Anterior fixation of thoracolumbar traumatic spinal injuries.

BACKGROUND: Traumatic spinal fractures require surgical treatment to restore the anatomical curvatures of the spine and release the nervous structures. However, uniform management guidelines have not been established and thus the literature includes papers focussing only on the posterior techniques as well as those assessing the anterior or anteroposterior approaches. This paper presents the outcomes of the treatment of spinal fractures with anterior and anteroposterior fixation. MATERIAL AND METHODS: The study enrolled 48 patients. The age of the patients at the time of injury was 36.8 years on average and the mean follow-up period was 3.8 years. All the fractures were unstable and caused stenosis of the spinal canal lumen. We used anterior or combined anterior and posterior approaches with a titanium implant in all the cases. Radiological assessment involved determination of the monosegmental and bisegmental Cobb angle, and the neurological status was evaluated according to the Frankel classification. RESULTS: The mean post-traumatic monosegmental angle was -17.1°, compared to -9.1° post-operatively and -9.2° at followup. The bisegmental angle was -12.7° at baseline, -7.9° post-operatively, and -8° in the follow-up period. Neurological assessment showed no neurological deficits in 27 patients while 2 persons had complete limb paralysis and the other 19 patients had various degrees of neurological deficits. The last follow-up examination did not show any improvement with respect to the neurological status of the patients with complete paralysis. However, an improvement of at least 1 Frankel group was noted in 15 patients with partial neurological deficits. CONCLUSIONS: 1. The most common causes of traumatic spinal injuries are falls from a height and road accidents. 2. fractures occur most often at the thoracolumbar junction of the spine. 2. Anteroposterior fixation with release of the spinal canal and spinal fusion is a beneficial treatment method. 3. Apart from vertebral body mesh, treating lumbar spine fractures requires the additional use of vertebral body screws or transpedicular posterior fixation. 4. Anterior fixation ensures the restoration of the physiological curvatures of the spine and stabilizes the spine until a complete bone union is achieved, preventing the loss of correction during the follow-up period.

[Endoscopic procedures in spinal surgery]. / Zabiegi endoskopowe w chirurgii kregoslupa.

Background. The anterior approach to the spine enables good correction and stabilization of the anterior spinal column. The broad application of the anterior procedure via thoracotomy caused problems, however, due to the gravity of the surgical procedure. The introduction of transthoracic endoscopy has made it possible to avoid the disadvantages of open surgery. Material and methods. Between 2000 and 2003, 129 endoscopic operations were performed in our hospital on 125 patients, suffering from idiopathic scoliosis (77 patients), congenital scoliosis (8), scoliosis in systemic diseases (6), neuromuscular scoliosis (3), cardiogenic scoliosis (1), Scheuermann's kyphosis (8), pathological spine fracture (6), spondylodiscitis (4), chylothorax (2), pectus excavatum - MIRPE technique (10). The mean age at surgery was 15 years, range 4-62. The mean follow-up was 17 months, range 5-36. Results. In the whole group, the mean duration of endoscopy was 112 minutes, and mean intraoperative blood lose was 126 ml. Stable fusion was obtained in all patients. The duration of endoscopic procedures was shorter than the open technique, and intraoperative blood loss was lower. A decreased need for analgesics was also noted after surgery. Conclusions. The advantages of the endoscopic spinal procedure are its minimally invasive nature, good visualization of the operative area, decreased blood loss, and decreased need for analgesics.

Early outcome in the surgical treatment of idiopathic scoliosis by "bone on bone" anterior interbody fusion.

