RESUMEN
A variety of treatments has been described in the literature for the treatment of HV. We report the results of early surgical anterior instrumented fusion with partial preservation of the HV and posterior non-instrumented fusion in the treatment of progressive congenital scoliosis in children below the age of six. Between 1996 and 2006, 31 consecutive patients with 33 lateral HV and progressive scoliosis underwent short segment fusions. Mean age at surgery was 2 years and 10 months. Mean follow-up period was 6.1 years. The major scoliotic curve improved from 41 degrees preoperatively to 17 degrees on follow-up. Preoperative segmental Cobb angle averaging 39 degrees was corrected to 15 degrees after surgery, being 15 degrees at the last follow-up (62% of improvement). Compensatory cranial and caudal curves corrected by 47 and 45%, respectively. The angle of segmental kyphosis averaged 16 degrees before surgery, 11 degrees after surgery, and 11 degrees at follow-up. There were two wound infections requiring surgical debridment, one intraoperative fracture of the vertebral body and one case lost correction due to implant failure. All went on to stable bony union. There were no neurological complications. Early diagnosis and early and aggressive surgical treatment are mandatory for a successful treatment of congenital scoliosis and prevention of the development of secondary compensatory deformities. Anterior instrumentation is a safe and effective technique capable of transmitting a high amount of convex compression allowing short segment fusion, which is of great importance in the growing spine.
Asunto(s)
Escoliosis/congénito , Escoliosis/cirugía , Fusión Vertebral/instrumentación , Fusión Vertebral/métodos , Columna Vertebral/anomalías , Columna Vertebral/cirugía , Tirantes/normas , Preescolar , Falla de Equipo , Femenino , Fracturas Óseas/diagnóstico por imagen , Fracturas Óseas/etiología , Fracturas Óseas/patología , Humanos , Lactante , Fijadores Internos/normas , Fijadores Internos/estadística & datos numéricos , Fijadores Internos/tendencias , Cifosis/congénito , Cifosis/diagnóstico por imagen , Cifosis/cirugía , Imagen por Resonancia Magnética , Masculino , Hemorragia Posoperatoria/etiología , Radiografía , Estudios Retrospectivos , Escoliosis/diagnóstico por imagen , Columna Vertebral/diagnóstico por imagen , Tiempo , Resultado del TratamientoRESUMEN
STUDY DESIGN: A consecutive case retrospective chart and radiographic review. OBJECTIVES: To determine the incidence of nine radiographic dystrophic features acquired during the process of modulation, and to analyze the statistical correlation of these acquired dystrophic features with clinical progression of a spinal deformity. SUMMARY OF BACKGROUND DATA: In patients with neurofibromatosis, spinal deformities with seemingly few initial dystrophic features have shown a tendency to acquire dystrophic changes during long-term follow-up periods. Similarly, deformities with dystrophic changes can acquire further dystrophic features. This phenomenon is termed "modulation," a feature unique to spinal deformities in neurofibromatosis. These dystrophic changes may evolve slowly or aggressively, and may spread to other regions as well. METHODS: A review was done of the clinical records, photographs, radiographs, and other imaging studies of 457 patients referred between 1982 and 1995 with the diagnosis of neurofibromatosis Type 1. One hundred twenty-eight patients were diagnosed with a spinal deformity. Ninety-one patients who had a complete set of clinical and radiographic data were included in the study. Location and type of curve as well as the extent of spinal deformity were studied for their effect on the tendency for modulation. Initial spinal radiographs were analyzed for nine radiographic dystrophic features: rib penciling, vertebral rotation, posterior vertebral scalloping, anterior vertebral scalloping, lateral vertebral scalloping, vertebral wedging, spindling of the transverse process, widened interpedicular distance, and enlarged intervertebral foramina. Subsequent radiographs were analyzed critically for evolution, progression, or spread of these features. Correlation of acquisition in these dystrophic features with clinical progression in the spinal deformity, as measured in increments of scoliosis and kyphosis, was analyzed. RESULTS: In 81% of patients with spinal deformity diagnosed before 7 years of age and in 25% of patients with such a diagnosis after 7 years of age, evidence of modulation was observed. Location, side, and extent of the deformity and patient gender did not influence the propensity of the deformity to modulate. Correlation of modulation with clinical progression of the deformity showed rib penciling to be the only singular factor statistically influencing risk of progression. Of the deformities that acquired three or more penciled ribs, 87% showed significant clinical progression. No other radiographic dystrophic feature individually influenced progression. However, when three or more of the dystrophic skeletal features were acquired, the risk of progression reached statistical significance in 85% of patients. CONCLUSIONS: Spinal deformities in patients with neurofibromatosis 1 should be regarded as deformities in evolution. One should resist assigning these evolving deformities to either the dystrophic or nondystrophic end of the spectrum without considering the possibility of modulation across the spectrum. A spinal deformity that develops before 7 years of age should be followed closely for evolving dystrophic features (i.e., modulation). When a curve acquires either three penciled ribs or a combination of three dystrophic features, clinical progression is almost a certainty.
