RESUMEN
PURPOSE OF THE STUDY Unplanned revision spinal surgeries constitute a complication in the treatment algorithm for the patient, surgeon and the entire treatment team. Any complication leading to an unplanned revision surgery is therefore undesirable. The percentage of complications referred to in publications on this topic focusing on unplanned revision surgeries only varies from 0.7% to 29.8%, with obvious diversity of causes and significant risk factors. The purpose of the submitted paper is to carry out a prospective evaluation of the most serious complications requiring unplanned revision spinal surgeries in the course of 13 years at a single department performing a broad range of spinal surgeries, namely 1300 procedures annually on average. MATERIAL AND METHODS In the period 2006 - 2018, a total of 16872 patients underwent a surgery at our department. During this period, in 556 patients an unplanned revision spinal surgery was performed. In agreement with literature, the patients were categorised by cause for revision: 1/ impaired wound suprafascial (superficial) healing - superficial infection, 2/ impaired wound subfascial (deep) healing - deep infection, 3/ surgical wound hematoma, 4/ deterioration or occurrence of new neurological symptoms, 5/ cerebrospinal fluid leak (liquorrhoea) and 6/ others. The patients operated on for inflammatory diseases of the spine with subsequent infectious complications, primarily treated at another department, and the patients with open spinal injury were excluded from the study. According to these criteria, a cohort of 521 patients was followed up, namely 236 (45.3%) women and 285 (54.7%) men, aged 1 year to 86 years, with the mean age of 55.0 years (median 60 years). Demographic effects, tobacco smoking and comorbidities were followed up in the cohort, together with the effects of surgery, diagnosis, surgical approach and physician. All parameters were statistically evaluated at a p-value below 0.05, including comparison with the control group. RESULTS Of the total number of 16872 operated patients, a group of 521 (3.09%) patients undergoing a revision surgery for complications was analysed in detail. Impaired wound healing - infection (SSI) was found in 199 (1.18%) patients, of whom superficial infection in 124 cases (0.73%) and deep infection in 75 cases (0.44%). Hematoma in a surgical site was detected in 149 (0.88%) patients. In 63 (0.37%) cases, deterioration of the existing neurological finding or occurrence of a new neurological finding were observed, in 68 (0.40%) cases cerebrospinal fluid leak was reported and in 40 (0.24%) cases other complications were identified. As concerns the surgical assistant, the percentage of complications in a board-certified physician is 2.77 (1.14 - 3.29%), in a medical resident it increases to 3.60 (0.00 - 9.38%) (p<0.05). The prevalence of smokers in the group with complications (N=521) was 34.7%. The control group (N=3650) included 30.1% of smokers (p<0.05). The mean age of patients in the group with complications (N=521) was higher, i.e. 55.0 years, with the median age of 60.0 years, than in the primary cohort (N=16872) with the mean age of 49.8 years and the median age of 52.0 years (p<0.05). The mean BMI in the group with complications was (N=521) 27.3, the median BMI was 26.9. In the control group (N=16872), the mean BMI was 27.11, the median BMI was 26.8. In this case the significance (p>0.05) was not confirmed. The complications prevailed strongly in posterior surgical approach, namely in 483 patients (92.7%). As concerns the surgically treated segment, lumber spine dominates with 320 (61.4%) cases. Corticosteroid therapy was used twice as often in women, namely in 13.1% vs. 6.3%. The group of patients with complications (N=521) showed a much higher average length of hospital stay of 12.8 days compared to the average of 4.6 days (N=16872). DISCUSSION In our cohort, the complication rate was 3.09%, of which infections constituted 1.18%, which is in agreement with similarly focused papers. As regards the patient-related factors, in our study the results reported by literature were confirmed with respect to the age, smoking and comorbidities. Moreover, the posterior surgical procedure, lumber spine surgery and presence of a medical resident are essential (p<0.05). No major age difference was observed between women and men (p>0.05). Obesity is one of the key risk factors, especially in infectious complications. In our cohort, a higher BMI did not increase the risk of complications in general (p>0.05). CONCLUSIONS In correlation with current literature, our cohort confirmed a significantly higher risk of complications leading to revision spinal surgery associated with age, smoking, posterior surgical procedure in thoracic or lumber spine, and presence of a medical resident as a surgical assistant. The average length of hospital stay was demonstrably longer in complicated patients, it almost tripled compared to the whole cohort. Contrary to literature, the effect of obesity on the occurrence of complications was not confirmed. Key words: spinal surgery, complications, infection, reoperation, risk factor, hematoma, cerebrospinal fluid leak, screw malposition, smoking, obesity.
