Spinal surgery in patients with Parkinson's disease: unsatisfactory results, failure and disappointment.

Previous studies on spinal surgery in PD patients report an exceptionally high rate of complications. Failure and re -operation are frequent outcomes. This is a retrospective case series with the aim of establishing the rate of complications in patients with concomitant Parkinson's disease. Ten patients were subjected to spinal surgery from 2005 to 2009. The indications and type of operation varied. Cases of Failed Back Surgery and re-operation were sought. Follow - up was between 6 - 42 months. All 10 patients presented some clinical or radiological complication. The most common complications were screw pull - out and progressive spinal deformity. Re - operations were performed in 5 patients, while clinical and radiological results were poor in the majority of cases. Patients with Parkinson's disease have a very high complication rate and often have to undergo revision surgery. This particular group of patients should be informed of the increased risk of failure and be closely followed - up on a regular basis.

The impact of bone mineral density on the degree of curvature of the lumbar spine.

OBJECTIVE: The prevailing perception is that one of the causes of postural deformities is osteoporosis. Nonetheless, studies of the correlation between bone mineral density (BMD) and spinal curvatures have produced contradictory results. This study was undertaken in order to determine whether (BMD) is associated with the curvature of the lumbar spine. METHODS: 105 postmenopausal women, aged 45-76 years (average= 57.3 years), were examined. All the participants underwent DXA scanning and spinal radiography using the same equipment and techniques. Lumbar curvatures were measured using the Cobb method. Subjects were divided according to their T-score into osteoporosis patients (n=54) and controls (n=51). Statistical analysis was performed using one way ANOVA, Mann-Whitney as well as Pearson and Spearman rank correlations. RESULTS: There were no statistically significant correlations between BMD and lumbar curvature angles either in the total sample or in either group individually. Furthermore, these angles were not significantly different between patients with osteoporosis and controls. CONCLUSIONS: The reduction in BMD and the alteration of the lumbar curvature that are observed in elderly individuals are concurrent but not related phenomena. The findings of this study contradict the claim that reduced bone mineral density is the cause of postural deformities.

Neurological outcome following early versus delayed lower cervical spine surgery.

PURPOSE: To determine whether the timing of surgery affects neurological outcome in patients with lower cervical spine trauma. METHODS: 29 patients with a fracture and 38 with a fracture-dislocation of C3 to C7 cervical vertebrae were treated operatively during the inclusive period January 1987 to December 2000. Surgery was performed as soon as the patient's medical condition allowed, within 72 hours in 31 and more than 72 hours after the injury in 36. RESULTS: Only patients with incomplete spinal cord injury had neurological improvement after surgery. There was no statistically significant difference in final neurological outcomes in patients having early as opposed to delayed surgery. CONCLUSION: Surgical intervention for cervical injuries is safe, as no postoperative neurological deterioration was recorded. Timing of surgery does not affect neurological outcome.

Informal in-hospital care in a rehabilitation setting in Greece: an estimation of the nursing staff required for substituting this care.

PURPOSE: To explore: (a) the type and frequency of care-giving activities provided by family members in the Rehabilitation Setting (RS), (b) opportunities for family members to receive training in care-giving activities, (c) to what extent caregivers feel free to ask the nursing staff for help and (d) to estimate the number of nursing staff required to substitute this care and thus to estimate the money saved by the RS due to the in-hospital informal care. METHOD: A convenience sample of 80 family members was selected. A questionnaire was developed to investigate several aspects of informal in-hospital care. Data was analysed using SPSS for Windows (Release 10.1). RESULTS: Cultural reasons and nursing staff shortage led 78.8% (n = 63) of the sample to provide informal in-hospital care. Oral and facial care (67.5%), help with getting dressed (62.5%), help with feeding (61.25%, n = 49), making patients' beds (57.5%, n = 46) and assistance with transferring patients from one hospital department to another (56.25%, n = 45) was provided on a daily basis by the subjects. 48.75%, (n = 39) changed sheets 1 - 2 times per week, while assistance with transfers from bed to wheel-chair and vice-versa (43.75%, n = 35) was provided 3 - 4 times per week. The estimated total time spent per week by the subjects on care-giving activities was 34,034 minutes that corresponds to a total of 75.6 working days or 15.12 working weeks. In order to substitute this care, the RS would need to hire 17 more assistant nurses, entailing a cost of from Euro 14,450 to Euro 20,060 per month. CONCLUSIONS: Informal in-hospital care is provided by Greek families in the RS. Nursing care staff shortage combined with cultural factors are the main reasons for this phenomenon. However, it saves the RS and the Greek State money and policy makers should be looking for ways to overcome the nursing shortage.

