[Complications in Spine Surgery: Prospective 13-year follow-up of unplanned revision spinal surgeries]. / Komplikace ve spondylochirurgii: prospektivní 13leté sledování neplánovaných revizních operací pátere.

PURPOSE OF THE STUDY Unplanned revision spinal surgeries constitute a complication in the treatment algorithm for the patient, surgeon and the entire treatment team. Any complication leading to an unplanned revision surgery is therefore undesirable. The percentage of complications referred to in publications on this topic focusing on unplanned revision surgeries only varies from 0.7% to 29.8%, with obvious diversity of causes and significant risk factors. The purpose of the submitted paper is to carry out a prospective evaluation of the most serious complications requiring unplanned revision spinal surgeries in the course of 13 years at a single department performing a broad range of spinal surgeries, namely 1300 procedures annually on average. MATERIAL AND METHODS In the period 2006 - 2018, a total of 16872 patients underwent a surgery at our department. During this period, in 556 patients an unplanned revision spinal surgery was performed. In agreement with literature, the patients were categorised by cause for revision: 1/ impaired wound suprafascial (superficial) healing - superficial infection, 2/ impaired wound subfascial (deep) healing - deep infection, 3/ surgical wound hematoma, 4/ deterioration or occurrence of new neurological symptoms, 5/ cerebrospinal fluid leak (liquorrhoea) and 6/ others. The patients operated on for inflammatory diseases of the spine with subsequent infectious complications, primarily treated at another department, and the patients with open spinal injury were excluded from the study. According to these criteria, a cohort of 521 patients was followed up, namely 236 (45.3%) women and 285 (54.7%) men, aged 1 year to 86 years, with the mean age of 55.0 years (median 60 years). Demographic effects, tobacco smoking and comorbidities were followed up in the cohort, together with the effects of surgery, diagnosis, surgical approach and physician. All parameters were statistically evaluated at a p-value below 0.05, including comparison with the control group. RESULTS Of the total number of 16872 operated patients, a group of 521 (3.09%) patients undergoing a revision surgery for complications was analysed in detail. Impaired wound healing - infection (SSI) was found in 199 (1.18%) patients, of whom superficial infection in 124 cases (0.73%) and deep infection in 75 cases (0.44%). Hematoma in a surgical site was detected in 149 (0.88%) patients. In 63 (0.37%) cases, deterioration of the existing neurological finding or occurrence of a new neurological finding were observed, in 68 (0.40%) cases cerebrospinal fluid leak was reported and in 40 (0.24%) cases other complications were identified. As concerns the surgical assistant, the percentage of complications in a board-certified physician is 2.77 (1.14 - 3.29%), in a medical resident it increases to 3.60 (0.00 - 9.38%) (p<0.05). The prevalence of smokers in the group with complications (N=521) was 34.7%. The control group (N=3650) included 30.1% of smokers (p<0.05). The mean age of patients in the group with complications (N=521) was higher, i.e. 55.0 years, with the median age of 60.0 years, than in the primary cohort (N=16872) with the mean age of 49.8 years and the median age of 52.0 years (p<0.05). The mean BMI in the group with complications was (N=521) 27.3, the median BMI was 26.9. In the control group (N=16872), the mean BMI was 27.11, the median BMI was 26.8. In this case the significance (p>0.05) was not confirmed. The complications prevailed strongly in posterior surgical approach, namely in 483 patients (92.7%). As concerns the surgically treated segment, lumber spine dominates with 320 (61.4%) cases. Corticosteroid therapy was used twice as often in women, namely in 13.1% vs. 6.3%. The group of patients with complications (N=521) showed a much higher average length of hospital stay of 12.8 days compared to the average of 4.6 days (N=16872). DISCUSSION In our cohort, the complication rate was 3.09%, of which infections constituted 1.18%, which is in agreement with similarly focused papers. As regards the patient-related factors, in our study the results reported by literature were confirmed with respect to the age, smoking and comorbidities. Moreover, the posterior surgical procedure, lumber spine surgery and presence of a medical resident are essential (p<0.05). No major age difference was observed between women and men (p>0.05). Obesity is one of the key risk factors, especially in infectious complications. In our cohort, a higher BMI did not increase the risk of complications in general (p>0.05). CONCLUSIONS In correlation with current literature, our cohort confirmed a significantly higher risk of complications leading to revision spinal surgery associated with age, smoking, posterior surgical procedure in thoracic or lumber spine, and presence of a medical resident as a surgical assistant. The average length of hospital stay was demonstrably longer in complicated patients, it almost tripled compared to the whole cohort. Contrary to literature, the effect of obesity on the occurrence of complications was not confirmed. Key words: spinal surgery, complications, infection, reoperation, risk factor, hematoma, cerebrospinal fluid leak, screw malposition, smoking, obesity.

[Surgical Therapy of Fixed Atlantoaxial Rotatory Dislocation - Monocentric Study of 15 Patients]. / Chirurgická terapie fixované atlantoaxiální rotacní dislokace ­ monocentrická studie 15 pacientu.

