Fluoroscopy for transpedicular screw placement in scoliosis: to what extent can radiation exposure be reduced by the freehand technique?

AIM: In spinal surgery, high doses of radiation are delivered during surgical procedures that require fluoroscopic control. The aim of this study was to determine the amount of radiation delivered from the fluoroscopic unit and also the factors to reduce the amount of radiation during the surgery of adolescent idiopathic scoliosis patients. MATERIAL AND METHODS: In this retrospective study 21 patients with adolescent idiopathic scoliosis treated by transpedicular screws between 2009 and 2012 were enrolled the study. Dose Area Product (DAP) values , number of views obtained during screw placement and other data were retrieved from the medical records of the patients. RESULTS: The mean number of transpedicular screws used was 18. An average of 10,1 vertebrae were instrumented. The mean number of images obtained was 7.76. Mean fluoroscopy time was 7.95 seconds. The total mean DAP was 64.6 cGy.cm < sup > 2 < /sup > . CONCLUSION: The amount of ionizing radiation transmitted to the patient and the surgical team can be reduced by freehand insertion, confirmation of screw position by AP and lateral fluoroscopic views including more than one segment, the use of K-wires as a guide in spinal segments with abnormal pedicular anatomy and neuromonitorization of the patient during the surgical correction of adolescent idiopathic scoliosis.

Ankylosing pelvitrochanteric heterotopic ossification in a patient with spinal cord injury.

Heterotopic ossification is a frequent complication after spinal cord injury. It usually develops around major weight bearing joints. However, ankylosing hip is a rare presentation. Various treatment methods have been reported and advocated as efficacious methods for management of heterotopic ossification. We report a case of ankylosing pelvitrochanteric heterotopic ossification treated with surgical excision before full maturation, postoperative radiation therapy and indomethacine without recurrence after 1 year. Treatment options are discussed in this particular case.

The importance and efficacy of posterior only instrumentation and fusion for severe idiopathic scoliosis.

AIM: In mild and moderate idiopathic scoliosis (IS), posterior only instrumentation and fusion can provide satisfactory reduction. However in severe and rigid curvatures, combined anterior and posterior fusion is generally required. In this study we have aimed to evaluate the efficacy of posterior only instrumentation in severe thoracolumbar scoliosis clinically and radiologically and compare these results with the literature. MATERIAL AND METHODS: In this retrospective study, 29 consecutive patients with severe idiopathic scoliosis who underwent posterior only instrumentation and fusion between March 2003 and February 2011 were included the study. Radiological evaluation was performed with preoperative, postoperative and folllow up standing AP and lateral x-rays. Clinical evaluation was made with shoulder balance and trunk shift. REAULTS: Major curve magnitude decreased to 24,1° and compensatory curve magnitude decreased to 12.20° at postoperative period. There was no significant difference in sagittal plane angles. Major curve correction rate was %68,65 in screw only instrumentation and % 65 in hybrid instrumentation. CONCLUSION: Transpedicular screw instrumentation in severe IS is a safe and effective method in proper hands when flexibility of the curve evaluated accurately in preoperative period.

Posterior spinal fusion in adolescent idiopathic scoliosis with or without intraoperative cell salvage system: a retrospective comparison.

This study investigates efficacy and safety of routine cell salvage system use in adolescent idiopathic scoliosis patients undergoing primary posterior spinal fusion surgery with segmental spinal instrumentation. Forty-five consecutive adolescent idiopathic scoliosis patients undergoing posterior spinal fusion by two surgeons at a single hospital were studied. Intraoperative cell salvage system was used in 23 patients, and the control group was 22 patients who underwent surgery without cell salvage system. The cell salvage system was the Haemonetics Cell Saver 5. The primary outcome measures were intraoperative and perioperative allogeneic transfusion rate, difference between preoperative and discharge Hg and Hct levels. Average patient age was 14.65 ± 1.49 in cell saver group and 13.86 ± 2.0 in control group. In cell saver group, average intraoperative autotransfusion was 382.1 ± 175 ml. Average perioperative allogeneic blood transfusion need was 1.04 ± 0.7 unit in cell saver group and 2.5 ± 1.14 unit in control group. No transfusion reactions occurred in either group. Average hemoglobin level in cell saver group was 10.7 ± 0.86 and average hemoglobin level in control group was 10.7 ± 0.82 on discharge. Cell saver reduces perioperative transfusion rate in patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis.

