficits, when they are still in reversible phase. Although IONM cannot provide complete protection of neurological deficit (it reduces risk of paraplegia about 75%), it at least afford a comfort to the surgeon being fear free that his patient is neurologically intact during long lasting procedures.

Clinical and radiological morphometry of posterior parts of thoracic and lumbal vertebras.

The aim of this work is to measure clinically important dimensions of thoracic and lumbal vertebras. Charts of one-hundred and seventeen patients with implanted internal fixateur on the thoracic and lumbal spine between 01.01. 2008. and 31.3.2010. at the Department for Orthopedics and Traumatology, of the Sarajevo Clinical center were retrieved, and only 14 patients, with 46 vetrtebras and 89 pedicles have had complete documentation (clearly visible measured structures on X-ray and CT scans). Digitalized antero-posterior and latero-lateral X-ray, and transversal and sagital CT scans were basic inputs for measurement of height and width of the pedicle--PH, PW, axial and vertical cortico-cortical transpedicular distances--AL, VL, and interpedicular distance--IP. The correction of enlargement on X-ray pictures was performed according to known dimensions of implants and length scale on CT scans. Enlargement of those parameters, from T1 to L5 level was from 50 to 150%. This increasing was not always linear, sometimes there was even decreasing. For instance, the IP on second and third thoracic vertebra was shorter compared to the first thoracic vertebra. Pedicles from the third to the eighth thoracic vertebra were narrower compared to the second thoracic vertebra. The importance of this work is in to analyze the mentioned dimensions by methods available to the clinician. Every other in vivo measurement is impossible because of the excessive surgical approach, while preoperative CT scanning with a great number of slices per one millimeter for this purpose is not ethical.