Background. The aim of our study was to evaluate a new surgical method developed by Robert Gaines for the treatment of idiopathic scoliosis, called the "bone on bone" procedure. Material and methods. We examined 100 patients (81 female and 19 male) selected from 259 scoliotic patients operated at our center between 2002 and 2004. The mean age at surgery was 16 years and 2 months (range: 12 yrs, 2 months to 39 yrs). The mean follow-up was 18 months (range: 15-24). The average range of fusion was 5 vertebrae (range 3-6). The mean Cobb angle was 63 degrees (range: 49 degrees -98 degrees ). The mean Cobb angle of upper secondary curve was 32 degrees (range: 9 degrees -70 degrees ), the lower 32 degrees (range: 7 degrees -740). The mean apical vertebral rotation (AVR) was 30 degrees (range: 15 degrees -55 degrees ), apical vertebral translation (AVT) 58 mm (range: 8-110). The average thoracic kyphosis was 19 degrees (range: 8 degrees -40 degrees ), and lumbar lordosis 23 degrees (range: 18 degrees -38 degrees ). Technical note. The anterior transthoracic and /or retroperitoneal approach was performed; all discs on the apex of curvature were removed and no bone grafts were used (fusion by contact of vertebrae surfaces). Transvertebral screws were implanted with stabilization by means of a rod. Results. After surgical treatment the mean Cobb angle was 27 degrees (range 0 degrees -58 degrees ), and the correction of the base angle was 58%. The mean Cobb angle of the upper secondary curve was 25 degrees (range: 4 degrees -60 degrees ), the lower 19 degrees (range: 1 degrees -56 degrees ). The average AVR was 20 degrees (range: 5 degrees -45 degrees ), correction was 33%. The mean AVT was 16 mm (range: 0-62 mm), accounting for a 72% correction of basic translation. The average kyphosis after surgical treatment was 26 degrees (range: 15 degrees -45 degrees ), lordosis 20 degrees (range: 7 degrees -35 degrees ). After a mean 18 months follow-up, the average Cobb angle was 31 degrees (range: 0 degrees -73 degrees ), with average 12% loss of correction. The mean upper secondary curve was 25 degrees (range: 5 degrees -62 degrees ), the lower 21 degrees (range: 2 degrees -55 degrees ). The average thoracic kyphosis was 28 degrees (range: 14 degrees -48 degrees ), lordosis 21 degrees (range: 7 degrees -37 degrees ). The mean AVR and AVT remained at the same level after follow-up. Conclusions. The "bone on bone" procedure allows the surgeon to decrease the number of segments involved in spinal fusion, and gives high correction of idiopathic scoliosis with a low rate of operative complications.

The natural history of idiopathic scoliosis.

Background. The natural history of idiopathic scoliosis is a crucial issue in the planning and assessment of different treatment methods. This article presents the evaluation of scoliotic deformity in immature patients who have been in observation without any treatment. Material and methods. 159 patients (128 girls, 31 boys) were examined between 1971 and 2002. Skoliosis was diagnosed at a mean age of 6 years 4 months (range 2.1-8.10), and observation was concluded at a mean age of 16 years 11 months (range 14.6-20.3). The mean follow-up was 10 years 5 months. The prognostic factors analyzed were: age, sex, Cobb angle, Mehta angle, apical vertebral rotation, specific rotation, Risser test. The progression and regression of curvature was analyzed in different biological age periods, and was measured by calculating the difference in the Cobb angle on successive x-rays divided by the interval between x-rays. Results. The mean progression of curvature before age 5 was 5.7 degrees per year; in the 6-10 age bracket, 2.3 degrees per year; in the 11-15 age bracket, 7.4 degrees per year; in the >15 age bracket, 0.3 degrees per year. The mean progression for patients with Risser 1 was 8.8 degrees per year; Risser 2, 7.3 degrees per year; Risser 3, 5.1 per year; Risser 4, 2.1 degrees per year; Risser 5, 0.3 degrees per year. Conclusions. The progression of curvature in idiopathic scoliosis is variable, and is influenced by age. Knowledge of the natural history of idiopathic scoliosis is a crucial tool in predicting the development of spinal curvature. The Risser test and biological age are the only effective predictors of progression.

Comparison of radiological results of conservative and operative treatment by Salter osteotomy in severe cases of Perthes' disease.

Background. The goal of treatment in Perthes' disease is the creation of best conditions for good hip reconstruction. The aim of this work was the comparison of radiological results of conservative and operative treatment by Salter osteotomy in Perthes' disease. Material and methods. 193 hips with severe Perthes' disease were analyzed (Catterall group III, IV), 105 hips were treated conservatively, 88 - were operated. Minimal follow-up time was 5 years. Following data were evaluated: Wiberg angle, acetabular angle, acetabulum-head index, acetabular and epiphyseal index. Additionally, head sphericity according to Mose, results estimation according to Stulberg and presence of arthritic changes were evaluated. Results. In conservative treatment group, Mose good result was achieved in 25 hips (23,8%), fair result - in 54 (51,4%), and poor result - in 26 (24,8%). According to Stulberg classification, class I was in 25 hips (23,8%), class II - 37 (35,2%), class III - 28 (26,7%), class IV - 9 (8,6%), class V - 6 (5,7%). In operative treatment group, Mose good result was achieved in 45 hips (51,2%), fair result - in 19 (21,6%), and poor result - in 24 (27,2%). According to Stulberg classification, class I was in 39 hips (44,3%), class II - 26 (29,5%), class III - 13 14,7%), class IV - 8 (9,1%), class V - 2 (2,3%). Radiological parameters of femoral head coverage were better after operative treatment. The amount of arthritic changes after conservative treatment were greater than after surgery. Conclusions. 1. Operative treatment by Salter osteotomy creates better conditions for spherical femoral head reconstruction. 2. Patients with III and IV Catterall group should be treated surgically.

