Fractures and dislocations of the lower cervical spine: surgical treatment. A review of 83 cases.

The authors examine 83 consecutive cases of fracture and dislocation of the lower cervical spine submitted to surgery over a period of 5 years. Sixty-five patients were monitored with minimum 5-months follow-up, 5 died, 13 could not be traced. Lesions were classified based on the method proposed by Argenson3 with the purpose of identifying guidelines for surgical treatment. Thus, different methods are proposed based on the type of lesion and on any neurologic deficit. Intersomatic fusion with anterior approach is the method of choice in most lesions. The exception to this is monoarticular dislocations that cannot be reduced, so that reduction by posterior approach associated with discectomy and anterior fusion are recommended. Circumferential fusion is proposed for traumatic spondylolistheses, complete dislocations with unsatisfactory anterior reduction, in lesions in flexion-extension and rotation associated with complete spinal cord injury, in order to favor functional rehabilitation free from ortheses. The need to review many cases of traumatic lesions of the lower cervical spine (LCS) collected over a relatively short period of time derives from the need to identify guidelines that will help the surgeon in his or her choice of the type of surgery to perform on the patient with emergency injury. The basic premise, as for other sites of traumatic injury, resides in an efficient classification (corresponding to the anatomic injury and of immediate and intuitive application) to which options for treatment may be related. In particular, an evaluation of the type of approach (anterior, posterior, combined) and of the sequence of surgical stages is essential to obtaining effective results with an acceptable complication rate. Finally, treatment must be definitive, and in cases of severe spinal cord injury it must allow for rapid rehabilitation and freedom from the use of ortheses.

The treatment of thoracic and lumbar spine fractures: a study of 123 cases treated surgically in 101 patients.

For a total of 123 thoracolumbar traumatic lesions treated surgically in 101 patients over approximately 2 years (all monitored clinically and radiographically up to consolidation by follow-ups after from 6 to 26 months, mean 10 months) the technique used, complications and treatment are reported. The treatment procedure included: emergency surgery decompression, osteosynthesis, and fusion (posterior and possibly intersomatic); immediate recovery of function and loading; clinical and radiographic monitoring within 4-6 weeks, and possible anterior fusion in case of insufficient reconstruction of the anterior column. The complications observed out of 123 fractures were: collapse of the implant (4 cases), infection (5 cases), liquoral fistula (1 case), transitory paralysis of the abdominal muscles homolateral to the lombotomic incision (1 case), TVP (2 cases), bronchial pneumonia (2 cases), paralytic ileum (1 case). There was no sagittal deformity (secondary kyphosis) except for 5 cases of mechanical collapse that were resolved with a new operation. Neurologic deficit was caused by fracture in 49 patients (40% of the fractures or 48% of the patients). Six patients out of 30 affected with spinal cord lesion (20%) and 15 out of 19 affected with cone and/or cauda lesion (79%) improved. There was no progression of the neurologic findings after surgery. The authors conclude by proposing a protocol of posterior osteosynthesis for the use of a system in titanium made up of pedicle screws and hooks connected to a pair of cylindrical bars joined together.

Posterior lumbar interbody fusion a mid-term review of 60 cases.

It is the purpose of this study to evaluate the clinical and radiographic medium-term results of a series of 60 patients submitted to intersomatic lumbar fusion by posterior approach, using a system constituted by carbon wedges to be associated with bone grafts for intersomatic fusion, and by steel or titanium plates or bars used for posterior pedicle osteosynthesis. Satisfactory clinical results were obtained in 88.2% of cases and complete radiographic fusion in 91.4% of cases. Complications were generally observed in 8.3% of cases. In light of these results, we may consider intersomatic lumbar fusion by posterior approach a method that is perhaps aggressive, but effective in the treatment of severe lumbar spondylolysis. The use of carbon wedges brings several advantages that favor intersomatic fusion, its progressive control, and the restoration of normal lordosis of the lumbar spine.

Autogenous patella as replacement for a resected femoral or tibial condyle. A report on 19 cases.