PURPOSE OF THE STUDY Atlantoaxial Rotatory Dislocation (AARD) mostly occurs in children and prevailing majority of cases are successfully managed by non-operative treatment. Surgical intervention is necessary in patients in whom non-operative treatment failed, in case of repeated dislocations and in patients with anatomical defects of the atlantoaxial complex. The purpose of the presented study is the radiological and clinical evaluation of patients with AARD surgically treated at our department. MATERIAL AND METHODS In the period from 2001 to 2017, altogether 15 patients with AARD were surgically treated at our department, namely 6 men and 9 women aged 5-72 years, with the mean age of 27.3 years. 8 patients were younger than 18 years of age. Apart from regular checks, all the patients were examined also at the end of the study, which means at a follow-up of 12-214 months, i.e. 112.1 months postoperatively on average. In the study, the anatomy of the atlantoaxial complex and craniocervical junction, course of the surgical procedure, correction of deformity, bone fusion, clinical condition of the patient and complications were monitored and evaluated. The clinical evaluation was performed using the Visual Analogue Scale (VAS) for neck pain and the Neck Disability Index (NDI). All the parameters were statistically evaluated at the p-level below 0.05. RESULTS In all 15 patients the surgery was preceded by unsuccessful non-operative treatment. The period between the rotation and the surgery was 4 days to 48 months, with the mean value of 11.3 months. All the patients included in the study showed an intact dens axis, the other patients were excluded from the study. In 10 patients their head was rotated to the left, in 5 patients to the right. The anterior atlantodental interval (ADI) was 2-7 mm with the mean value of 3.5 mm. In 13 cases the ADI was less than 5 mm, in 2 cases it was greater. According to the Fielding and Hawkins classification there were 9 cases of type I, 4 cases of type II and two cases of type III. According to the Ishii et al. classification, 2 cases of type I, 12 cases of type II and one case of type III were identified. In 9 patients predisposing factors were found in the history, namely 7 cases of trauma, 2 cases of infection. Mutual rotation of C1-C2 from 7.0° to 60.0° with the mean value of 27.3° was observed preoperatively, while after the correction it was from 1.0° to 7.0° with the mean value of 3.9° (p < 0.05). Lateral inclination was 3.4°-23.6° preoperatively with the mean value of 9.9°, and 0.7°-4.0° after the correction with the mean value of 2.2° (p < 0.05). The postoperative ADI ranged from 1 to 3 mm, with the mean value of 1.9 mm (p < 0.05). The bone fusion of C1-C2 or C1-C2-C3 was achieved in all the relevant cases (N = 13, 100%), in two patients a temporary fixation was used. The mean value of VAS for neck pain was 6.3 preoperatively, 1.0 (p < 0.05) at one year and 1.0 (p < 0.05) again at the final examination. The mean value of NDI was 50.4 % preoperatively, 9.3% (p < 0.05) at one year and 9.5% (p < 0.05) at the final examination. All patients that we operated on stated that they would undergo surgery again. DISCUSSION Compared to the other authors, our group of patients included surprisingly many adult patients (46.7%) with a high percentage of neurological defects (33.3%). In agreement with the literature, the cause of rotation was revealed in 60% of cases. At our department, correction is preferred in all the patients, while especially in paediatric patients in situ fixation causes the developmental deformities of the face and cervical spine. High success rate of bone fusion was confirmed (13/15, 13 = 100%) and also the transient atlantoaxial fixation was successfully used in two patients, both with traumatic etiology. CONCLUSIONS If non-operative treatment fails, surgical correction of AARD is a suitable treatment method which ensures favourable position of the atlantoaxial complex, improves the clinical condition of the patient and prevents the asymmetric development of the face in children. The Goel-Harm's fixation technique and C1-C2 fusion are considered by us the method of choice in older paediatric and adult patients. Key words: AARD, atlantoaxial rotatory dislocation, atlantoaxial rotatory subluxation, pediatric cervical spine, atlantoaxial fixation.

Anatomy of the dens and its implications for fracture treatment: an anatomical and radiological study.

PURPOSE: The most common injuries to the upper cervical spine are fractures of the dens axis. Therefore, the purpose of our study was to answer three questions, namely (1) whether the size of the dens is adequate at all levels to accommodate two screws, (2) what the angle of the posterior tilt of the dens is in a healthy individual and (3) compare the measured variables between the sexes. METHODS: The cohort comprised 50 males and 50 females CT examination of the craniocervical junction. We measured the five diameters of the dens and posterior dens angulation angle (PDAA) and screw insertion angle (SIA). The same dimensions were measured in a control group, consisting of 40 non-pathological second cervical vertebrae specimens. RESULTS: On CT scans, the mean PDAA was 162.7 degrees in males and 160.26 degrees in females; the mean SIA was 62.0 degrees in males and 60.2 degrees in females. On specimens, the mean PDAA was 169.47 degrees in males and 166.95 degrees in females; the mean SIA was 65.42 degrees in males and 64.47 degrees in females. All obtained values were higher in males; regardless of their measuring on either CT scans or specimens, differences between males and females were statistically significant (p < 0.05) in a, c, d and e values. CONCLUSIONS: The values of our measurements correlate with the dimensions identified previously in other studies. Based on our clinical experience and measurements, we presume that two 3.5-mm screws can be inserted into the dens of all adult patients, except for those with pronounced anatomical anomalies. Posterior dens angulation angle is slightly larger than we expected. The dens is significantly larger in males almost in all measurement. These slides can be retrieved under Electronic Supplementary Material.

[Surgical Treatment of High-Grade High-Dysplastic Spondylolistheses in Young Patients - Prospective Monocentric Study of 29 Patients]. / Operacní lécba vysokostupnových vysoce dysplastických spondylolistéz u mladých jedincu ­ prospektivní monocentrická studie 29 pacientu.