Evaluation and comparison of the effects of hyperbaric oxygen and ozonized oxygen as adjuvant treatments in an experimental osteomyelitis model.

BACKGROUND: We evaluated and compared the efficacy of ozone (O(3)) and hyperbaric oxygen (HBO) therapies in an experimental rat model of osteomyelitis. MATERIALS AND METHODS: Forty-eight male Sprague-Dawley rats were divided into sham, osteomyelitis (control), vancomycin (V), vancomycin + HBO (VHB), vancomycin + O(3) (VO), and vancomycin + HBO + O(3) (VOHB) groups. Osteomyelitis was induced by a bone injection of 10(8) CFU/mL methicillin-resistant Staphylococcus aureus. HBO was administered daily at 2.8-atm pressure for 90 min; O(3) therapy was provided as intraperitoneal injections of 0.7 mg/kg O(3)/O(2) gas mixture once daily. Treatments were continued from d 7 to 21 after induction of osteomyelitis. Bone tissues and blood samples were harvested for biochemical, histopathologic, and microbiologic analyses. RESULTS: Rats in the sham, VO, and VOHB groups gained weight but those in the control, V, and VHB groups did not. Levels of malondialdehyde, superoxide dismutase, and glutathione peroxidase were lower in the VHB, VO, and VOHB groups than in V and control groups. Levels of interleukin-10 and -1ß and tumor necrosis factor-α were decreased in the VHB, VO, and VOHB groups; transforming growth factor-ß was increased in these groups compared with V and control groups (P ≤ 0.001). Bacteria counts in VOHB were significantly lower than those in group of V (P = 0.012). Histopathologic scores in group VO were significantly lower than those in group V (P = 0.046). CONCLUSIONS: O(3) was as effective as HBO in decreasing oxidative parameters and inflammatory cytokines. Rats in the VO and VOHB groups gained more weight than did the other groups. Bacteria counts were significantly decreased in group VOHB compared with the other groups. Histopathologic scores in group VO were significantly decreased compared with the other groups.

AO tension band technique application in proximal humerus fractures.

OBJECTIVES: The aim of this study was to report our functional results after an intramedullary Kirschner wires (K-wires) and tension band wiring combination for the treatment of a large group of humeral head fractures was performed. PATIENTS AND METHODS: Seventy-four patients (54 females, 20 males; mean age 42 years; range 24 to 73 years) who had proximal humerus fractures were treated with an intramedullary K-wire and tension band technique and were retrospectively analyzed. Fracture patterns were according to Neer classification type II in 43 patients, type III in 23 patients and type IV in five patients. The Constant-Murley shoulder score test was used to evaluate the function of both shoulders. The outcome was graded according to Neer's criteria. The pain score was determined with a 10-point visual analog scale. RESULTS: All fractures were healed (radiologically and clinically) within 3.6 months (range 2.5 to 4.7 months) after the surgery. In one patient, the cerclage wire was broken and in eight patients, K-wires produced impingement like symptoms that required a second procedure (wire removal) after healing. The results of the patients with regard to Constant-Murley score and Neer criteria were indifferent when the 6th and the 12th month data were compared (p<0.05). Visual analog scale scores of the patients between the two control visits were significant different (p>0.05). CONCLUSION: The type of fixation depends on the bone quality and the degree of comminution. But the recent trend is towards osteosynthesis -the limited, less invasive technique- which is performed with minimal soft tissue dissection and minimal osteosynthesis. It allows less stripping of bone and therefore preservation of the blood supply to the humeral head. This procedure is simple to perform and provides good postoperative results.

Coccygectomy with or without periosteal resection.