Asunto(s)
Complicaciones Posoperatorias , Fusión Vertebral , Pérdida de Líquido Cefalorraquídeo/complicaciones , Pérdida de Líquido Cefalorraquídeo/cirugía , Femenino , Estudios de Seguimiento , Hematoma/etiología , Humanos , Masculino , Persona de Mediana Edad , Obesidad/complicaciones , Obesidad/cirugía , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugía , Reoperación , Estudios Retrospectivos , Fusión Vertebral/efectos adversosRESUMEN
PURPOSE OF THE STUDY: Radical resection of a vertebra is reserved only for specific tumors that invade the surrounding tissues and recur when not removed completely. The vertebra may be removed using a piecemeal technique or en bloc, using only two (in thoracolumbar spine) or more osteotomies (in cervical spine). We present our technique of en bloc resection of subaxial cervical vertebra for Ewing's sarcoma of C3, with preservation of all nerve roots and both vertebral arteries. To our knowledge, this surgical technique has not been reported in the English literature. The aim of this study is to describe the new technique of radical resection of subaxial cervical vertebra. MATERIAL AND METHODS: A transoral biopsy of tumor tissue anterior to C2-C3 was performed in 8-year old boy, revealing a diagnosis of Ewing's sarcoma. The patient was started on neoadjuvant chemotherapy. After 6 chemotherapy cycles with the VIDE regimen, the soft-tissue component completely regressed, with the only a residual deposit in C3 vertebral body. Based on further multidisciplinary meeting, an en bloc spondylectomy of C3 was recommended, preferably with preservation of nerve roots and vertebral arteries. In August 2014, prior to the planned surgery, we performed another thorough examination of the patient using plain films, CT and MRI. Neither angiography nor embolization was performed. DESCRIPTION OF SURGICAL TECHNIQUE: The first stage of the operation consisted of resection of the posterior structures. We exposed the posterior elements of C2 to C4 by the mid-line incision. The C3 arch was without pathological changes. After partial resection of the C2 inferior and C4 superior articular processes we performed bilateral osteotomy in the region of the pedicle adjacent to the arch with a chisel and removed the whole of the C3 posterior arch. Subsequently we perforated the transverse foramina close to the pedicle, using fine Kerrison rongeurs. The lateral parts around vertebral arteries were left in situ. In the next step we used instrumentation with polyaxial screws to stabilize the C2-C4 section. After 19 days we performed the second stage surgery from an anterior approach with the removal of the anterior and lateral parts of the vertebra. We made a transverse incision anterior to the sternocleidomastoid between the internal carotid artery and the trachea on the right side at the level of C3 to expose the spine. We resected C2-C3 and C3-C4 intervertebral discs and then performed osteotomy with fine Kerrison rongeurs on both sides, again, close to the vertebral body. Subsequently, the vertebral body was released and extracted en bloc. In the next step, both vertebral arteries were mobilized and shifted medially and the lateral portions of the transverse processes were released and removed en bloc. The empty space was filled with solid allograft and the C2-C4 levels were bridged by the cervical plate in 2+1+2 configuration. RESULTS: There were no complications during both surgeries. The follow-up CT examination 4 months after the operation revealed a clear bone fusion of C2-C4, both anteriorly between vertebral bodies and posteriorly between the arches. Clinically the patient has reached 8 month follow up and had no complaints, both he and his parents were satisfied. Physiotherapy is proceeding according to plan. The patient remains under supervision at our centre. DISCUSSION: Total en bloc resection of a subaxial cervical vertebra with preservation of neural and vascular structures has been described in the English literature only once. In 2007 was published a total en bloc resection of C5 for chordoma, preserving the above mentioned structures. Authors removed the lamina en bloc after bilateral osteotomy. Transverse foramina were perforated by the Gigli saw and removed in piecemeal fashion, including the posterior tubercle. In the next step, they removed the vertebral body and the anterior tubercle from the anterior approach. However, their treatment differs from the technique described here and does not correspond fully to the principle of en bloc resection. Our surgical technique is based on a similar principle of performing several osteotomies without the use of high speed burr, while preserving all neural and vascular structures. The difference can be particularly seen in the approach to remove lateral parts of the transverse foramen, which are surrounding the vertebral arteries. We consider it as ideal to split the cervical vertebra by smooth cuts into four parts and remove them en bloc. CONCLUSION: Total en bloc spondylectomy of a subaxial cervical vertebra with preservation of vertebral arteries and nerve roots is a radical surgery that should be used to treat only the most serious conditions. The risk of neurological deficit is outweighed by the benefits of oncological radicality. This new surgical technique has not yet been described and it is clear, that a larger cohort of patients is necessary to assess and potentially modify this technique so that it can be used more frequently in the future.
