[Comparison of two surgical methods for treatment of idiopathic thoracic scoliosis - anterior versus posterior approaches]. / Srovnání výsledku dvou typu operacního lécení idiopatických hrudních krivek - prední versus zadní výkon.

PURPOSE OF THE STUDY: The aim of this retrospective randomised study is a comparison of two surgical approaches (anterior versus posterior) for the treatment of idiopathic thoracic scoliosis by corrective spondylodesis with segmental instrumentation in adolescents aged 13 to 20 years. MATERIAL AND METHODS: The study included patients with right-sided idiopathic thoracic scoliosis (Cobb's angle, 40°-70°; Lenke type I). The group of patients treated from the posterior approach by fusion and segmental instrumentation, involving the use of a hybrid, tworod system or screws only, comprised 31 girls with an average age of 14.5 years (group 1). In this group three instrumentation systems were used. The patients treated from the anterior approach, which included thoracotomy for disc excision, fusion and segmental instrumentation with a one- or two-rod system, consisted of 25 girls and six boys with an average age of 15.3 years (group 2). In this group four instrumentation systems were employed. In all patients radiographs were evaluated before surgery, immediately after the procedure and then every 12 months. The evaluation also included the operative time, blood loss, length of hospital stay, hospital costs and complications. The random selection was based on casting lots. Some patients indicated for the anterior approach withdrew after receiving detailed information on this procedure and therefore patients operated on from the anterior approach before the study had begun were enrolled. The statistical comparison of the results of anterior and posterior procedures was made using the two-sample t-test or Wilcoxon's test. The Shapiro-Wilk test was used for normality testing and Fisher's F-test for the equality of variances. The paired t-test or non-parametric paired Wilcoxon's test was employed for testing two variables within each group. The level of significance was set at 0.05. RESULTS In group 1, anteroposterior radiographs showed, on the average, 54.3° before surgery, 18.7° immediately after it and 19.1° at one year after surgery. The sagittal profile before surgery was T5 +30.0° T12 -57.7° S1; the surgery resulted in reducing thoracic kyphosis by 9.5° and lumbar lordosis by 14.2°. The average operative time was 245.8 min, intra-operative blood loss was 1095.2 ml and drained blood loss was 636.9 ml. The average hospital stay lasted 10.2 days. In group 2, anteroposterior radiographs had the average values of 53.7° pre-operatively, 23.6° post-operatively and 25.9° at one year after surgery. The pre-operative sagittal profile was T5 +21.5° T12 -54.2° S1 and, post-operatively, thoracic kyphosis increased by 7.0° and lumbar lordosis decreased by 2.2°. The average operative time was 226.8 min, intra-operative and drained blood losses were 1095.2 ml and 636.9 ml, respectively, and length of hospital stay was 15.5 days.. In group 2, the operative time and intra-operative blood loss were lower and post-operative drained blood loss (due to longer duration of chest drainage) was higher than in group 1. All findings were statistically significant. Significant differences between the groups were also found in the costs of implants and hospital stay because, for the posterior approach, they were higher by a total of 68 466 CZK and 52 250 CZK, respectively. DISCUSSION: In the frontal plane, thoracic kyphosis corrections through either surgical approach are comparable; in the sagittal plane, surgery from the posterior approach results in reducing thoracic kyphosis and that from the anterior approach produces a mild increase in it. CONCLUSIONS: In terms of surgical treatment selection, the anterior approach is more economical and requires spinal fixation and instrumentation to a lesser extent. However, prolonged chest wound drainage results in a longer hospital stay. The majority of idiopathic scoliosis cases are indicated for a posterior approach. In scoliosis with marked hypo-kyphosis or lordosis, an anterior approach can be considered because it produces an increase in thoracic kyphosis.

[Simple bony fusion or instrumented hemivertebra excision in the surgical treatment of congenital scoliosis]. / Prostá kostená fúze versus instrumentovaná hemivertebrektomie v operacní lécbe kongenitálních skolióz.