The purpose of this study was to compare the clinical outcomes and wound complications in coccygectomy with or without subperiosteal resection. This retrospective study included 25 patients who underwent coccygectomy. Resection of all mobile coccygeal segments including the periosteum was performed in 11 patients (group 1) and resection was performed subperiostally sparing the periosteum in the remaining 14 patients (group 2). A visual analogue scale was used for pain assessment before and after the surgery both in sitting and standing positions. A questionnaire to evaluate subjective patient satisfaction was also used. The two groups were statistically similar in terms of age, sex, aetiology, duration of symptoms before surgery and follow-up time. Both surgical techniques resulted in a statistically similar clinical outcome. Overall, 84% of patients who underwent coccygectomy benefited from surgery. We observed four wound infections (two superficial and two deep) that caused delayed wound healing in group 1. The rate of infection in group 1 was statistically higher than in group 2. The results of this study suggest that periosteal preservation and closure are related to low risk of infection.

Isolated zone I vertical fracture of first sacral vertebra: a case report.

Isolated sacral fractures which occur by shear forces on the pelvic ring are seen less commonly and they are commonly transversely oriented. A 29-year-old Turkish female patient, who sat in front seat in the car, was unrestrained, and another car hit them from right front side of their vehicle. Physical examination revealed considerable tenderness over the right superior gluteal region and excruciating pain during sacral and iliac compression. There was no clear fracture line in her plain radiographs. CT revealed incomplete, zone I fracture located on the superior and anterior part of the first sacral vertebra. Type 1 lateral compression pelvic fractures are relatively common and they include impacted sacral and ipsilateral rami fractures. Only a few cases, related with the isolated sacral fracture, have been reported in the literature. To our knowledge, no isolated vertical zone I fracture of the first sacral vertebra which occurred with the lateral compression injury has been described previously. Fracture of the sacrum should be suspected in the presence of sacral pain and tenderness.

Burst fracture of the lumbar vertebra due to a landmine injury: a case report.

INTRODUCTION: The reason we report this case is that spine injuries may well occur due to landmines similar to other injuries like traumatic limb amputations and more over they may be overlooked. CASE PRESENTATION: The patient was 29-years-old Turkish male and was a member of the military. He detonated the landmine that caused his injuries while in a conflict zone. He had a right below knee and left above knee traumatic amputations. He had also mild intermittent pain in his lower back. There were no focal neurological findings such as weakness, altered sensibility, or alteration in the function of the bowel or bladder. Radiographs of the lumbar spine revealed an L2 burst fracture. Computed tomography scans and magnetic resonance imaging of the lumbar spine demonstrated a burst fracture of the L2 vertebrae and moderate compression in the anterior portion of the thecal sac due to the fracture fragment. Because of the stabile nature of the L2 burst fracture and lack of neurological disturbance, operative decompression, instrumentation and fusion was not performed. After healing of the stumps, the patient was mobilized with immediate prostheses and a thoracolumbosacral brace. CONCLUSION: Spine injuries should not be overlooked when evaluating patients after landmine explosions. After the patient has been stabilized, the secondary screening and radiographic evaluations should also comprise the thoracic, thoracolumbar and lumbar spine when treating patients after landmine injuries.

An unusual cause of foot pain in a child: osteochondrosis of the intermediate cuneiform.

UNLABELLED: Osteochondrosis of the intermediate cuneiform is a rare entity that may cause foot pain and limping in children. We report a case of osteochondrosis of the intermediate cuneiform in a child who underwent a spontaneous recovery after conservative treatment. LEVEL OF CLINICAL EVIDENCE: 4.

Pronation versus supination maneuvers for the reduction of 'pulled elbow': a randomized clinical trial.

OBJECTIVES: The purpose of this study was to compare the efficiency of the hyperpronation and supination-flexion maneuvers in the reduction of the pulled elbow. METHODS: Sixty-six patients with pulled elbow were randomized for reduction with either hyperpronation or supination-flexion maneuvers. When the first attempt failed, a second attempt was performed with the same reduction maneuver. After failure of the second attempt the reduction maneuver was changed to the alternate method. The success rate of the reductions and the subjective rating on the difficulty of the reduction by the physician were recorded and analyzed statistically. RESULTS: Thirty-two of 34 patients (94%) in the hyperpronation group and 22 of 32 patients (69%) in the supination-flexion group were reduced at first attempt (P=0.007). Two patients in the hyperpronation group and seven patients in the supination-flexion group were reduced at the second attempt. Reduction rates were statistically similar (P=0.06). Three patients in the supination-flexion group had failed reduction at the second attempt and the reduction maneuver needed to be changed. They were successfully reduced with hyperpronation maneuver at the first attempt. Final success rate of the hyperpronation maneuver at the first attempt was statistically higher than the supination-flexion maneuver (P=0.004). Furthermore, the hyperpronation maneuver was rated significantly easier than the supination-flexion maneuver by physicians (P=0.003). CONCLUSION: Although final reduction rates were similar, the hyperpronation maneuver was more efficient at the first attempt, easier for physicians and less painful for the children.