Asunto(s)
Vértebras Cervicales/cirugía , Vértebras Lumbares/cirugía , Sarcoma de Ewing/cirugía , Neoplasias de la Columna Vertebral/cirugía , Artrodesis/métodos , Vértebra Cervical Axis/cirugía , Biopsia , Niño , Estudios de Seguimiento , Humanos , Imagen por Resonancia Magnética/métodos , Masculino , Osteotomía/métodos , Cuidados Posoperatorios , Procedimientos de Cirugía Plástica , Sarcoma de Ewing/patología , Neoplasias de la Columna Vertebral/patologíaRESUMEN
The case of a 63-year-old man diagnosed with Collet-Sicard syndrome due to a fracture of the right occipital condyle is presented. The cause of injury was falling off a bicycle. Dysphonia and dysphagia were present from the moment of injury, with the gradual development of light atrophy of the tongue muscles and right trapezius muscle. The diagnosis was based on examination by CT and MRI methods, the act of swallowing and physical examination by an otorhinolaryngology specialist and a neurologist who confirmed the diagnosis of injury to cranial nerves IX, X and XI on the right side. The patient was treated conservatively with application of a Philadelphia collar. Dysphagia required PEG tube insertion. Skull fracture healing was evident on a CT scan at 3-month follow-up. However, dysphonia with dysphagia and muscle atrophy remained persistent.
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Enfermedades de los Nervios Craneales/etiología , Trastornos de Deglución/etiología , Disfonía/etiología , Fracturas Óseas/complicaciones , Hueso Occipital/lesiones , Atrofia/etiología , Ciclismo/lesiones , Fracturas Óseas/diagnóstico por imagen , Fracturas Óseas/patología , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Músculos Superficiales de la Espalda/patología , Síndrome , Tomografía Computarizada por Rayos X , Lengua/patologíaRESUMEN
PURPOSE OF THE STUDY: Injuries to the upper cervical spine in children are rare and account for 0.6 to 9.5% of all cervical spine injuries. We present a detailed analysis of the children and adolescents with unstable upper cervical spine injuries treated at our spinal centre. MATERIAL: During 16 years of follow-up, unstable injury to the upper cervical spine was recorded in 23 children and adolescents. Two patients (8.7%) were treated conservatively and 21 (91.3%) underwent surgery. The patients were allocated by age to three groups: 0-9 year, 10-14 year and 15-18 year categories. Twenty patients were seen at the final clinical and radiographic follow-up. One patient died at 62 months after surgery and two patients unfit for transport were evaluated on the basis of mailed interviews. The interval between injury and final evaluation ranged from 6 to 137 months, with an average of 53.4 months. METHODS: The patients treated conservatively first wore a Philadelphia collar, then a custom-made brace, and eventually a soft Schanze cervical collar to finish the healing process. Application of a halo vest was considered a surgical procedure and was used only in very small children. In unstable odontoid fractures, direct osteosynthesis with two cannulated titanium screws was performed from the anterior approach in older children while, in small children, transoral or submandibular retropharyngeal decompression to treat spinal stenosis caused by bone fragments was carried out and a halo vest was applied. Hangman's fractures were treated by anterior cervical discectomy, fusion with bone graft and anterior plate fixation. The other types of unstable fractures were managed from the posterior approach by occipitocervical fixation, atlantoaxial fixation or instrumented fusion extended caudally. The patients characteristics included gender, age, mechanism of injury, type of injury, neurological findings, type of therapy or surgery, complications and treatment outcome. Neurological status was evaluated using the Frankel classification. RESULTS: The patient group comprised 14 boys (60.9%) and nine girls (39.1%), which gave a gender ratio of 3 : 2. The age of patients at injury ranged from 2 to 18 years, with an average of 11 years and 6 months. The most frequent injuries included rotational or vertical atlantoaxial dislocation in eight (34.8%) and odontoid fractures in seven (30.4%) patients; atlas fracture was recorded in three (13.0%) and hangman's fracture also in three (13.0%) patients; occipitocervical displacement was found in one (4.3%) and complex atlantoaxial fracture also in one patient (4.3%). At the time of injury, 17 patients (73.9%) had no neurological deficit (Frankel grade E), three had Frankel grade A (one paraplegic with a concomitant T5 spinal cord injury) and three had Frankel grade D neurological deficits. Of the six patients