PURPOSE OF THE STUDY An optimal technique to surgically treat high-grade high-dysplastic (HG HD)spondylolistheses remains disputable. There are multiple surgical procedures described, ranging from a simple posterior fusion in situ without fixation through a standalone anterior lumbar interbody fusion with the oblique insertion of a structural bonegraft to instrumented full reduction and 360-degree fusion. At our department, preference is given to the instrumented monosegmental reduction and fixation by a fixator with Schanz screws. The aim of this paper is a prospective clinical and radiological evaluation of the group of operated patients below 30 years of age with HG HD spondylolisthesis with a slip greater than 50%. MATERIAL AND METHODS In the period from 11/2007 to 2/2017, a total of 29 patients with HG HD spondylolisthesis always of the L5-S1 segment were treated at the Department of Spinal Surgery of the First Faculty of Medicine of the Charles University and the Teaching Hospital Motol. They were 10 men and 19 women aged 10 to 28 years, with the mean age of 18.4 years. In 27 patients reduction and single-segment fixation of L5-S1 were performed as primary treatment, in one case decompression and noninstrumented-fusion only was carried out and in one case in situ fixation of L4-L5-S1 for distinctive osteoporosis. RESULTS The average duration of posterior surgery without the reconstruction of the anterior column was 88.9 min, in case of anterior fusion it was 46.6 min and in case of only posterior approach and fusion with the reconstruction of the anterior column it was 141.5 min. The average blood loss in the posterior fusion without the reconstruction of the anterior column reached 384.3 ml, in the stand-alone anterior fusion it was 21.6 ml. and in the posterior fusion with the reconstruction of the anterior column 430.0 ml. In 27 patients in whom the reduction was carried out, a shift of the L5 vertebral body observed on the CT scan prior to the surgery was 64.3% on average, while postoperatively and also at 6 months after the surgery during the follow-up examination it was 8.1%. A clear bone posterolateral fusion was found by the CT examination after 4-6 months in all 29 patients (100%, N = 29), while bone intersomatic fusion was reported in 25 cases (96.2%, N = 26). Altogether 6.9% of residual neurological deficits were observed. The statistical processing of VAS values for lumbar back pain and ODI values before the surgery and after two years confirmed a significant improvement of the clinical condition (p < 0.001). When asked whether they would undergo the same surgery with their current experience with the treatment, all the 29 patients answered "yes" and stressed the functional as well as the aesthetic results of the surgery. DISCUSSION In agreement with the other authors, the PT, SS and PI values are measured and we consider the SA, SDSG LSA and Dubousset s LSA assessments to be essential. All the measured values showed statistically significant changes postoperatively, only the pelvic incidence(PI) value remained unchanged. In patients with HG HD spondylolisthesis, we prefer reduction and the 360-degree monosegmental fusion, in the case of sacral osteotomy always using the posterior approach, in the cases where osteotomy is not performed using the next anterior approach. Even in the cases of the most severe deformities, we prefer to maintain the body of L5 and, where necessary, rather shorten the sacrum, which in our opinion leads to a better aesthetic result. CONCLUSIONS The reduction by single-segment instrumentation is a suitable alternative to the surgical therapy of HG HD spondylolistheses in young patients. It provides a high success rate of bone fusion and good clinical results including the aesthetic aspects. The complications associated with full reduction are not markedly higher than in other surgical techniques. Key words:spondylolisthesis, HGHD, high-grade, high-dysplastic, reduction, pelvic incidence, pelvic tilt, sacral slope.

[Giant Ganglioneuroma of the Spine and Mediastinum]. / Objemný ganglioneurom pátere a mediastina.

UNLABELLED: The case of a 15-year-old girl with a large ganglioneuroma in the mediastinum and spinal canal is presented. The tumour initially manifested as scoliosis. Its diagnosis was made on the basis of CT scanning and magnetic resonance imaging, and confirmed by thoracoscopic mediastinal biopsy. Radical tumour excision was indicated. The first stage involved removal of the tumour from the spinal canal through a posterior approach, and transpedicular fixation of the spinal column with correction of the curve. At the second-stage procedure, the tumour was removed from the pleural cavity and mediastinum through thoracotomy. At two years after surgery, the spondylodesis was completed with autologous bone grafts that healed within 6 months. At 3-year follow-up the patient was with neither clinical findings, nor subjective complains and imaging methods showed no signs of tumour recurrence. KEY WORDS: ganglioneuroma, scoliosis, correction, thoracotomy, spinal canal, mediastinum.

Total En Bloc Spondylectomy of C3: A New Surgical Technique and Literature Review.