Halo pin intracranial penetration and epidural abscess in a patient with a previous cranioplasty: case report and review of the literature.

STUDY DESIGN: Report of a patient with an epidural abscess after halo pin intracranial penetration at the site of a previous cranioplasty. OBJECTIVES: To report a rare case of intracranial penetration at the site of a previous cranioplasty associated with epidural abscess, and to discuss the diagnostic and therapeutic approach to its management. SUMMARY OF BACKGROUND DATA: The most serious complications associated with use of halo device occur when pins penetrate the inner table of the skull, resulting in cerebrospinal fluid leak and rarely in an intracranial abscess. However, no mention of intracranial halo pin penetration at the site of a previous cranioplasty was found in the literature. METHODS: A 64-year-old man with ankylosing spondylitis had a halo vest placed for management of a fracture dislocation through the C5-C6 intervertebral disc space associated with left C6 radiculopathy. One week later, the patient experienced fever and headache associated with pain, redness, and drainage at the site of the insertion of the left posterior pin. Computed tomography of the brain showed a 1.5-cm intracranial penetration of the halo pin through a previous cranioplasty of the temporal bone, associated with epidural abscess and cerebral edema in the left temporoparietal lobe. The pins and the halo vest were removed, the pin site was cleaned, and a Philadelphia cervical collar was applied. Staphylococcus epidermidis grew on the culture of drainage from the pin site. The patient started immediate intravenous antibiotic treatment for 2 weeks, followed by oral antibiotics for 2 additional weeks. RESULTS: The patient had gradual improvement of his symptoms within the first 48 hours. At the latest follow-up visit, he had fully recovered and his fracture had healed. CONCLUSIONS: The halo device should not be used for patients with a previous cranioplasty, especially if the pins cannot be inserted at other safe areas of the skull. A thorough medical history and physical examination of the skull are important before the application of a halo device. Computed tomography of the skull may be necessary before elective halo application for patients with concomitant head trauma, confusion, or intoxication and for patients with a previous cranioplasty to ascertain the safest pin sites.

Evaluation of lumbar spine bone mineral density in the anteroposterior and lateral projections by dual-energy X-ray absorptiometry.

Dual-energy x-ray absorptiometry (DXA) is an established method for estimating bone mineral density (BMD) of the lumbar spine. In a prospective study, the sensitivity of BMD measurements between anteroposterior and lateral projections were evaluated in 204 postmenopausal women based on their DXA analysis. Patients were divided into two groups according to the absence or presence of lumbar scoliosis. Lateral projection DXA measurements were more sensitive than AP projection measurements for early detection of bone loss in postmenopausal women. Lateral projection DXA analysis is not recommended in spines with lumbar scoliosis.

Perceptions of body image, happiness and satisfaction in adolescents wearing a Boston brace for scoliosis treatment.

AIMS: To explore the impact of bracing on the perceptions of body image, happiness and satisfaction of adolescents with scoliosis. DESIGN: The study was designed as compare of 134 girls and 16 boys who wore a Boston type brace for scoliosis treatment and a control group of 99 healthy girls and 51 healthy boys. All them were secondary school pupils living in Athens Greece and were interviewed. A semi-structured schedule included general questions, and the Piers-Harris scale was used. Data were analysed using the SPSS/PC+ software, and descriptive statistics, factor analysis and the non-parametric Mann-Whitney U-test. Statistical significance was set at P=0.05 or less. RESULTS: The scoliosis group had a poorer perception of body image in comparison to the control group (P=0.048), while boys with scoliosis (P=0.030) had a better perception of body image than girls with scoliosis. Girls with scoliosis had a statistically significant difference (P=0.0388) in perception of happiness and satisfaction, in comparison with girls in the control group. Cohabitation with the mother seemed to be negatively correlated with body image, happiness and satisfaction perceptions because adolescents with scoliosis who were not living with their mother had a better body image perception (P=0.027) as well as better perceptions of happiness and satisfaction (P=0.047). Nevertheless, only 5% of those with scoliosis declared that they had opportunities to discuss their feelings and problems with health professionals, while 90% of them declared that they wanted to have more opportunities to do this. CONCLUSION: Adolescents with scoliosis face problems during bracing and they need to be supported by health care professionals.