Painful neuroma requiring surgical excision after lower limb amputation caused by landmine explosions.

This article reports an analysis of 75 consecutive lower limb amputees who developed painful neuroma requiring surgical excision after lower limb amputation following landmine explosions. This retrospective study analyses the results of 75 patients who were treated for painful neuroma after lower limb amputation following landmine explosions between the years 2000 and 2006. The average time period from use of prosthesis to start of symptoms suggesting neuroma was 9.6 months. The average time period from start of pain symptoms to neuroma surgery was 7.8 months. All clinically proven neuromas were surgically resected. In the mean follow-up of 2.8 years, all patients were satisfied with the end results and all were free of any pain symptoms. Painful stump with clinical diagnostic findings of neuroma described above may be regarded as neuroma without requiring any further imaging modalities and is an indication for surgery if conservative measures fail.

Benign fibrous histiocytoma of the lumbar vertebrae.

Benign fibrous histiocytoma is an extremely rare spinal tumor with ten reported cases in the literature. Benign fibrous histiocytoma constitutes a diagnostic challenge because it shares common clinical symptoms, radiological characteristics, and histological features with other benign lesions involving the spine. We present a case of benign fibrous histiocytoma of the lumbar spine and discuss its differential diagnosis and management.

Primary paraspinal hydatid cyst treated with puncture, aspiration, injection and re-aspiration (PAIR) technique: a case report.

Hydatid disease is a parasitic tapeworm infection that usually involves liver and lungs. Primary skeletal muscle hydatid cyst without liver and lung involvement is rare. En bloc resection without inducing rupture and spreading the daughter cyst is recommended treatment strategy and accepted to be curative for intramuscular hydatid cyst. We report a case of primary hydatid cyst of the erector spinae muscle which was treated successfully with ultrasonography guided puncture, aspiration, injection of 95% ethanol and re-aspiration (PAIR) technique.

[Removal of a bent inflatable femoral nail: a case report]. / Egilmis sisirilebilir femur çivisinin çikarilmasi: olgu sunumu.

Intramedullary nailing is the gold standard for the treatment of diaphyseal femoral fractures. Bending of the nail secondary to trauma is a rare complication encountered in unhealed and comminuted fractures. A 23-year-old man was admitted with refracture of the right femoral shaft and a 32-degree bending of an inflatable intramedullary nail due to a fall, two months after the initial surgical treatment. The nail was first straightened by exerting an external force, which decreased the angulation to 10 degrees. Then, the fracture site was opened, the lateral wall of the nail was drilled, and one of the four metal bars of the nail was cut. This allowed complete straightening of the nail by the same maneuver and its removal. A new inflatable intramedullary nail was placed and union was achieved after four months. Tools that may be necessary to cut the nail partially or totally should be made available for removal of bent nails.

Total elbow arthroplasty in patients who have elbow fractures caused by gunshot injuries: 8- to 12-year follow-up study.

INTRODUCTION: In this retrospective study, we aimed to present 8-12-year clinical and radiographic evaluation of total elbow arthroplasty in young patients who had open fractures due to gunshot injuries. MATERIALS AND METHODS: The study included a consecutive series of seven patients who had insertion of total elbow prosthesis (semi-constrained type) for the treatment of comminuted intra-articular elbow fractures resulting from gunshot injuries between 1994 and 1998. All patients were male and the mean age at the time of operation was 23 years. RESULTS: The average time from the original fracture to the joint replacement was 26 months (range 14-39). The mean follow-up period was 117 +/- 15 months. At the time of the latest follow-up, 5 of 7 elbows had a poor result. Radiological evaluations revealed that three patients had ulnar and two patients had humeral component loosening at the last follow-up examination. No intra-operative complications were observed. In the long-term evaluation, two patients had prosthesis loosening that resulted from deep infection and three patients had aseptic loosening that necessitated re-operation. The prosthesis removal was performed. CONCLUSION: As a result, the patients in whom we implemented total elbow prosthesis in comminuted elbow fractures due to gunshot wounds seemed to get back into active life in the early period without any problem and it seemed that their pain disappeared and their functional capacity increased. In the long period, however, these values showed a distinct decrease with the same patients.