PURPOSE OF THE STUDY: Radical resection of a vertebra is reserved only for specific tumors that invade the surrounding tissues and recur when not removed completely. The vertebra may be removed using a piecemeal technique or en bloc, using only two (in thoracolumbar spine) or more osteotomies (in cervical spine). We present our technique of en bloc resection of subaxial cervical vertebra for Ewing's sarcoma of C3, with preservation of all nerve roots and both vertebral arteries. To our knowledge, this surgical technique has not been reported in the English literature. The aim of this study is to describe the new technique of radical resection of subaxial cervical vertebra. MATERIAL AND METHODS: A transoral biopsy of tumor tissue anterior to C2-C3 was performed in 8-year old boy, revealing a diagnosis of Ewing's sarcoma. The patient was started on neoadjuvant chemotherapy. After 6 chemotherapy cycles with the VIDE regimen, the soft-tissue component completely regressed, with the only a residual deposit in C3 vertebral body. Based on further multidisciplinary meeting, an en bloc spondylectomy of C3 was recommended, preferably with preservation of nerve roots and vertebral arteries. In August 2014, prior to the planned surgery, we performed another thorough examination of the patient using plain films, CT and MRI. Neither angiography nor embolization was performed. DESCRIPTION OF SURGICAL TECHNIQUE: The first stage of the operation consisted of resection of the posterior structures. We exposed the posterior elements of C2 to C4 by the mid-line incision. The C3 arch was without pathological changes. After partial resection of the C2 inferior and C4 superior articular processes we performed bilateral osteotomy in the region of the pedicle adjacent to the arch with a chisel and removed the whole of the C3 posterior arch. Subsequently we perforated the transverse foramina close to the pedicle, using fine Kerrison rongeurs. The lateral parts around vertebral arteries were left in situ. In the next step we used instrumentation with polyaxial screws to stabilize the C2-C4 section. After 19 days we performed the second stage surgery from an anterior approach with the removal of the anterior and lateral parts of the vertebra. We made a transverse incision anterior to the sternocleidomastoid between the internal carotid artery and the trachea on the right side at the level of C3 to expose the spine. We resected C2-C3 and C3-C4 intervertebral discs and then performed osteotomy with fine Kerrison rongeurs on both sides, again, close to the vertebral body. Subsequently, the vertebral body was released and extracted en bloc. In the next step, both vertebral arteries were mobilized and shifted medially and the lateral portions of the transverse processes were released and removed en bloc. The empty space was filled with solid allograft and the C2-C4 levels were bridged by the cervical plate in 2+1+2 configuration. RESULTS: There were no complications during both surgeries. The follow-up CT examination 4 months after the operation revealed a clear bone fusion of C2-C4, both anteriorly between vertebral bodies and posteriorly between the arches. Clinically the patient has reached 8 month follow up and had no complaints, both he and his parents were satisfied. Physiotherapy is proceeding according to plan. The patient remains under supervision at our centre. DISCUSSION: Total en bloc resection of a subaxial cervical vertebra with preservation of neural and vascular structures has been described in the English literature only once. In 2007 was published a total en bloc resection of C5 for chordoma, preserving the above mentioned structures. Authors removed the lamina en bloc after bilateral osteotomy. Transverse foramina were perforated by the Gigli saw and removed in piecemeal fashion, including the posterior tubercle. In the next step, they removed the vertebral body and the anterior tubercle from the anterior approach. However, their treatment differs from the technique described here and does not correspond fully to the principle of en bloc resection. Our surgical technique is based on a similar principle of performing several osteotomies without the use of high speed burr, while preserving all neural and vascular structures. The difference can be particularly seen in the approach to remove lateral parts of the transverse foramen, which are surrounding the vertebral arteries. We consider it as ideal to split the cervical vertebra by smooth cuts into four parts and remove them en bloc. CONCLUSION: Total en bloc spondylectomy of a subaxial cervical vertebra with preservation of vertebral arteries and nerve roots is a radical surgery that should be used to treat only the most serious conditions. The risk of neurological deficit is outweighed by the benefits of oncological radicality. This new surgical technique has not yet been described and it is clear, that a larger cohort of patients is necessary to assess and potentially modify this technique so that it can be used more frequently in the future.

[Collet-Sicard Syndrome due to Occipital Condyle Fracture. Case Report]. / Colletuv-Sicarduv syndrom pri zlomenine okcipitálního kondylu - kazuistika.

The case of a 63-year-old man diagnosed with Collet-Sicard syndrome due to a fracture of the right occipital condyle is presented. The cause of injury was falling off a bicycle. Dysphonia and dysphagia were present from the moment of injury, with the gradual development of light atrophy of the tongue muscles and right trapezius muscle. The diagnosis was based on examination by CT and MRI methods, the act of swallowing and physical examination by an otorhinolaryngology specialist and a neurologist who confirmed the diagnosis of injury to cranial nerves IX, X and XI on the right side. The patient was treated conservatively with application of a Philadelphia collar. Dysphagia required PEG tube insertion. Skull fracture healing was evident on a CT scan at 3-month follow-up. However, dysphonia with dysphagia and muscle atrophy remained persistent.

[Unstable injuries to the upper cervical spine in children and adolescents]. / Nestabilní poranení horní krcní pátere u detí a adolescentu.