PURPOSE OF THE STUDY: In a retrospective study, to analyze long-term radiographic results of two surgical procedures used to treat congenital scoliosis. MATERIAL AND METHODS: A total of 685 patients with congenital scoliosis were treated at the Department of Orthopaedic Surgery, Bohunice Teaching Hospital in Brno, between 1976 and 2007. Of these, 102 patients, with an average age of 6.6 years at the time of surgery, were treated by simple bony fusion, and 22 children, with an average age of 10.2 years, underwent instrumented hemivertebra excision via simultaneous anterior and posterior exposures involving fixation with cannulated compression screws and a wire loop. The follow-up periods for the former and latter groups were 14.2 and 12.1 years, respectively. RESULTS: In the patients treated by simple bony fusion, the mean correction rate was 22.1 %, with Cobb angle values averaging from 44.2 degrees pre-operatively to 38 degrees post-operatively; the correction loss was 3.9 degrees at the last follow up. In the patients with hemivertebra excision, the mean correction rate was 61 %, with pre- and post-operative values of 51.3 degrees and 20.3 degrees , respectively, and a correction loss of 1.1 degrees at the last follow-up. DISCUSSION: The early detection of a deformity and simple bony fusion in low-magnitude curves can prevent progression of scoliosis and allows for maintenance of a compensated spine. Hemivertebra excision with compression instrumentation results in a better surgical correction of the deformity. The average 61 % correction rate achieved in our patients is in agreement with the results reported by authors using the same surgical technique, as well as with the results of posterior hemivertebra resection. The best correction, 78 %, has been achieved with surgery at a very young age. Complications associated with the two techniques are rare. CONCLUSIONS: Congenital scoliosis due to failure off either formation or segmentation is indicated for surgical treatment at young age. Its early detection and subsequent surgical treatment at young age. Its early detection and subsequent surgical correction of the curve result in a long-term maintenance of a compensated spine. Instrumented hemivertebra excision provides the highest rate of correction, particularly if carried out before 3 years of age.

[Neuromuscular deformity of the pelvis and its surgical treatment]. / Neuromuskulární deformity pánve a jejich mozné operacní resení

PURPOSE OF THE STUDY: To evaluate the efficacy of surgical treatment in pelvic deformities associated with neuromuscular spine deformity, using radiographic parameters and clinical outcome analysis. In the lumbo-pelvic region, spinal deformity is most frequently combined with pelvic obliquity, lumbar hyperlordosis, hip deformity and leg-length discrepancy. Pelvic deformities include an excessive posterior or anterior pelvic tilt, obliquity or rotation and windblown hip syndrome. MATERIAL AND METHODS: In the period from 1994 to 2006, 42 paediatric patients (28 girls and 14 boys) underwent surgical correction of spine and pelvic deformities by the Luque-Galveston technique. The group included 25 patients with an underlying diagnosis of a spastic form of cerebral palsy, seven patients affected by paralysis, six with Duchenne muscular dystrophy and four with spinal muscular atrophy. The average age at the time of surgery was 14 years and 3 months and the patients were followed- up for 7 years and 5 months on the average. The results were evaluated on the basis of findings on antero-posterior and lateral radiographs including the pelvis, hip joints and the whole spine. The patients were examined before surgery, then immediately after it, and at yearly follow-up intervals. RESULTS: The mean pre-operative pelvic obliquity was 37 degrees (+/-6.0) and it improved to 9 degrees (+/-4.5) post-operatively. Horizontalization of the sacrum was corrected from the mean preoperative value of 19 degrees (+/-5.0) to 37 degrees (+/-6.1) post operatively. This difference was statistically significant (p=0.001). Scoliosis curve correction achieved by the surgery was from 79 degrees (+/-21.3) pre-operatively to 35 degrees (+/-14.5) post-operatively, with a mean correction rate of 56 %. The following complications were recorded: faulty insertion of the pelvic fixation resulting in perforation of the medial cortical substance of the iliac crest in one patient, pseudoarthrosis in the region of thoraco-lumbal junction in two patients, instrumentation failure with the need of pseudoarthrosis resection and re-instrumentation in one patient, and deep infection requiring wound irrigation and longterm antibiotic therapy. DISCUSSION: The surgical correction of pelvic deformity is always associated with operative treatment of scoliosis. However, the procedure is regularly preceded by surgical correction of muscular imbalance of the lower limbs and pelvis and of hip deformities. The surgical stabilization of spinal and pelvic deformities brings about the loss of some alternative motor stereotypes. This disadvantage is compensated for by a better sitting stability and better prospects for prosthetic care. CONCLUSIONS: The radiographic and clinical findings in the patients treated showed good correction of pelvic deformities in the frontal and sagittal planes. Pelvic obliquity correction thus contributes to the improvement of sitting stability in physically disabled patients.

[Surgical options in the treatment of myeloma of the spine]. / Moznosti operacního resení myelomového postizení pátere.