with neurological deficit, two showed improvement by one or two Frankel grades. The method of dorsal atlantoaxial fixation was used in eight patients (Magerl fixation in 2 and Harms method in 6). Direct osteosynthesis of an odontoid fracture was performed in four patients, halo fixation was applied in four, C2-C3 discectomy with tricortical bone grafting and plating was carried out in three, occipitocervical fixation was used in three patients, and direct atlas osteosynthesis, simple decompression and simple non-instrumented dorsal spondylodesis each was performed in one patient. Neither intra-operative complications nor post-operative complications related to the surgical technique were recorded. Osteoarthritis or bone non-union, as late post-operative complications, were found in two patients. All other patients showed bone healing by first intention in the desired extent. Superficial or deep wound infections were not recorded. DISCUSSION: In the first age category, the number of boys and girls with injuries to the upper cervical spine was equal while, in the third one, the boys outnumbered the girls more than twice. Of the 23 patients, 91.3% were surgically treated; the anterior approach was used in approximately one third of the patients and the posterior approach in the rest of them. The high number of surgical interventions is due to the fact that the most serious paediatric spinal injuries are referred to our centre. CONCLUSIONS: 1. Injuries to the upper cervical spine are most frequently found in the youngest children and in adolescents who, however, frequently have injury also to the lower cervical spine. 2. Neurological deficit is relatively frequent but has a better prognosis than in adults. The youngest children with mild deficits have the best prognosis. 3. The mortality rate in young children with upper cervical spine injuries is evidently high, mostly due to associated head, chest and abdomen trauma 4. Therapy, particularly in small children, is strictly individual.
Asunto(s)
Vértebras Cervicales/lesiones , Fracturas de la Columna Vertebral/cirugía , Adolescente , Articulación Atlantoaxoidea/lesiones , Vértebras Cervicales/cirugía , Niño , Femenino , Humanos , Luxaciones Articulares/terapia , Masculino , Procedimientos Ortopédicos , Fracturas de la Columna Vertebral/terapiaRESUMEN
PURPOSE OF THE STUDY: To present the results of an independent prospective monocentric study of patients with ProDisc-C Total Disc Replacement (CTDR) followed up for 4 years, and to analyse the most frequent late complications, in particular heterotopic ossification. MATERIAL: In the period from October 2004 to May 2006, a total of 61 patients underwent ProDisc-C CTDR involving one or two segments at the Department of Spinal Surgery, University Hospital in Motol. This study included 39 patients who were followed up for at least 4 years. With the exception of one patient operated on two segments, the patients were treated by ProDisc-C CTDR at one level. METHODS: In the study, only the surgical procedure recommended by the implant manufacturer (Synthes, USA) was used and all operations were performed by a team with the same leading surgeon. Clinical assessment. The patients were examined before surgery, immediately after it and at 6 and 12 weeks and 6, 12, 24 and 48 months post-operatively. At each follow-up, responses to the questionnaire were obtained, and the patients' health status was evaluated on the basis of Neck Disability Index (NDI) and Visual Analogue Score (VAS) values for cervical spine and radicular pain, the use of analgesics and personal satisfaction Radiographic assessment. Pre- and post-operative radiographs were taken in antero-posterior and lateral projection, and flexion, extension and lateral bending films were obtained The height of the intervertebral disc space at the affected level was measured and range of motion in flexion and extension was evaluated together with the adjacent levels. In addition, subsidence, loosening, failure or displacement of the implant was assessed, as well as the presence of heterotopic ossification. The results were statistically analysed using Student's t-test. RESULTS: The clinical results at 1, 2 and 4 years of follow-up were as follows: NDI values, 44.9 pre-operatively, 26.1, 25.8 and 25.1 post-operatively, improvement by 44.1% after 4 years; VAS for cervical spine pain, 5.8 pre-operatively, 3.0, 2.7 and 2.7 postoperatively, improvement after 4 years by 53.7%; VAS for radicular pain, 6.3 pre-operatively, 2.9, 2.9 and 2.7 postoperatively, improvement by 57.1% after 4 years. The radiographic findings showed the average intervertebral disc space height of 3.2 mm at the affected