PURPOSE OF THE STUDY: Injuries to the upper cervical spine in children are rare and account for 0.6 to 9.5% of all cervical spine injuries. We present a detailed analysis of the children and adolescents with unstable upper cervical spine injuries treated at our spinal centre. MATERIAL: During 16 years of follow-up, unstable injury to the upper cervical spine was recorded in 23 children and adolescents. Two patients (8.7%) were treated conservatively and 21 (91.3%) underwent surgery. The patients were allocated by age to three groups: 0-9 year, 10-14 year and 15-18 year categories. Twenty patients were seen at the final clinical and radiographic follow-up. One patient died at 62 months after surgery and two patients unfit for transport were evaluated on the basis of mailed interviews. The interval between injury and final evaluation ranged from 6 to 137 months, with an average of 53.4 months. METHODS: The patients treated conservatively first wore a Philadelphia collar, then a custom-made brace, and eventually a soft Schanze cervical collar to finish the healing process. Application of a halo vest was considered a surgical procedure and was used only in very small children. In unstable odontoid fractures, direct osteosynthesis with two cannulated titanium screws was performed from the anterior approach in older children while, in small children, transoral or submandibular retropharyngeal decompression to treat spinal stenosis caused by bone fragments was carried out and a halo vest was applied. Hangman's fractures were treated by anterior cervical discectomy, fusion with bone graft and anterior plate fixation. The other types of unstable fractures were managed from the posterior approach by occipitocervical fixation, atlantoaxial fixation or instrumented fusion extended caudally. The patients characteristics included gender, age, mechanism of injury, type of injury, neurological findings, type of therapy or surgery, complications and treatment outcome. Neurological status was evaluated using the Frankel classification. RESULTS: The patient group comprised 14 boys (60.9%) and nine girls (39.1%), which gave a gender ratio of 3 : 2. The age of patients at injury ranged from 2 to 18 years, with an average of 11 years and 6 months. The most frequent injuries included rotational or vertical atlantoaxial dislocation in eight (34.8%) and odontoid fractures in seven (30.4%) patients; atlas fracture was recorded in three (13.0%) and hangman's fracture also in three (13.0%) patients; occipitocervical displacement was found in one (4.3%) and complex atlantoaxial fracture also in one patient (4.3%). At the time of injury, 17 patients (73.9%) had no neurological deficit (Frankel grade E), three had Frankel grade A (one paraplegic with a concomitant T5 spinal cord injury) and three had Frankel grade D neurological deficits. Of the six patients with neurological deficit, two showed improvement by one or two Frankel grades. The method of dorsal atlantoaxial fixation was used in eight patients (Magerl fixation in 2 and Harms method in 6). Direct osteosynthesis of an odontoid fracture was performed in four patients, halo fixation was applied in four, C2-C3 discectomy with tricortical bone grafting and plating was carried out in three, occipitocervical fixation was used in three patients, and direct atlas osteosynthesis, simple decompression and simple non-instrumented dorsal spondylodesis each was performed in one patient. Neither intra-operative complications nor post-operative complications related to the surgical technique were recorded. Osteoarthritis or bone non-union, as late post-operative complications, were found in two patients. All other patients showed bone healing by first intention in the desired extent. Superficial or deep wound infections were not recorded. DISCUSSION: In the first age category, the number of boys and girls with injuries to the upper cervical spine was equal while, in the third one, the boys outnumbered the girls more than twice. Of the 23 patients, 91.3% were surgically treated; the anterior approach was used in approximately one third of the patients and the posterior approach in the rest of them. The high number of surgical interventions is due to the fact that the most serious paediatric spinal injuries are referred to our centre. CONCLUSIONS: 1. Injuries to the upper cervical spine are most frequently found in the youngest children and in adolescents who, however, frequently have injury also to the lower cervical spine. 2. Neurological deficit is relatively frequent but has a better prognosis than in adults. The youngest children with mild deficits have the best prognosis. 3. The mortality rate in young children with upper cervical spine injuries is evidently high, mostly due to associated head, chest and abdomen trauma 4. Therapy, particularly in small children, is strictly individual.

[Spinal cord concussion: a retrospective study of twenty-four patients]. / Komoce mísní: retrospektivní studie 24 pacientu.

PURPOSE OF THE STUDY: Spinal cord concussion is characterised as fully reversible, temporary inhibition of conductive function due to trauma, without signs of structural changes. Although neurological deficit is usually related to the severity of spinal injury, this is different in spinal cord concussion. The aim of this retrospective study was to evaluate a group of 24 patients with spinal cord concussion, to design a diagnostic algorithm and propose an effective therapy with a good prognosis for the patients. MATERIAL: We reviewed clinical records of 9 768 patients hospitalised at the Department of Spinal Surgery, University Hospital in Motol, from September 2002 till December 2010, and of 457 patients treated at other departments of the Hospital between January 2008 and December 2010; this was a total of 10 225 patients. The data were retrospectively analysed and only the patients with a clear history of trauma and subsequent conservative therapy were selected to comprise a group characterised by the generally known criteria of spinal cord concussion: (1) spinal injury with immediate neurological deficit of varying degree; (2) neurological deficit corresponding to the level of spinal injury; (3) recovery of neurological function within 72 hours of injury; (4) no morphological evidence of injury to the spinal structures obtained by imaging methods. This group comprised 24 patients. METHODS: The patients were followed up from 6 to 95 months, with a mean of 46 months and a median of 48 months, at intervals of 6 and 12 weeks and 6 and 12 months after injury, and then every following year. The recorded information included the patient's age at the time of injury, their gender, the mechanism of injury, reports on alcohol consumption, the first detected neurological deficit, its development immediately after injury, during the hospital stay and at follow-ups in the out-patient department, methylprednisolone administration according to the National Acute Spinal Cord Injury Study (NASCIS) 2, and findings of imaging methods, particularly MRI. RESULTS: Our group consisted of 22 men (91.7%) and two women (8.3%), with an average age of 29 years; the average age was 30 years in men and 18.5 years in women. Seven patients (29.2%) were younger than 18 years, with an average of 16.14 years; the remaining 17 patients (70.8%) were older than 18 years, with an average of 34.35 years. The major mechanisms of injury included falls from a height in 10 patients (41.7%) and injury due to alcohol consumption in five patients (20.1%). Clinical findings involved lesions of the medullary cone in 12 (50.0%), cervical spinal cord in seven (29.2%) and thoracic spinal cord in five (20.8%) patients. Motor function deficit was present in all patients, of whom 10 (41.2%) showed a complete loss of motor function. Impaired sensory function was found in 21 (87.5%) patients. One patient had perianal and genital sensory deficit and one (4.2%) had urinary retention. Neither radiograms nor CT scans showed traumatic changes in any of the patients; MRI findings free of any traumatic spinal changes were recorded in 21 patients (87.5%). One patient had oedema of the T5 and T8 vertebral bodies. No complications were recorded. All patients experienced rapid resolution of neurological deficit, which occurred within 6 hours of injury in two (8.4%), within 12 hours in two (8.4%), within 24 hours in 12 (50.0%) and within 48 hours in six (25.0%) patients, and later than 48 hours after injury in two patients (8.4%). However, recovery always occurred within 72 hours of injury. DISCUSSION: A good prognosis for patients with this injury is supported by our findings, because all patients experienced rapid resolution of neurological deficit within 72 hours of injury. This result is in agreement with the relevant international studies reporting no serious complications associated with spinal trauma. There are no clear recommendations for administration of high doses of methylprednisolone according to the NASCIS system. CONCLUSIONS: Spinal cord concussion is not a frequent injury; in our study, it accounted for 3.54% of the patients with trauma histories out of the total number of 678 patients, or for 2.40% out of 997 injured spinal levels. The first steps should be the same as in any other injury to the spinal cord. An early examination of the patient with imaging methods including MRI is of primary importance. At present administration of methylprednisolone according to the NASCIS system is disputable. The patient diagnosed with spinal cord concussion has a good prognosis, with rehabilitation as the main therapeutic approach.