Myeloma of the spine seriously affects the stability of the spine and can lead to compression of nerve structures. Instability of the spine caused by pathological vertebral fracture without compression of the nerve structures can be addressed conservatively using an external orthesis. Surgery is indicated in patients whose survival prognosis is 3-6 months in a situation of existing or imminent spinal collapse or nerve damage. The primary aim of the surgery is to stop the progress, improve or, in ideal cases, prevent damage to the nerves. The surgery renews stability of the spine, and reduces or eliminates the painful symptoms. From a surgical perspective, we distinguish between back, front, and combined procedures. The results are evaluated according to the changes found in the nerve findings based on the Frankel grading system. In our sample of 98 patients with myeloma of the spine who underwent surgery, 37 (38%) showed improved nerve findings, 57 (58%) stayed on the same level, neurologically, and only 4 (4%) showed post-operation deterioration of the nerve findings. Early diagnosis and urgent surgical decompression involving eventual stabilization of the spine can prevent irreversible damage to the nervous system under pressure from the myeloma of the spine.

[Replacement of the vertebral body with an expansion implant (Synex)]. / Náhrada obratlového tela expanzním implantátem (Synex).

PURPOSE OF THE STUDY: This paper describes replacement of the vertebral body with the expansion implant Synex. Usually, autologous bone graft is used to replace the vertebral body. In patients with bone cancer or multiple injuries to the spine, cement filling is preferred whereas, in other indicated cases, implants are inserted, of which Harms' titanium cage has been the most common one. However, this needs filling with a large amount of bone tissue and it is often difficult to adjust its size into the space available. Telescopic devices, on the other hand, are easier to implant and their application requires only a minimum amount of autologous bone tissue. MATERIAL: In the period from January 2000 to June 2001, we used telescopic implants Synex to replace vertebral bodies in 34 patients. Indications for treatment were: vertebral fractures in 14, post-traumatic kyphosis in six, vertebral metastatic tumours in eight and a primary tumour in six patients. METHODS: In 25 cases, the vertebral body replacement was completed by posterior stabilization using internal fixation and, in nine cases, by anterior stabilization with a Ventrofix fixator. In 32 patients, the implant was inserted from the anterior approach and, in two, from the posterior approach following complete spondylectomy. RESULTS: The L1 vertebra was replaced most frequently (nine patients), then T 12 (seven patients) and L2 (six patients). For treatment of fresh fractures, the Synex implant was used in 14 cases. Of these one was inserted from the posterior approach in the L1 region where trauma had caused severe injury to the spinal cord. In spinal tumours. Synex was used in 14 patients, i.e., in six with diagnosed plasmacytoma, in two with metastatic dissemination from prostate carcinoma, in four with vertebral metastases from breast cancer and in two patients with non-differentiated metastases. The anterior approach was performed by conventional thoracotomy or combined thoracotomy and lumbotomy in 20 patients and a less invasive retroperitoneal approach was used in 12 patients. One patient died of multiple metastases at 7 months after surgery and one patient had relapse of a local tumour resulting in paraparesis that required a repeat decompression of the spinal canal. The operation took 1 h and 50 min when the anterior approach and anterior stabilization with a Ventrofix fixator were used; the operation lasted from 3 h 20 min to 6 h 10 min when complementary posterior stabilization was involved. The patients were followed up for 2 to 24 months. No failure of the implant in terms of migration, change in position or penetration into adjacent vertebral bodies occurred. DISCUSSION: The replacement of a vertebral body has conventionally been performed with the use of a massive bone graft. However, collection of an autologous bone graft large enough to suit this purpose is not always possible. Complications at the donor site have been described. A homologous bone graft carries a risk of disease transmission and the reconstruction ability of a massive graft has not been confirmed for certain. Cement filling augmented with Kirschner's wires is usually used in cancer patients. Titanium cages require application of a large amount of spongiose bone tissue into their interior. Consequently, bone in the centre fails to remodel. A sharp edge of the mesh may induce migration of the cage towards the vertebral body and failure of the implant. Mechanical failure and collapse of cages have also been described. Telescopic cylindrical implants, on the other hand, need only a small amount of spongiose bone tissue to fill. They can be adapted directly to the implantation site by means of a special distractor and, therefore, before adjusting its final length, the exact position and orientation of the implant can be achieved in the space prepared. This facilitates close contact with the endplates of adjacent vertebral bodies and the development of osteointegration. The use of telescopic implants enabled us to avoid the force that is often necessary to apply during insertion of Harms' cages in the patients whose spines had already been stabilized with posterior fixation or to avoid the need of a triple surgical procedure in order to achieve better stability of the implant. In two patients, Synex was inserted from a non-standard posterior approach. Indications for Synex implantation should be evaluated in view of disease prognosis in each patient. If only limited survival is expected, cement filling with K-wires should be preferred. CONCLUSIONS: Synex is a sophisticated implant to replace severely damaged vertebral bodies regardless of the nature of lesion. Its application required additional stabilization by either posterior or anterior fixation (internal transpedicular fixator and Ventrofix or Kaneda, respectively). Its use is indicated in post-traumatic defects of vertebrae in acute or poorly healed scervical.