The size and shape of the patella make it suitable for the partial replacement of a femoral or tibial condyle resected for tumour, or destroyed by trauma. It can provide a good articular surface and may give satisfactory knee function. Nineteen cases of patellar grafts are presented, with follow-up from two to nine years. Good consolidation of the graft and fair stability of the joint were obtained; the range of movement was 90 degrees or more in 79% of cases. In contrast with an allograft of a femoral or tibial condyle, the technique described does not need an allograft bank, has a lower risk of infection, and allows better and quicker consolidation and revascularisation of the grafts, as well as a better range of movement at the knee, probably because of the lack of fibrosis from immunological reaction. Merle d'Aubigné's technique, using a patellar graft with a vascular muscle pedicle, is useful only for some cases, requires a longer period of immobilisation and weakens the extensor apparatus. Our series shows that consolidation and revascularisation of a patellar graft can occur in the absence of a pedicle.

Auto-immunity and intervertebral disc disease.

The immunological approach to intervertebral disc disease is based on a number of clinical and biological facts observed in human pathology. Even allowing for the fact that the number of cases reported in recent research is small, and that the methods of clinical and biological investigation have not been standardised, and that there are differences of opinion concerning the nature of the disc antigen, encouraging results have nonetheless been reached in support of the immunity hypothesis. The importance of the immunity phenomenon in the multifactorial pathogenesis of disc disease still remains open to discussion. In the present paper the immunological data recently acquired on disc disease is reviewed.

Pseudo-tumoral ossification of the muscles and/or periosteum. (A study of 57 cases).

The authors present a study of fifty-seven cases of pseudo-tumoral ossification of the muscles ("circumscribed ossifying myositis") and of the periosteum, supported by clinical, radiographic and histological evidence. This pathological condition is characterised by the formation of hyperplastic bone callus in muscle or periosteum, with a typical radiographic appearance, and with a relationship to trauma. We have excluded from our study pseudo-tumoral periosteal ossification in conditions of congenital origin (osteogenesis imperfecta, neurofibromatosis, Sane et al., 1971; Kullman et al., 1972), hyperplastic fracture callus in cranial trauma, ossification of muscles in limbs which are paretic or paralysed due to cerebral or cord lesions, and hyperplastic fracture callus in congenital syphilis. The form which is the subject of this study is absolutely benign, develops over a period of twelve to twenty-four months, with spontaneous maturation and partial regression. It can abe treated by radiotherapy to accelerate maturation, or by surgery when maturation has been completed.

Giant cell tumour in a vertebra affected by Paget's disease of bone.

A case of giant cell tumor in a vertebra affected by Paget's disease of bone is presented. This lesion, which is quite rare, has usually been observed in the bones of the skull and face, and is benign. It is probably hyperplastic rather than neoplastic in nature. Radiotherapy is contraindicated, since bone affected by osteitis deformans may possibly become malignant.

Adjuvant chemotherapy associated with surgery in the treatment of osteosarcoma. Preliminary results.

The results are presented of thirty five cases of osteosarcoma in which radical surgery was associated with cyclic chemotherapy with vincrystin, adriamycin and methotrexate. Nine patients had pulmonary metastases at intervals of from three to twenty one months after operation; of these, seven died between six and twenty six months after operation. The remaining twenty six patients are in good health and show no signs of disease at follow up varying from twelve to forty eight months. The mortality rate and the percentage of patients with pulmonary metastase from six to forty eight months after operation are notably lower than in a previous series treated by surgery only.

Aneurysmal bone cyst (a study of 127 cases, 72 with longterm follow up).

127 cases of aneurysmal bone cyst are analysed, seventy two of which were followed up from one to fifteen years after treatment. Statistics on sex, age, site and localisation are reported. Symptoms, radiographic features, histological appearances and differential diagnosis are discussed. In half the cases the cyst was clearly shown to be of subperiosteal origin. The aetiology is unknown, but the pathogenesis seems to consist of a haemorrhagic and hyperplastic (not neoplastic) process which is progressive but has a tendency to become stabilised on reaching a certain point of maturation. Local excision is indicated or, in cases where this is difficult to carry out, radiotherapy. Recurrences occurred in 12 per cent of the cases, always within one year after operation. All cases were eventually cured and there was no evidence of malignant transformation.