Simultaneous versus sequential one-stage combined anterior and posterior spinal surgery for spinal infections (outcomes and complications).

To compare simultaneous with sequential one-stage (same anaesthesia) combined anterior and posterior spinal surgery in the treatment of spinal infections in terms of the operation time, blood loss and complication rate. Fifty-six patients who underwent one-stage (same anaesthesia) simultaneous or sequential anterior decompression and posterior stabilisation of the involved vertebrae for spinal infection from January 1994 to December 2002 were reviewed. In group I (n=29), sequential anterior and posterior surgery was performed. In group II (n=27), simultaneous anterior and posterior spinal surgery was performed. With regard to age and gender, there was no statistical difference between both groups (P=0.05). The analysed and compared data between the two groups included the age, gender, blood loss, operation time and postoperative complications. There was a statistically significant difference between the two groups in terms of the duration of surgery, amount of blood transfusion needed and occurrence of major postoperative complications (P<0.05). The mean correction of the kyphotic deformity was similar in both groups (P>0.05) without a subsequent loss of correction on follow-up radiographic films at a mean follow-up of 6.5 years (range, 3 to 11 years). Simultaneous anterior and posterior surgery is a good alternative procedure. It provides the ability to manipulate both anterior and posterior aspects of the spine at the same time and appears to result in less blood loss, a shorter operative time and fewer complications. However, gaining experience and the availability of two surgical teams are important factors in the success of the procedure.

Coccygectomy in the surgical treatment of traumatic coccygodynia.

THE PURPOSE OF THE STUDY: Direct or indirect trauma to the coccygeal bone can induce chronic coccygodynia. The aim of this study is a retrospective analysis of our patients surgically managed for traumatic coccygodynia and a critical review of the results obtained in comparison to the literature. BASIC PROCEDURES: We have retrospectively investigated patients with traumatic coccygodynia referred to our centre after a failure of conservative treatment. Surgery (coccygectomy) was performed in 74 patients (64 women, 10 men) suffering from coccygodynia resistant to conservative treatment, all without serious complications, between the years 1998 and 2004. The mean follow up was 4.1 years (range, 2-8 years). The mean age of patients on the date of surgery was 43.4 years (range, 16-65 years). The average duration of pain prior to surgery was 7 months (range, 3 months to one year). MAIN FINDINGS: All but three patients had either good or excellent results after surgery. Three patients reported postoperative pain lasting 3-6 months. All three had good results after re-operation of a proximal segment without excision. Five postoperative complications, four superficial and one deep infection were observed. PRINCIPAL CONCLUSIONS: In patients with posttraumatic, conservative therapy-resistant coccygodynia, operative treatment with coccygectomy is a feasible management option. We recommend total or partial coccygectomy using a longitudinal incision in carefully selected and well-informed patients.

Transforaminal epidural steroid injection for the treatment of severe back pain caused by cement leakage during kyphoplasty procedure.

Kyphoplasty is a minimally invasive procedure that is increasingly used to treat pain caused by compression fractures of vertebral bodies. A 56-year-old woman who had a compression fracture on the vertebral body of L5 vertebra was admitted to the Algology Department with a severe low back and leg pain. Kyphoplasty was planned for pain relief. She suffered severe pain in her back and left leg immediately after the procedure because of a leakage of injected cement through the fracture line. After injection of triamcinolone and bupivacaine transforaminally into the L5-S1 anterior epidural space, her pain complaints ended. If radicular pain symptoms caused by cement leakage are secondary to a chemically mediated non-cellular inflammatory reaction, transforaminal epidural steroid injection should be useful.