[Radical surgery in tumors of the thoraco-lumbar spine]. / Radikální operace pri nádorovém onemocnení torakolumbální pátere.

PURPOSE OF THE STUDY: In this retrospective study, the outcomes of anterior and posterior approaches, performed either simultaneously or consecutively, in the radical surgical treatment of tumors of the thoracolumbar spine were compared in terms of surgery duration, intra-operative blood loss, neurological findings and complications. MATERIAL: A total of 547 patients with malignant tumors of the spine were treated between 1981 and 2001. Of these, the thoracolumbar spine was affected in 422 cases. Spondylectomy from the combined anterior and posterior approach with decompression, vertebral body replacement and stabilization was indicated in 117 patients, 69 men and 48 women (59% and 41%, respectively). Etiology included metastases in 63 subjects (54%), primary malignant tumor in 37 (32%), benign tumors in 11 (9%) and tumor-like lesions in six patients (5%). Surgery involving two procedures carried out simultaneously by two teams of surgeons was used in 45 cases (38%) and approaches performed consecutively (in either the anteroposterior or the posteroanterior order) were applied in 72 cases (62%). Both groups were nearly identical in relation to the patients' average age and disease etiology. METHODS: In young patients with a solitary tumor of the thoracolumbar spine whose disease had a good prognosis, radical surgery including complete removal of the vertebra affected, decompression of nervous structures, vertebral body replacement and stabilization with 360 degrees fusion was carried out. The simultaneous and consecutive procedures were compared in terms of operative time, intra-operative blood loss, neurological findings and complications. RESULTS: The approaches carried out simultaneously by two teams reduced the total time of surgery and permitted a better correction of the spine affected. This surgical procedure, however, was more demanding in terms of operative skills and involved increased intraoperative blood losses. In 45 patients treated by this procedure, the average operative time was 244 min and intra-operative blood loss was 3313 ml. In 72 patients undergoing consecutive surgery, the average operative time was 345 min and blood loss was 2500 ml. The neurological finding was generally better or unchanged. Of the patients treated consecutively, four (5.5%) experienced deterioration; of those operated on simultaneously, only one patient (2.2%) got worse. Two patients died in each group (2.8% and 4.4%, respectively). DISCUSSION: In order to provide the optimal therapy, each cancer patient should be considered individually with respect to all basic rules of cancer treatment. In this, the radical approach is nowadays preferred. Some authors, however, use only the posterior approach. At our department, the combined anteroposterior approach under one anesthesia is our method of choice with the exception of a serious intra-operative complication such as large blood loss. In this case, the treatment is completed at a subsequent operation one week later. CONCLUSIONS: We prefer an active and radical approach to the therapy of spinal tumors. The simultaneous surgery resulted in an operative time reduced by about 100 min (29%). The consecutive treatment, on the other hand, produced lower blood losses by 813 ml (24%). Complete surgery under one anesthesia was preferred.

[The action of cisplatin on the developing meso- and metanephros of chick embryos]. / Osobennosti deistviia tsis-platina na razvivaiushchiisia mezo- i metanefros kurinykh émbrionov.

Injection of various doses of cisplatin to 2-14-day chick embryos showed that within 2-8 days of incubation cisplatin produces total toxic effect, the number of dead embryos being dependent on a dose of the drug. Within 9-16 days of incubation, i.e. a period when both the mature mesonephros and the developing metanephros are in action, no significant changes were observed in the content of urea and uric acid, the weight of the meso- and metanephros, their water content, and ion content of the blood. Electron microscopic studies revealed no structural changes in the renal tubules. The data obtained suggest that cisplatin does not produce any nephrotoxic effect in chick embryos irrespectively of their age.