Support of the anterior column with allografts in tuberculosis of the spine.
Fresh-frozen allografts from the humerus were used to help to stabilise the spine after anterior decompression for tuberculosis in 47 children with a mean age of 4.2 years (2 to 9). The average angle of the gibbus, before operation, was 53 degrees; at follow-up, two years later, it was 15 degrees. Rejection of the graft or deep sepsis was not seen. Cross trabeculation between the allograft and the vertebral body was observed at six months, with remodelling occurring at approximately 30 months. (+info)
Pathological fracture of a lumbar vertebra caused by rheumatoid arthritis--a case report.
We describe a case of rheumatoid arthritis (RA) with collapse of the L3 lumbar vertebra for which surgery was performed. The pathogenesis of lumbar lesions affected by RA is discussed and the literature reviewed. (+info)
Cotrel-Dubousset instrumentation for the treatment of severe scoliosis.
In a multicentric study, 36 cases (40 curves) of severe scoliosis were analysed; 19 were idiopathic and 17 neurological, Cobb angles ranged from 70 degrees to 145 degrees, all had undergone three-rod Cotrel-Dubousset (CD) instrumentation. The correction on the frontal plane achieved more than 50% of the preoperative angle (53.9% for idiopathic curves and 55.6% for neurological ones). On the sagittal plane the pathological shape of the spine was reduced and distinctly ameliorated. In ten patients, the authors successfully applied a technique, alternative to the original one, which was based on the use of two or three screws in the lumbar area, one supplementary pedicle transverse claw on the cranial area and two rods connected by a domino, instead of a single rod (the longer one applied on the concave side). The main complications were: one case of infection, three of vascular compression of the duodenum, one of crank-shaft phenomenon and one laminar hook displacement. The excellent result achieved in both, idiopathic and neurological severe and stiff scoliosis shows the efficacy, reliability and versatility of CD three-rod instrumentation. (+info)
Long-term three-dimensional changes of the spine after posterior spinal instrumentation and fusion in adolescent idiopathic scoliosis.
This is a prospective study comparing the short- and long-term three-dimensional (3D) changes in shape, length and balance of the spine after spinal instrumentation and fusion in a group of adolescents with idiopathic scoliosis. The objective of the study was to evaluate the stability over time of the postoperative changes of the spine after instrumentation with multi rod, hook and screw instrumentation systems. Thirty adolescents (average age: 14.5+/-1.6 years) undergoing surgery by a posterior approach had computerized 3D reconstructions of the spine done at an average of 3 days preoperatively (stage I), and 2 months (stage II) and 2,5 years (stage III) after surgery, using a digital multi-planar radiographic technique. Stages I, II and III were compared using various geometrical parameters of spinal length, curve severity, and orientation. Significant improvement of curve magnitude between stages I and II was documented in the frontal plane for thoracic and lumbar curves, as well as in the orientation of the plane of maximum deformity, which was significantly shifted towards the sagittal plane in thoracic curves. However, there was a significant loss of this correction between stages II and III. Slight changes were noted in apical vertebral rotation, in thoracic kyphosis and in lumbar lordosis. Spinal length and height were significantly increased at stage II, but at long-term follow-up spinal length continued to increase while spinal height remained similar. These results indicate that although a significant 3D correction can be obtained after posterior instrumentation and fusion, a significant loss of correction and an increase in spinal length occur in the years following surgery, suggesting that a crankshaft phenomenon may be an important factor altering the long-term 3D correction after posterior instrumentation of the spine for idiopathic scoliosis. (+info)
Complications of scoliosis surgery in children with myelomeningocele.
The purpose of the present study was to evaluate whether the high incidence of complications in scoliosis surgery in myelomeningocele (MMC) could be attributed to the surgical technique and whether improvements were possible. Between 1984 and 1996, 77 patients with MMC and scoliosis were treated surgically. The clinical and radiological follow-up ranged from 1 to 10 years with a mean follow-up of 3.6 years. The mean age at time of surgery was 12 years 8 months. The average preoperative scoliosis measured 90.20 degrees and was corrected by 47%. The first four patients were stabilized with Harrington rods after anterior correction with a Zielke device (group 1). Twenty-five patients were operated only from posterior, using Cotrel-Dubousset (CD) instrumentation (group 2). In 13 patients an anterior release and discectomy was performed prior to CD posterior instrumentation (group 3). In 26 patients (group 4) this was combined with an anterior instrumentation. The 9 patients of group 5 had congenital vertebral malformations which made a special treatment necessary. Complications could be divided into hardware problems, such as implant failure, dislocation or pseudarthrosis, infections, anesthetic, and neurologic complications. Hardware problems were seen in 29% of all patients. More hardware problems were seen with the Harrington rod (75%) and after solitary posterior instrumentation (30%). The occurrence of pseudarthrosis was dependent on the surgical technique, the extent of posterior spondylodesis, and lumbosacral fusion. Patients with hardware problems had a mean loss of correction of 49% compared to 13% in the other patients. Depending on the different surgical techniques a loss of more than 30% was seen in 12-75% of the cases. Early postoperative shunt failure occurred in four cases; delayed failure - after more than 1 year - in three cases. One patient died within 1 day due to an acute hydrocephalus, another died after 2 1/2 years because of chronic shunt insufficiency with herniation. Wound problems were not dependent on the surgical technique, but on the extent of posterior spondylodesis and the lumbosacral fusion. Based on this analysis we believe our current practice of instrumented anterior and posterior fusion is justified. Further, we are very careful to check shunt function prior to acute correction of spinal deformity. (+info)
Can autologous bone culture predict spinal fusion capacity?