Salter osteotomy in Perthes' disease. Late radiological results.

Background. Surgical treatment in Perthes' disease has been used for many years, but the choice of operation method still remains controversial. The aim of this work is to analyze long-term radiological results at patients after Perthes' disease treated by Salter osteotomy. Material and methods. 113 hips were analyzed at 110 patients. Males were 90, females 20. Due to severity of changes in hips, patients were divided into groups according to Catterall: group II - 25 hips (22.1%), group III - 14 hips (12.4%), group IV - 74 hips (65.5%). Average patient's age at the time of surgery was 7.2 years. Follow-up time was 9 years (5-14years). Salter osteotomy was performed as described by its author. The material was analyzed according to age of disease onset, extensiveness of necrosis (Catterall classification), and the length of follow-up period. Radiographs taken before surgery and during last examination were evaluated. For results estimation, Mose criteria and Stulberg classification were applied. Results. According to Mose criteria, 63 hips (55.3%) had good result, 25 (21.9%) - fair and 25 hips (21.9%) - bad result. Using Stulberg classification, group I included 55 hips (49.4%), group II - 33 hips (29.1%), group III - 14 hips (12.3%), group IV - 8 hips (7.8%), group V - 2 hips (1.5%). Radiological parameters of head coverage improved after surgery. Arthrotic changes were noted in 8 hips (7.8%). Conclusion. Salter osteotomy assures good head coverage by the acetabulum and creates favorable conditions for spherical head reconstruction. Results after Salter osteotomy are permanent and do not depend on the length of follow-up period.

Surgical treatment of congenital vertebral displacement Type A in the sagittal plane only: a retrospective study involving eleven cases.

STUDY DESIGN: The essence of congenital vertebral displacement Type A pathology is a congenital structure defect including a vertebral or intervertebral disc with instant curvature of the spinal canal in the sagittal plane. Clinically this defect assumes the shape of kyphosis or kyphoscoliosis. A retrospective review of 11 patients with this congenital deformity was conducted. OBJECTIVES: To evaluate the effectiveness of surgical treatment for congenital vertebral displacement, and to establish the optimal operative management. METHODS: Nine patients with a mean age of 3.3 years (range, 1.8-5.5 years) underwent surgery. Two patients were treated conservatively. All the patients underwent radiologic investigation, which included radiographs, three-dimensional computed tomography scans, and magnetic resonance imaging scans. The neurologic condition was assessed by clinical neurologic examination and somatosensory-evoked potentials. The following surgical techniques were performed: 13 posterior fusions in situ in eight patients; 4 anterior fusions in situ in four patients, 8 total or partial vertebrectomies with anterior fusion and stabilization using cylindric cage in 6 patients, 3 total or partial vertebrectomies with anterior fusion and stabilization using fibula graft in 3 patients, and 5 posterior fusions with instrumentation in 2 patients. The total mean follow-up period was 5.7 years (range, 2.1-9.9 years). RESULTS: The mean follow-up period after the last operation was 22 months (range, 2-48 months). The general results observed during the follow-up period were as follows. Deformity stabilization was obtained in six patients, whereas it was still progressive in three patients. In five patients, regression of neurologic deficits was obtained, whereas in patients, it was stable. Progression of neurologic deficits was observed in one patient (paraplegia). Retrospectively, the best clinical results were achieved after extensive decompression of the spinal cord with anterior stabilization of the spine using a cylindric cage or fibula autograft. These procedures were preceded or followed by posterior fusion. CONCLUSIONS: The findings showed that only extensive vertebrectomy and anterior stabilization using a cylindric cage or fibula graft combined in one operative procedure, preceded or followed by posterior fusion, ensures patients against progression of neurologic deficits and deformity of spine.