[ProDisc-C Total Disc Replacement. A four-year prospective monocentric study]. / Mobilní náhrada krcní meziobratlové ploténky ProDisc-C: prospektivní monocentrická ctyrletá studie.

PURPOSE OF THE STUDY: To present the results of an independent prospective monocentric study of patients with ProDisc-C Total Disc Replacement (CTDR) followed up for 4 years, and to analyse the most frequent late complications, in particular heterotopic ossification. MATERIAL: In the period from October 2004 to May 2006, a total of 61 patients underwent ProDisc-C CTDR involving one or two segments at the Department of Spinal Surgery, University Hospital in Motol. This study included 39 patients who were followed up for at least 4 years. With the exception of one patient operated on two segments, the patients were treated by ProDisc-C CTDR at one level. METHODS: In the study, only the surgical procedure recommended by the implant manufacturer (Synthes, USA) was used and all operations were performed by a team with the same leading surgeon. Clinical assessment. The patients were examined before surgery, immediately after it and at 6 and 12 weeks and 6, 12, 24 and 48 months post-operatively. At each follow-up, responses to the questionnaire were obtained, and the patients' health status was evaluated on the basis of Neck Disability Index (NDI) and Visual Analogue Score (VAS) values for cervical spine and radicular pain, the use of analgesics and personal satisfaction Radiographic assessment. Pre- and post-operative radiographs were taken in antero-posterior and lateral projection, and flexion, extension and lateral bending films were obtained The height of the intervertebral disc space at the affected level was measured and range of motion in flexion and extension was evaluated together with the adjacent levels. In addition, subsidence, loosening, failure or displacement of the implant was assessed, as well as the presence of heterotopic ossification. The results were statistically analysed using Student's t-test. RESULTS: The clinical results at 1, 2 and 4 years of follow-up were as follows: NDI values, 44.9 pre-operatively, 26.1, 25.8 and 25.1 post-operatively, improvement by 44.1% after 4 years; VAS for cervical spine pain, 5.8 pre-operatively, 3.0, 2.7 and 2.7 postoperatively, improvement after 4 years by 53.7%; VAS for radicular pain, 6.3 pre-operatively, 2.9, 2.9 and 2.7 postoperatively, improvement by 57.1% after 4 years. The radiographic findings showed the average intervertebral disc space height of 3.2 mm at the affected level before and 7.4 mm after surgery, with no significant change in the following period. The average range of disc motion at the affected level was 4.2 degrees before and 11.1 degrees after surgery, with 11.4 degrees at 4 years of follow-up. During that period, heterotopic ossification was recorded in 10 (25%) treated discs, with five of them (12.5%) classified as grade III or IV. Spontaneous fusion across the disc replacement level was found in three cases (7.5%). Two patients (5%) developed kyphosis at the affected disc level. The statistical analysis showed a significant difference between the pre-operative VAS values and those at 6 post-operative weeks for both cervical spine and radicular pain (t = 4.4 and t = 5.3, respectively; p < 0.05). No significant difference in VAS values was found between 6 weeks and 3 months after surgery for either condition (t = 1.69 and t = 0.3; p > 0.05). Changes in VAS values in the following period were minimal and non-significant. The differences in NDI values before surgery and at 6 weeks after it, and between 6 weeks and 3 months post-operatively were significant (t = 11, p < 0.05 and t = 3.8, p < 0.05, respectively). In the following period, changes in the values were minimal and non-significant. DISCUSSION: Short-term studies on various types of cervical disc replacement have been optimistic and reported good clinical results and few complications. However, with longer follow-ups there has been an increasing incidence of heterotopic ossification as the most frequent late complication. Although the number of patients diagnosed with it is growing, heterotopic ossification influences the patient's clinical problems only little. What are its causes and how to prevent it are questions to be fully answered yet CONCLUSIONS: Heterotopic ossification is the most frequent late complication of total disc replacement. Many factors may be responsible for its development and therefore its prevention is not clear. The correct indication and appropriate surgical technique are most often recommended, and are considered also by the authors to be most important. Restricted motion at the treated segment/s has no significant effect on the patient's clinical status.