level before and 7.4 mm after surgery, with no significant change in the following period. The average range of disc motion at the affected level was 4.2 degrees before and 11.1 degrees after surgery, with 11.4 degrees at 4 years of follow-up. During that period, heterotopic ossification was recorded in 10 (25%) treated discs, with five of them (12.5%) classified as grade III or IV. Spontaneous fusion across the disc replacement level was found in three cases (7.5%). Two patients (5%) developed kyphosis at the affected disc level. The statistical analysis showed a significant difference between the pre-operative VAS values and those at 6 post-operative weeks for both cervical spine and radicular pain (t = 4.4 and t = 5.3, respectively; p < 0.05). No significant difference in VAS values was found between 6 weeks and 3 months after surgery for either condition (t = 1.69 and t = 0.3; p > 0.05). Changes in VAS values in the following period were minimal and non-significant. The differences in NDI values before surgery and at 6 weeks after it, and between 6 weeks and 3 months post-operatively were significant (t = 11, p < 0.05 and t = 3.8, p < 0.05, respectively). In the following period, changes in the values were minimal and non-significant. DISCUSSION: Short-term studies on various types of cervical disc replacement have been optimistic and reported good clinical results and few complications. However, with longer follow-ups there has been an increasing incidence of heterotopic ossification as the most frequent late complication. Although the number of patients diagnosed with it is growing, heterotopic ossification influences the patient's clinical problems only little. What are its causes and how to prevent it are questions to be fully answered yet CONCLUSIONS: Heterotopic ossification is the most frequent late complication of total disc replacement. Many factors may be responsible for its development and therefore its prevention is not clear. The correct indication and appropriate surgical technique are most often recommended, and are considered also by the authors to be most important. Restricted motion at the treated segment/s has no significant effect on the patient's clinical status.
Asunto(s)
Vértebras Cervicales/cirugía , Reeemplazo Total de Disco , Adolescente , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Reeemplazo Total de Disco/efectos adversos , Reeemplazo Total de Disco/instrumentación , Reeemplazo Total de Disco/métodos , Adulto JovenRESUMEN
PURPOSE OF THE STUDY: The development of a cervical kyphotic deformity can be associated with a degenerative disease, trauma, tumour, developmental anomaly and also a surgical procedure. Post-operative kyphosis can develop after both the anterior and posterior surgical approaches. The deformity can also result from systemic diseases, such as ankylosing spondylitis or rheumatoid arthritis. The aim of the study was to make the clinical and radiographic evaluation of a group of patients with kyphotic deformity treated at our department. MATERIAL: Between May 2005 and April 2010, a total of 102 patients underwent correction of cervical kyphosis at our department. (Center for Spinal Surgery). Of them, 90 patients with complete medical records and post-operative periods longer than 6 months were included in this study. There were 36 men and 54 women ranging in age from 13 to 90 years and with an average of 56.7 years. In six patients cervical kyphosis was caused by an inveterate injury, in 71 by degenerative disease, in six it developed in association with rheumatoid arthritis, and in seven patients it was due to previous surgery. Patients with acute trauma, tumour, infectious disease or congenital anomaly were not included. METHODS: All patients were examined before surgery by radiography in antero-posterior and lateral projection, including flexion- extension bending films, and by CT scanning of ultrathin cross-sections with sagittal, frontal and recently also 3D reconstructions. Magnetic resonance imaging in three planes was also performed. On the basis of the results and clinical examination, the operative strategy was planned. Surgery was carried out from the anterior or the posterior approach, or the combined approach was used. Three-stage surgery was performed in one patient. The surgical outcome was assessed using the Nurick score and Neck Disability Index (NDI), the Visual Analogue Scale (VAS) was used to evaluate pain intensity or paraesthesia. Statistical analysis was done using the Chi-square test and paired t-test. RESULTS: The average NDI value was 25.5 before surgery and 14.3 and 14.9 at one and two years after surgery, respectively. Compared with