Fixation of femoral shaft fractures with a flexible bundle-type nail.

In a prospective study, 31 consecutive patients with a femoral shaft fracture were treated with the Marchetti-Vicenzi intramedullary flexible bundle-type nail. Open reduction of the fracture was necessary in 25 of the 31 patients (81%). Twenty-five of the 31 fractures (81%) united within 2.5 to 6 months after the operation (mean, 4.2 months). Nonunion occurred in one patient (3.2%). Other complications included delayed union in five patients (16%), femoral shortening in five (16%), breakage of the distal pins in two (6.5%), and severe varus malunion in two patients (6.5%). Because of the high complication rate in this series, the authors no longer use the Marchetti-Vicenzi flexible nail for treatment of femoral shaft fractures.

The clinical performance of a small diameter tibial nailing system with a mechanical distal aiming device.

We present the clinical and radiographic results of a prospective study with the Orthofix tibial nailing system. The ease and safety of distal locking with the use of an improved targeting system was also evaluated. Sixty fresh tibial fractures in 60 patients with a mean age of 37.3 years (range 17-73 years) were treated. Eighteen of the fractures were grade I open fractures. All operations were performed in a conventional operating theatre on a simple transparent operating table, with reduction of the fracture performed under manual traction and manipulation of the fracture site. Hand reaming was then performed to ensure, where possible, the insertion of a nail of at least 9 mm in diameter. Fracture healing was observed at a mean of 17 weeks (12-28 weeks). No tibial non-unions occurred in our series, and only three fractures, two segmental and one severely comminuted, showed delayed union. No infection, either superficial or deep, was found and no cardio-pulmonary complications were recorded. Following surgery, all patients gained a full range of pain-free movement of the ankle and knee joints and only six patients (10%) complained of mild anterior knee pain. All patients returned to their previous jobs one month after fracture healing had been confirmed clinically and radiographically. Following nailing, no deviation from normal tibial alignment was detected. No mechanical failure of either the nails or the locking screws was recorded. The mean duration of operation (skin to skin) was 30 min (range 20-45 min) and the mean total theatre time was 55 min (range 40-75 min). The mean total intensification time was 5 s. In total, 120 distal locking screws were inserted using the external targeting device. All attempts at distal locking except five (4.2%) were successful with two failures in the same patient being a result of inappropriate use of the system. We conclude that this nailing system is clinically effective and that distal locking can be performed easily, without exposure to radiation.

Seven- to 20-year outcome of lumbar discectomy.