Asunto(s)
Neurofibromatosis 1/complicaciones , Neurofibromatosis 1/diagnóstico por imagen , Curvaturas de la Columna Vertebral/diagnóstico por imagen , Curvaturas de la Columna Vertebral/etiología , Adolescente , Adulto , Niño , Preescolar , Progresión de la Enfermedad , Femenino , Humanos , Lactante , Modelos Logísticos , Masculino , Neurofibromatosis 1/fisiopatología , Radiografía , Estudios Retrospectivos , Factores de Riesgo , Curvaturas de la Columna Vertebral/fisiopatologíaRESUMEN
Sixty-six consecutive patients with adolescent idiopathic scoliosis treated by posterior spinal fusion using Harrington distraction compression instrumentation were followed for a minimum of 3 years. Initial surgical correction was satisfactory, but during the follow-up period, mean 4.4 years (3-5 years), there was a loss of correction. Several factors (age, sex, the number of vertebrae in the fusions, and the use of cross wires) were important influences on correction. A method of assessing the balance of a posterior spinal fusion is described that is useful when assessing radiographs.
Asunto(s)
Vértebras Lumbares/cirugía , Dispositivos de Fijación Ortopédica , Escoliosis/cirugía , Fusión Vertebral/métodos , Vértebras Torácicas/cirugía , Adolescente , Hilos Ortopédicos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Análisis Multivariante , Estudios Prospectivos , Fusión Vertebral/instrumentación , Factores de TiempoRESUMEN
The incidence of venous thromboembolism after elective knee surgery has previously been studied almost exclusively in patients receiving total knee replacements, in whom the risk of a deep vein thrombosis is approximately 60%. We report the results of ipsilateral ascending venography in 312 patients undergoing a wide variety of elective knee operations under tourniquet ischaemia, none of whom received any specific prophylaxis against thromboembolism. Total knee replacement was confirmed to carry a high risk with ipsilateral deep vein thrombosis in 56.4% and symptomatic pulmonary embolism in 1.9%. By contrast, arthroscopy was associated with a low incidence of venous thrombosis (4.2%). Meniscectomy, arthrotomy, patellectomy, synovectomy and arthrodesis were all high-risk procedures, particularly in patients over 40 years of age, and were associated with deep vein thrombosis rates of 25% to 67%. On the basis of these findings, we advise prophylaxis against venous thromboembolism in all patients over 40 years of age undergoing elective knee surgery other than arthroscopy.
Asunto(s)
Articulación de la Rodilla/cirugía , Trombosis/epidemiología , Adulto , Anciano , Anticoagulantes/uso terapéutico , Niño , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Flebografía , Complicaciones Posoperatorias/epidemiología , Estudios Prospectivos , Trombosis/tratamiento farmacológicoRESUMEN
The authors report four cases of cauda equina lesions following posterior surgery for severe dysplastic spondylolisthesis: three following fusion in situ, and one following decompressive laminectomy. The patients developed urinary retention, saddle anesthesia, and lax anal tone immediately after surgery. The mechanism of the nerve root damage is thought to be mechanical, occurring during decortication before bone grafting. It is recommended that patients should be counseled about the risk of neurologic impairment following decompressive laminectomy or fusion in situ for severe spondylolisthesis.