[Kyphotic deformities of the cervical spin]. / Kyfotické deformity krcní pátere.

PURPOSE OF THE STUDY: The development of a cervical kyphotic deformity can be associated with a degenerative disease, trauma, tumour, developmental anomaly and also a surgical procedure. Post-operative kyphosis can develop after both the anterior and posterior surgical approaches. The deformity can also result from systemic diseases, such as ankylosing spondylitis or rheumatoid arthritis. The aim of the study was to make the clinical and radiographic evaluation of a group of patients with kyphotic deformity treated at our department. MATERIAL: Between May 2005 and April 2010, a total of 102 patients underwent correction of cervical kyphosis at our department. (Center for Spinal Surgery). Of them, 90 patients with complete medical records and post-operative periods longer than 6 months were included in this study. There were 36 men and 54 women ranging in age from 13 to 90 years and with an average of 56.7 years. In six patients cervical kyphosis was caused by an inveterate injury, in 71 by degenerative disease, in six it developed in association with rheumatoid arthritis, and in seven patients it was due to previous surgery. Patients with acute trauma, tumour, infectious disease or congenital anomaly were not included. METHODS: All patients were examined before surgery by radiography in antero-posterior and lateral projection, including flexion- extension bending films, and by CT scanning of ultrathin cross-sections with sagittal, frontal and recently also 3D reconstructions. Magnetic resonance imaging in three planes was also performed. On the basis of the results and clinical examination, the operative strategy was planned. Surgery was carried out from the anterior or the posterior approach, or the combined approach was used. Three-stage surgery was performed in one patient. The surgical outcome was assessed using the Nurick score and Neck Disability Index (NDI), the Visual Analogue Scale (VAS) was used to evaluate pain intensity or paraesthesia. Statistical analysis was done using the Chi-square test and paired t-test. RESULTS: The average NDI value was 25.5 before surgery and 14.3 and 14.9 at one and two years after surgery, respectively. Compared with the pre-operative state, improvement or no changes were recorded in 89.7 % of the patients; transient deterioration occurred in 10.3 %. Improvements found were as follows: by one degree in 46.2 % of the patients, by two degrees in 18 %, by three degrees in 5.1 % and by five degrees in 2.6 % of the patients. The condition remained unchanged in 18 % of the patients. The average outcome was an improvement by one degree. The average pre-operative Nurick score was 0.7; an average post-operative value of 0.6 was recorded at both one and two years of follow-up. The average VAS value for neck and radicular pain was 5.7 pre-operatively, and 2.5 and 2.7 at one and two post-operative years, respectively. Out of 90 patients, complete bone union was achieved at 6 months after surgery in 88 patients (97.8 %). The average pre-operative value for the cervical curvature index (Ishihara) was -13.7; the average pre-operative cervical kyphosis was -14.4 degrees, ranging from -2.2 to -44.0 degrees. After surgery, the average Ishihara index was +15.3 and the average lordosis was +13.5 degrees, with a range of -16.0 to + 37.4 degrees. DISCUSSION: A single/isolated anterior approach can be used for fixed deformities without ankylosing spondylitis. It allows for decompression of the anterior pathology and for correction of cervical kyphosis with use of instrumentation and structural graft. A combined ventral-dorsal approach is appropriate in fixed deformities or deformities involving the cervico-thoracic junction. The main principle of correction is to lengthen the cervical spinal column in the front and to shorten it at the back by anterior decompression with or without instrumentation and by subsequent posterior stabilisation. An isolated/single dorsal correction can be used in the case of successful correction by traction or specific head positioning on the table without anterior nerve compression. In severe fixed deformities such as Bekhterev's disease, the chin can be so close to the chest as to interfere with eating and breathing. The deformity most often develops at the cervico-thoracic junction and requires treatment by osteotomy. CONCLUSIONS: The results of the study showed a marked improvement in the patients' quality of life after kyphosis correction, improved neurological status and an improved posture seen on radiograms of the cervical spine. The study also revealed a higher number of potential complications associated, in particular, with corrective osteotomy. The best results were achieved with the combined surgical approach; however, the choice of a surgical method was independent of the patient's clinical status.

[Pulmonary polymethylmetacrylate embolism: a rare complication of percutaneous vertebroplasty]. / Plicní embolizace polymetylmetakrylátu - vzácná komplikace perkutánní vertebroplastiky.

Percutaneous vertebroplasty is a minimally invasive surgical technique involving transpedicular injection of polymethylmetacrylate into the vertebral body. The aim of this procedure is to enhance the mechanical strength of a pathologically changed vertebra. Currently, the method is most often used for painful osteoporotic vertebral fractures, aggressive haemangiomas, necrotic lesions and spinal tumours, particularly the metastatic ones. Although this method is less invasive, relatively straight-forward and effective, there may be complications. The authors present the case of a 70-year-old woman who, on the second day after surgery, developed a rare symptomatic pulmonary polymethylmetacrylate embolism after per- cutaneous vertebroplasty performed for osteoporotic fractures of the lumbar spine.