the pre-operative state, improvement or no changes were recorded in 89.7 % of the patients; transient deterioration occurred in 10.3 %. Improvements found were as follows: by one degree in 46.2 % of the patients, by two degrees in 18 %, by three degrees in 5.1 % and by five degrees in 2.6 % of the patients. The condition remained unchanged in 18 % of the patients. The average outcome was an improvement by one degree. The average pre-operative Nurick score was 0.7; an average post-operative value of 0.6 was recorded at both one and two years of follow-up. The average VAS value for neck and radicular pain was 5.7 pre-operatively, and 2.5 and 2.7 at one and two post-operative years, respectively. Out of 90 patients, complete bone union was achieved at 6 months after surgery in 88 patients (97.8 %). The average pre-operative value for the cervical curvature index (Ishihara) was -13.7; the average pre-operative cervical kyphosis was -14.4 degrees, ranging from -2.2 to -44.0 degrees. After surgery, the average Ishihara index was +15.3 and the average lordosis was +13.5 degrees, with a range of -16.0 to + 37.4 degrees. DISCUSSION: A single/isolated anterior approach can be used for fixed deformities without ankylosing spondylitis. It allows for decompression of the anterior pathology and for correction of cervical kyphosis with use of instrumentation and structural graft. A combined ventral-dorsal approach is appropriate in fixed deformities or deformities involving the cervico-thoracic junction. The main principle of correction is to lengthen the cervical spinal column in the front and to shorten it at the back by anterior decompression with or without instrumentation and by subsequent posterior stabilisation. An isolated/single dorsal correction can be used in the case of successful correction by traction or specific head positioning on the table without anterior nerve compression. In severe fixed deformities such as Bekhterev's disease, the chin can be so close to the chest as to interfere with eating and breathing. The deformity most often develops at the cervico-thoracic junction and requires treatment by osteotomy. CONCLUSIONS: The results of the study showed a marked improvement in the patients' quality of life after kyphosis correction, improved neurological status and an improved posture seen on radiograms of the cervical spine. The study also revealed a higher number of potential complications associated, in particular, with corrective osteotomy. The best results were achieved with the combined surgical approach; however, the choice of a surgical method was independent of the patient's clinical status.
Asunto(s)
Vértebras Cervicales/cirugía , Cifosis/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Vértebras Cervicales/diagnóstico por imagen , Femenino , Humanos , Cifosis/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Radiografía , Adulto JovenRESUMEN
PURPOSE OF THE STUDY To evaluate retrospectively a group of patients with hyperextension injury to the cervical spine who were treated at the Department of Spinal Surgery of the University Hospital in Motol, Prague, between 2003 and 2006. MATERIAL The group comprised 22 patients, 17 men (77 %) and five women (23 %) in the age range of 35 to 81 years, with an average of 59.5 years. All patients had, in association with the injury, neurological deficit of varying degree. METHODS All patients underwent X-ray and magnetic resonance imaging examination and received methylprednisolone according to the National Acute Spinal Cord Injury Study (NASCIS) 2 trial. Eleven patients had urgent surgery within 24 hours of injury; eight patients were operated on within an interval of 3 days to 2 months because of the seriousness of their state and multiple morbidity; and three patients were treated conservatively. Neurological deficit in terms of upper- and lower-limb mobility was evaluated by the American Spinal Injury Association (ASIA) motor score. The values obtained for the urgently operated patients and for those operated on after a time interval were compared by Wilcoxons two-sample test. The other aspects evaluated included trauma aetiology, level of spinal cord injury, manner of treatment, and intra-operative and post-operative complications. RESULTS The most frequent cause of injury was a low-height fall (13 patients; 59 %); car accidents ranked second (9 patients; 41 %). In five patients (22.7 %) ebriety was found. Eighteen patients had no skeletal injury (81.8 %). Four patients (18.2 %). Four patients (18.2 %) suffered fractures of articular or spinous processes, but the anterior column skeleton was intact in all. The segment most frequently affected by myopathy