STUDY DESIGN: A retrospective, follow-up study. OBJECTIVES: To assess the effects of conventional surgery for lumbar disc herniation over an extended period of time and to examine factors that might correlate with unsatisfactory results. SUMMARY OF BACKGROUND DATA: Although the short-term results of lumbar discectomy are excellent when there is a proper patient selection, the reported success rates in the long-term follow-up studies vary, and few factors have been implicated for an unsatisfactory outcome. METHODS: One hundred-nine patients with surgically documented herniated lumbar disc were analyzed, retrospectively, by an independent observer. Long-term follow-up (mean 12.2 years) was done by a mailed, self-report questionnaire that included items about pain relief in the back and leg, satisfaction with the results, need for analgesics, level of activity, working capacity, and reoperations. Subjective disability was measured by the Oswestry questionnaire. Radiographic review was carried out in 66% of patients. End results were assessed using the modified Stauffer-Coventry's evaluating criteria. Several variables were examined to assess their influence to the outcome. RESULTS: The late results were satisfactory in 64% of patients. The mean Oswestry disability score was 18.9. Of the 101 patients who had primary procedures, 28% still complained of significant back or leg pain. Sixty-five percent of patients were very satisfied with their results, 29% satisfied, and 6% dissatisfied. The reoperation rate was 7.3% (8 patients), about one-third of which was due to recurrent disc herniation. Sociodemographic factors predisposing to unsatisfactory outcome, including female gender, low vocational education, and jobs requiring significant physical strenuousness. Disc space narrowing was common at the level of discectomy, but was without prognostic significance. CONCLUSIONS: The long-term results of standard lumbar discectomy are not very satisfying. More than one-third of the patients had unsatisfactory results and more than one quarter complained of significant residual pain. Heavy manual work, particularly agricultural work, and low educational level were negative predictors of a good outcome. These indicators should be used preoperatively to identify patients who are at high risk for an unfavorable long-term result.

Ten-year follow-up evaluation of a school screening program for scoliosis. Is the forward-bending test an accurate diagnostic criterion for the screening of scoliosis?

STUDY DESIGN: A 10-year follow-up evaluation of the effectiveness of school screening for scoliosis performed in a closed island population. OBJECTIVES: To evaluate the diagnostic accuracy of methods used for screening scoliosis and to re-examine the long-term effectiveness of the school scoliosis screening program. SUMMARY OF BACKGROUND DATA: The diagnostic accuracy of the forward-bending test and the long-term efficacy of the screening programs have not been clearly established. METHODS: In 1987, 2700 pupils aged 8 to 16 years from the island of Samos were screened for scoliosis. The Adams forward-bending test, Moire topography, the scoliometer, and the humpometer were used. Radiologic evaluation of the spine was available for each pupil and the number of false-negative and false-positive results of the screening methods was calculated. Subsequently, sensitivity, specificity, and positive and negative predictive values were estimated for each screening technique. Pupils found positive for spinal deformity were then followed up regularly at yearly intervals. In 1997, all positive subjects attended a 10-year clinical and radiologic follow-up, and the remaining subjects were re-evaluated by a postal questionnaire and were clinically examined if necessary. RESULTS: Spinal deformity was found in 153 (5.66%) pupils. Scoliosis (defined as a spinal curvature > or = 10 degrees) was found in 32 pupils, for a prevalence of 1.18%. For scoliosis, the Adams forward-bending test showed a number of false-negative results (in five cases), for a sensitivity of 84.37% and specificity of 93.44%. The sensitivities of Moire topography, the humpometer, and the scoliometer were 100%, 93.75%, and 90.62%, respectively, and specificity was 85.38%, 78.11%, and 79.76% respectively. The negative predictive value of the forward-bending test was inferior to those of the other methods. During this scoliosis screening program, if cutoff limits for referral had been used, such as the asymmetry of two Moire fringes, a humpogram deformity of (D + H) = 10 mm, and 8 degrees of scoliometer angle, it would have been possible to reduce radiologic examination by 89.4%. Three (0.11%) pupils aged between 12 and 14 years with scoliotic deformities greater than 20 degrees underwent satisfactory nonoperative treatment with Boston braces. One pupil with a 40 degrees thoracic curvature, underwent satisfactory surgical treatment because of progression 1 year later. Of the 121 spinal deformities with an initial Cobb angle less than 10 degrees, 44 (35.8%), and of the 29 scoliotic deformities with an initial Cobb angle between 10 degrees and 20 degrees, 14 (48.3%) progressed (a Cobb angle difference of at least 5 degrees in more than one examination). Observation and physiotherapy were the only treatments applied to all except one of the pupils in these groups. CONCLUSIONS: The Adams forward-bending test cannot be considered a safe diagnostic criterion for the early detection of scoliosis (especially when it is used as the only screening tool) because it results in an unacceptable number of false-negative findings. For the early detection of scoliosis, a combination of back-shape analysis methods can be safely used with the introduction of cutoff limits for referral being a useful procedure. The incidence of significant scoliosis is low, and its natural history seems to be independent of early detection. The wide-spread use of school scoliosis screening with the use of the forward-bending test must be questioned.