[Hyperextension trauma in patients with cervical spondylosis]. / Hyperextenzní poranení krcní pátere pri spondylóze.

PURPOSE OF THE STUDY To evaluate retrospectively a group of patients with hyperextension injury to the cervical spine who were treated at the Department of Spinal Surgery of the University Hospital in Motol, Prague, between 2003 and 2006. MATERIAL The group comprised 22 patients, 17 men (77 %) and five women (23 %) in the age range of 35 to 81 years, with an average of 59.5 years. All patients had, in association with the injury, neurological deficit of varying degree. METHODS All patients underwent X-ray and magnetic resonance imaging examination and received methylprednisolone according to the National Acute Spinal Cord Injury Study (NASCIS) 2 trial. Eleven patients had urgent surgery within 24 hours of injury; eight patients were operated on within an interval of 3 days to 2 months because of the seriousness of their state and multiple morbidity; and three patients were treated conservatively. Neurological deficit in terms of upper- and lower-limb mobility was evaluated by the American Spinal Injury Association (ASIA) motor score. The values obtained for the urgently operated patients and for those operated on after a time interval were compared by Wilcoxons two-sample test. The other aspects evaluated included trauma aetiology, level of spinal cord injury, manner of treatment, and intra-operative and post-operative complications. RESULTS The most frequent cause of injury was a low-height fall (13 patients; 59 %); car accidents ranked second (9 patients; 41 %). In five patients (22.7 %) ebriety was found. Eighteen patients had no skeletal injury (81.8 %). Four patients (18.2 %). Four patients (18.2 %) suffered fractures of articular or spinous processes, but the anterior column skeleton was intact in all. The segment most frequently affected by myopathy was C3-C4, then C4-C5 and C5-C6. Decompression was carried out to the extent of myopathy; and in the adjacent segments only if significant stenosis was present. In both subgroups of surgically treated patients (urgent and delayed management), comparisons of the ASIA scores at the time of injury and at one-year follow-up showed no significat improvement in post-operative mobility, as evaluated by Wilcoxons two-sample test at a level of significance a = 5 %. No intra-operative or post-operative complications, except for early death, were recorded. In all patients the wound healed by first intention and no loosening of instrumentation was foud on follow-ups at the out-patient departments. DISCUSSION Although the greatest narrowing of the spinal canal due to spondylosis occurs at the C5-C6 segment, the C4-C5 segment sustained most injuries. Although some relevant papers report no significant difference in improved neurological deficit between patients treated surgically and those undergoing conservative therapy, we prefer surgical management, in most of the cases from the anterior approach, which allows us to remove dorsal osteophytes and perform careful decompression to prevent damage to nerve structures and to preserve those which are still intact. There was no significant difference in the outcome between urgent and delayed trauma management, which is unusual amongst other injuries associated with neurological lesions and this indicates that the timing of surgery must be strictly individual and should be carried out at a time when operative benefit outweighs operative burden. The surgical treatment used should, in the first place, lead to early recuperation and rehabilitation. CONCLUSIONS Hyperextension injuries of the cervical spine are usually associated with serious neurological deficit. A correct algorithm of examination will result in good treatment outcomes. However, these injuries require a therapy that is long-lasting and difficult, with a need for cooperation of anaesthesiologists, spinal surgeons, physical therapists and, last but not least, psychologists. Key words: cervical spine, hyperextension injury, spondylosis, myelopathy.

[Distribution of orally administered aflatoxin B 1 in the tissues and organs of the goat (Capra)]. / Distribuce perorálne podaného aflatoxinu B1 ve tkáních a orgánech kozy (capra).

In the experiment the goat was administered an amount of 450 mg aflatoxin B1. The milk taken during the experiment was lyophilized and aflatoxins B1 and M1 were isolated. After the death of the goat some tissues, blood and bile of the experimental animal were analyzed to find out the aflatoxin content.

Aflatoxin and encephalopathy with fatty degeneration of viscera (Reye).

In the past 5 years we have observed 27 children at the age from 3 days to 8 years who died on the encephalic syndrome with fatty degeneration of the viscera (Reye). According to the morphological changes in the liver and to the clinical course, we have divided our cases into 3 groups. In the first group there were 20 children who died within 2-10 days after the first symptoms of the disease appeared. In their liver diffuse fatty degeneration was found. In the second group there were 3 children who died within 1-2 months after the acute onset of the disease. In their liver fibrosis with bile duct proliferation and steatosis were found. In the third group there were 4 children who died within 2-4 months after the first symptoms. Their liver showed cirrhosis. The bacteriological and virological investigations in all cases were negative, but in the most of them direct contacts with viral infections were proved. In the liver specimens of the children in all 3 groups the presence of aflatoxin B1 chromatographically and spectrophotometrically was found. The source of the intoxication in 5 cases was aflatoxin contaminated milk food. Our observations of 2 - 3 - days old newborns with the morphological changes similar to that of Reye's syndrome seems to support our hypothesis about the possibility of the intrauterine intoxication. We suggest that aflatoxin represents an important factor in the etiology of this syndrome and a high risk for human health.