was C3-C4, then C4-C5 and C5-C6. Decompression was carried out to the extent of myopathy; and in the adjacent segments only if significant stenosis was present. In both subgroups of surgically treated patients (urgent and delayed management), comparisons of the ASIA scores at the time of injury and at one-year follow-up showed no significat improvement in post-operative mobility, as evaluated by Wilcoxons two-sample test at a level of significance a = 5 %. No intra-operative or post-operative complications, except for early death, were recorded. In all patients the wound healed by first intention and no loosening of instrumentation was foud on follow-ups at the out-patient departments. DISCUSSION Although the greatest narrowing of the spinal canal due to spondylosis occurs at the C5-C6 segment, the C4-C5 segment sustained most injuries. Although some relevant papers report no significant difference in improved neurological deficit between patients treated surgically and those undergoing conservative therapy, we prefer surgical management, in most of the cases from the anterior approach, which allows us to remove dorsal osteophytes and perform careful decompression to prevent damage to nerve structures and to preserve those which are still intact. There was no significant difference in the outcome between urgent and delayed trauma management, which is unusual amongst other injuries associated with neurological lesions and this indicates that the timing of surgery must be strictly individual and should be carried out at a time when operative benefit outweighs operative burden. The surgical treatment used should, in the first place, lead to early recuperation and rehabilitation. CONCLUSIONS Hyperextension injuries of the cervical spine are usually associated with serious neurological deficit. A correct algorithm of examination will result in good treatment outcomes. However, these injuries require a therapy that is long-lasting and difficult, with a need for cooperation of anaesthesiologists, spinal surgeons, physical therapists and, last but not least, psychologists. Key words: cervical spine, hyperextension injury, spondylosis, myelopathy.
Asunto(s)
Vértebras Cervicales/lesiones , Espondilosis/complicaciones , Adulto , Anciano , Anciano de 80 o más Años , Vértebras Cervicales/diagnóstico por imagen , Vértebras Cervicales/cirugía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Radiografía , Espondilosis/diagnóstico por imagen , Espondilosis/cirugíaRESUMEN
PURPOSE OF THE STUDY: Occipitocervical fixation and spondylodesis is indicated in various cases of occipitocervical instability. The aim of this retrospective study was to evaluate the results of occipitocervical fixation at our institutions. MATERIAL: Between 1997 and 2007, a total of 57 patients underwent occipitocervical fixation (OC) there were 25 men and 32 women, from four to 77 years of age, with an average of 58.7 years. The patients were allocated to two groups according to the method of OC fixation used: tying wires or cables (group 1) screw-rod or screw-plate systems (group 2). Indications for OC fixation included trauma in 15, rheumatoid arthritis (RA) in 28, destruction due to psoriasis in one, tumour in eight, and congenital anomalies of the cervico-cranial junction in five patients. In five patients with tumour, OC fixation was completed with a transoral or transmandibular procedure. The C0-T 1 or C0-T 2 segments were fixed in 22 patients, C0-C2 segments in 14, C0-C3 segments in six, C0-C4 segments in two, C0-C5 segments in eight and C0-C6 segments in five patients. METHODS: In atlanto-occipital dislocation, comminuted fractures of the ;atlas or similar injuries, C0-C1-C2 segments were fused in congenital anomaly, the C0-to-lower cervical spine was fixed, with C1 being avoided. The RA patients were treated by fixation of the C0 to T1 or T2 segments. The atlas was fixed by the screw method of Goel, the C2 joint by that of Judet, or stable fusion of the two vertebrae was carried out by the Magerl transarticular technique. For the middle and lower cervical spine, lateral mass screw fixation by the Magerl method was used, and from C7 caudally the vertebrae were fixed transpedicularly. Occasionally, in small children in particular, a Ransford frame fixed with wires or cables was used. In principle, an extent of fixation as small as possible was employed. The patients were evaluated at a final follow-up ranging between 12 and 132 months after the primary surgery (average, 42.7 months). Indications for surgery and the method and extent of instrumentation were recorded. The evaluation included pain and neurological deficit assessment, radiographic evidence