Evaluation of pedicle screw position in thoracic and lumbar spine fixation using plain radiographs and computed tomography. A prospective study of 35 patients.

STUDY DESIGN: This was a prospective study of 35 consecutive patients in whom pedicle screw position was assessed after surgery, using lateral radiographs and computed tomography. OBJECTIVE: To evaluate the accuracy of plain radiographs and computed tomography in assessment of pedicle screw position. SUMMARY OF BACKGROUND DATA: Imaging techniques, such as postoperative anteroposterior and lateral plain radiographs and computed tomography, are currently the primary means of assessing pedicle screw placement. METHODS: Postoperative radiographs and computed tomographic scans were used to evaluate the position of 220 pedicle screws inserted in the spines of 35 consecutive patients who underwent thoracic and lumbar spine fusion and instrumentation. No recognized neurologic complication resulted from pedicle screw placement. Screw position was graded as in, out, or questionable. All observations were performed independently by three observers. The authors also analyzed the position of the screws according to the underlying spinal disease. RESULTS: More misplaced screws were clearly seen on computed tomographic scans than on plain radiographs; however, this difference was not statistically significant. Interobserver differences were not statistically significant. Intraobserver differences approached statistical significance when the results of the two test were compared. CONCLUSIONS: Although the accuracy of computed tomographic imaging is better than that of plain radiographs, the difference does not reach statistical significance. Postoperative use of plain radiographs remains a reliable method for evaluation of pedicle screw insertion in the absence of neurologic deficit.

Operative treatment of unstable injuries of the cervicothoracic junction.

The authors present their experience in the operative treatment of unstable lesions at the cervicothoracic junction. Ten patients, six men and four women, underwent operative procedures at the cervicothoracic junction (C7-T1) between 1990 and 1997. Six patients had sustained fracture-dislocations, three patients had metastases and one patient had a primary malignant lesion. All the patients had significant cervical pain and neurologic deficit. The spinal cord and nerves were decompressed in all cases. Posterior stabilization was accomplished using various types of implants including hooks, wires and rods. Anteriorly, the spine was stabilized with plates and screws. Partial or complete vertebrectomy was performed in five cases and a titanium cylinder or an iliac autograft replaced the vertebral body. Five patients were submitted to a posterior operation only, and the other five to bilateral procedures. In four of these a one-stage operation was performed and in the last case a two-stage procedure. The anatomic and biomechanical characteristics of the cervicothoracic junction require a precise pre-operative analysis of the local anatomy and the selection of the proper implants for anterior and posterior stabilization.

Surgical management for instability and paraplegia caused by spinal sarcoidosis. A case report.

STUDY DESIGN: Report of a patient with paraplegia caused by vertebral sarcoidosis. OBJECTIVES: To report a rare case of vertebral sarcoidosis accompanied by progressive neurologic symptoms from the lower extremities, and to discuss the diagnostic and therapeutic approach to its management. SUMMARY OF BACKGROUND DATA: Vertebral sarcoidosis is a rare condition, and only a few case reports exist in the literature. A needle or open biopsy is required to establish the diagnosis. In most cases, treatment with steroids improves associated neurologic symptoms. Operative intervention is necessary in cases with progressive vertebral destruction, spinal instability, and impending or progressive neurologic deterioration. METHODS: Operative treatment by a two-stage anterior vertebrectomy and fusion followed by posterior stabilization was given to a patient with vertebral sarcoidosis and progressive neurologic deterioration of the lower extremities. RESULTS: After surgery, the patient had a complete neurologic recovery and satisfactory spinal fusion. CONCLUSIONS: In the absence of any spinal instability, neurologic symptoms associated with vertebral sarcoidosis respond satisfactorily to nonoperative treatment with steroids. Progressive neurologic deterioration or spinal instability caused by bone destruction requires operative intervention. Anterior vertebrectomy and fusion combined with posterior stabilization provided a satisfactory result for the patient in this report.