The capacity of the individual patient to initiate osteoblast proliferation as a predictor for successful lumbar spinal fusion has not yet been reported. The objectives of this study were, first, to analyze the relationship between in vitro osteoblast proliferation and clinical bony fusion in the individual patient in order to predict the fusion outcome and, second, to measure the effect of preoperative tobacco smoking on osteoblast proliferation. Sixty-one patients (mean age 46 years) underwent posterolateral lumbar fusion in the period 1994-1995. Thirty-eight patients received CD pedicle screw implants and 23 received posterolateral fusions alone. During surgery, autogenous iliac bone was harvested and 1 g of trabecular bone without blood or bone marrow was then isolated for cell culturing. The cultures were classified as excellent (confluence within 4 weeks), good (confluence between 4 and 6 weeks) and poor (no or poor growth). Spine fusion was evaluated by two independent observers from plain anterior-posterior, lateral, and flexion/extension radiographs taken 1 year postoperatively, and the functional outcome was measured by the Dallas Pain Questionnaire (DPQ). Twenty-three patients had excellent, 19 good, and 19 poor in vitro osteoblast proliferation. Bony fusion was obtained in 77% of patients: 83% in the CD instrumentation group and 70% in the non-instrumentation group (NS). There was no significant correlation between osteoblast proliferation and spinal fusion or functional outcomes when analyzing the CD instrumentation and non-instrumentation groups together or separately. Elderly patients had a significantly poorer osteoblast proliferation than younger patients (P < 0.008). Preoperative tobacco consumption had no discernible effect on osteoblast proliferation, and no correlation between smoking and fusion was found. Further refinement of autologous osteoblast culturing may provide a biological tool for selection of patients who require biological enhancement of their bone fusion capacity. The poorer osteoblast proliferation related to advanced age supports the important negative biological influence of age on bony fusion. However, with more sensitive testing and better discrimination, other results are possible - or can in any event not be excluded. (+info)
Lumbar intradiscal pressure after posterolateral fusion and pedicle screw fixation.
In vitro biomechanical testing was performed in single-functional spinal units of fresh calf lumbar spines, using pressure needle transducers to investigate the effect of posterolateral fusion (PLF) and pedicle screw constructs (PS) on intradiscal pressure (IDP), in order to elucidate the mechanical factors concerned with residual low back pain after PLF. IDP of 6 calf lumbar spines consisting of L4 and L5 vertebrae and an intervening disc was measured under axial compression, flexion-extension and lateral bending in the intact spine, PS, PLF and the destabilized spine. Relative to the intact spines, the destabilized spines showed increased IDP in all of lordings and moments. IDP under PS and PLF were significantly decreased in axial compression, extension and lateral bending loads (p<0.05). In flexion, IDP under PS and PLF increased linearly proportional to the magnitude of flexion moment and reached as high as IDP of the intact spines. These results demonstrated that despite an increase in the stiffness of motion segments after PLF and PS, significant high disc pressure is still generated in flexion. Flexibility of PS and PLF may cause increased axial load sharing of the disc in flexion and increased IDP. This high IDP may explain patients' persisting pain following PS and PLF. (+info)
A new approach to scoliosis.
Despite the advantages that new derotation-based systems have brought to the treatment of scoliosis, the debate continues, especially regarding adolescent idiopathic scoliosis. Problems like decompensation, junctional kyphosis, and insufficient sagittal plane alignment are met with new proposals. We now are using a technique and system, the Ibn-I Sina Spinal System (IBS), that we think is able to overcome these problems. It makes use of sublaminar wires, hooks, screws, and rods for correction. The main innovation is that the major corrective force is a controlled translation force acting simultaneously on all segments of the curve. A retrospective assessment of 25 patients treated with this system showed that besides dealing well with decompensation and junctional kyphosis problems, the technique was superior in sagittal plane adjustments, mainly in that it carried the normal kyphosis to its physiologic location. IBS has proved easy and successful in scoliosis treatment, especially with lordotic rigid curves. We encountered no neurologic injury or instrument failure. In addition to these advantages, ease of preoperative planning and application, decreased operation time, easy removal or revision, and versatility and safety of the system has made the Ibn-I Sina Spinal System (IBS) a treatment of choice, especially for adolescent idiopathic scoliosis cases, in some centers in Turkey. (+info)