Asunto(s)
Cauda Equina , Laminectomía/efectos adversos , Enfermedades del Sistema Nervioso Periférico/etiología , Fusión Vertebral/efectos adversos , Espondilolistesis/cirugía , Adolescente , Placas Óseas , Niño , Femenino , Humanos , Región Lumbosacra , Radiografía , Fusión Vertebral/métodos , Columna Vertebral/diagnóstico por imagenRESUMEN
A prospective study involving 500 consecutive patients undergoing hip replacement was performed to find out whether a combination of heparin and dihydroergotamine was effective in preventing postoperative fatal and non-fatal emboli. Deep-vein thrombosis was demonstrated in 131 cases (26.2%), in 99 of whom thrombi were confined to the ipsilateral (operated) limb and in 13 to the contralateral limb; 19 patients developed bilateral thrombi. Nine patients (1.8%) died during the first four weeks after operation, before they were discharged from hospital; in one, major emboli were demonstrated in the right pulmonary artery. Three of the 500 patients developed non-fatal pulmonary emboli. Excessive bleeding occurred in 21 (4.2%) and in 19 of these prophylaxis was discontinued. Wound haematomas developed in 25 patients (5.0%); only six required evacuation but in none of these six did deep infection occur while in hospital; in three patients, however, the wound haematoma prolonged the stay in hospital. Thus the combination of heparin and dihydroergotamine proved an effective prophylaxis against pulmonary embolism in patients undergoing total hip replacement. The risk of bleeding complications is wholly acceptable when balanced against the advantages of the therapy.
Asunto(s)
Dihidroergotamina/uso terapéutico , Heparina/uso terapéutico , Prótesis de Cadera , Tromboembolia/prevención & control , Tromboflebitis/prevención & control , Anciano , Pruebas de Coagulación Sanguínea , Quimioterapia Combinada , Femenino , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/prevención & control , Estudios Prospectivos , Embolia Pulmonar/prevención & control , Tromboembolia/diagnósticoRESUMEN
A method for quantifying the uptake of Tc-99m-labeled phosphate complexes in the femoral head has been clinically evaluated, being used specifically for studying the uptake of these bone-seeking agents in Perthes' disease. The analysis depends on the selection, by computer program, of a reliable reference area in the femoral shaft, which is then compared with the mean uptake from each femoral head. The femoral-head activity is then represented as an uptake ratio. These ratios, together with a fixed contour representing the uptake in the femoral-head regions, provide more clinical information than the radiograph or scintiphoto, particularly in the early stages of unilateral or bilateral femoral-head disease and during followup. No correlation has been found between these ratios and qualitative techniques for assessing Perthes' disease by radiograph. From the quantitative data so far obtained it is clear that osteotomy reduces the vascularity of the femoral head, and in certain cases this reduction persists for some years. Tc-99m-labeled diphosphonate compounds were used in more recent studies, and a significant increase in sensitivity was obtained, compared with earlier polyphosphate data.
Asunto(s)
Cabeza Femoral/diagnóstico por imagen , Enfermedad de Legg-Calve-Perthes/diagnóstico por imagen , Osteocondritis/diagnóstico por imagen , Tecnecio/metabolismo , Niño , Difosfonatos/metabolismo , Estudios de Evaluación como Asunto , Cabeza Femoral/metabolismo , Humanos , Enfermedad de Legg-Calve-Perthes/metabolismo , Polifosfatos/metabolismo , CintigrafíaRESUMEN
Abnormal femoral head activity in Legg-Calve-Perthes' disease has been measured using 99Tcm -polyphosphate and a gamma camera/computer data collection system. A reference point on the data matrix, which is unaffected by the diease, is used for deriving comparative uptake ratios in each femoral head. The reference point remains unaltered after surgical procedures or short intervals between follow-up studies. Early abnormality can be measured in both unilateral and bilateral femoral head pathology.