Post traumatic paraplegics living in Athens: the impact of pressure sores and UTIs on everyday life activities.

This paper contains the findings of a scientific research which was done on post-traumatic paraplegics who live in the area of Athens. Greece, and measured the impact of pressure sores and UTIs on their everyday life activities. The target population was 127 individuals out of which 98 were observed and interviewed. A semi-structured questionnaire which consisted of two parts used; the first part of the questionnaire included general questions whereas the second contained the Sarno Functional Life Scale (SFLS) which is a tool measuring the level of independence of disabled people. Sixty-two per cent of the population was male. The mean age of the sample population at the time they had the accident which caused the paraplegia was 31.5, while the median was 28.5. The majority of the subjects comes from the lower socioeconomic class. Traffic accidents accounted for the 55% of the occurrences of paraplegia, falls for 37%, surgical complication for 4% and athletic activities for the remaining 4%. Forty-nine percent of the sample had been hospitalised in a rehabilitation centre. However, the multiple regressions used did not reveal any statistically significant relation between the hospitalisation in a rehabilitation centre and the paraplegic's scores in any of the Sarno Functional Life Scale's (SFLS) variables. Instead, the multiple regressions employed yielded paraplegics' scores in the SFLS's everyday life activities that were negatively related to age (P = 0.004) and pressure sores (P = 0.021). The paraplegics' scores on the SFLS's indoors activities are positively related to the years since injury (P = 0.048) and health education on daily fluid consumption (P = 0.003). The scores of the subjects on the SFLS's outdoor activities are positively related to the years of education (P = 0.008), the years since injury (P = 0.011), while are negatively related to pressure sores (P = 0.034) and UTIs (0.044). The subjects' scores on the SFLS variables regarding social relations had a negative relation to sex, (female) (P = 0.0001), age (P = 0.001) and pressure sores (P = 0.019), while they have a positive relation with the years since injury (P = 0.024).

Hydatid disease of bones and joints. 8 cases followed for 4-16 years.

Hydatid disease is a rare parasitic disease that seldom involves the skeleton. Treatment is difficult because of problems with the preoperative diagnosis, the invasive nature of the bony involvement and the variable anaphylactic reaction to the cyst fluid antigen. We present 8 cases with osseous hydatidosis who were treated over a period of 11 years. The spine was involved in 2 cases, the ilium in 2, the hip in 2, the tibia in 1 and the humerus in 1. We point out that diagnosis is difficult and the prognosis is often poor.

Spinal cord decompression and stabilization in malignant lesions of the spine.

20 patients with neurologic deficit and pain from malignant spinal tumors (7 primary) underwent 28 decompression and stabilization procedures. Their mean age was 57 (30-74) years and 11 were women. Indications for stabilization were pathological spine fractures or a previous spinal decompression procedure. An anterior procedure was used in 2 patients with disease limited to 1 or 2 levels. A posterior procedure was used in 10 patients with widespread disease and unsatisfactory condition. Anteroposterior procedures in 1 or 2 stages were performed on 8 patients in satisfactory general condition with a malignant lesion at 1 or 2 levels and an unstable spine. Patients were submitted to radio- and/or chemotherapy postoperatively. Survival of patients treated for primary malignant tumors averaged 30 months and was 11 months for metastatic disease. 16 of the patients, especially those with nonmetastatic disease, had substantial relief of pain. Neurologic recovery was achieved in all of the anterior and combined anterior-posterior procedures and in 60% of the posterior decompressions. Complications included failure of the instrumentation in 2 cases, skin breakdown in another 2 and dislodgment of the autograft in 1.

Anteriorly displaced transverse fractures of the sacrum in adolescents: report of two cases.

A fracture of the sacrum at the level of the first and second segments, with forward displacement of the first segment, is a very rare injury in adolescents. The cases of two patients, who both suffered a displaced transverse fracture of the sacrum with resulting neural disturbance, are reported here. We consider that these unstable fractures may be treated surgically, by extensive laminectomies of the lumbosacral area and posterolateral fusion. Stabilization of the displaced fracture is possibly preferable, because it provides the prerequisites for early mobilization and reduces pain.