of the stability of fixation and bone union and intra-operative and early and late post-operative complications. RESULTS: Of the 57 patients, bone fusion was the objective of surgery in 52. Further five patients died of associated injuries or serious medical complications shortly after the operation. Of the remaining 47, bone union was achieved in 44 patients (93.6%). Pseudoarthrosis developed in three patients who, however, because of a higher age and minimal complaints did not require revision surgery. In terms of bone union, there was no difference between a short (C0-C2) and a long (C0-CX or C-T) fixation. No differences among fixation materials were found. The differences in percent bone union after spondylodesis between the tying-wire and screw-rod fixation systems were not statistically significant (p > 0.05). In the patients treated for RA, psoriasis or congenital anomaly, the Nurick scale score significantly improved at 2 years after surgery (p < 0.05). In comparison with the others, the RA patients had a significantly higher number of complications (p < 0.05). The patients treated for tumour showed a significant difference between the pre- and post-operative VAS values (p < 0.05). DISCUSSION: Of the patients with RA, psoriasis or congenital anomaly, 57.6% showed post-operative improvement in the Nurick scale score by 1-2 but never more than by 2. A decrease in pain intensity and neurological findings was recorded in 88.2% of the patients. This is in agreement with the results published in the international literature. In the patients treated for trauma, a high proportion (53.3%) had neurological deficit, which is unusually high for craniocervical injuries. This can be explained by the fact that OC fixation is used only in the most serious injuries. Of five patients with neurological deficit of Frankel grade A or B, three died and two required mechanical ventilation. Less serious neurological findings of Frankel grade C or D in three patients improved to a normal condition. CONCLUSIONS: Rigid OC fixation is a very effective method for the treatment of craniocervical junction instability. The currently used implants allow us to achieve high stability and efficiency of bone union. Regardless of the instrumentation used, fusion is achieved in more than 90%, and clinical improvement in more than 80% of the patients.
Asunto(s)
Vértebras Cervicales/cirugía , Hueso Occipital/cirugía , Fusión Vertebral , Adolescente , Adulto , Anciano , Niño , Preescolar , Femenino , Humanos , Masculino , Persona de Mediana Edad , Fusión Vertebral/efectos adversos , Adulto JovenRESUMEN
In this case study, three patients are presented who had incomplete cauda equina syndrome following elective lumbar spine surgery for degenerative disease. In all patients, the neurological symptoms developed due to post-operative arachnoiditis. Its aetiology, pathogenesis and diagnostics are discussed, as well as the methods of prevention and therapy which are still limited and often not beyond experimentation.
Asunto(s)
Vértebras Lumbares/cirugía , Procedimientos Ortopédicos/efectos adversos , Polirradiculopatía/etiología , Adulto , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
PURPOSE OF THE STUDY: To present the results of an independent mono-centric prospective study on patients with a mobile ProDisc-C implant. This cervical artificial disc replacement (CADR), which is one of the options for avoiding cervical spine fusion, was evaluated during two-years follow-up. MATERIAL: A total of 61 patients underwent CADR with a ProDisc-C in one or two segments at the Department of Spinal Surgery of the University Hospital in Motol, Prague, in the period from October 2004 to May 2006. Of these, 39 were included in the study and followed up for 2 years at least. Except for one patient, one segment was replaced in all patients. METHODS: The surgical procedure recommended by the manufacturer (Synthes, USA) was used throughout the study. Clinical evaluation. Each patient was examined before and immediately after surgery, and followed up at 6 and 12 weeks, and 6, 12 and 24 months. At each follow-up the patient answered the questionnaire which included the Neck Disability Index (NDI) and Visual Analoque Scale (VAS) assessment for neck and radicular pain, analgesic use and the patient's satisfaction. Radiographic examination. Radiographs were taken in antero-posterior and lateral projection, and on bending films in flexion, extension and lateral flexion on both sides. The height of the intervertebral space of the involved segment and motion of the replaced and adjacent discs in flexion and extension were measured. The radiographs were examined for potential sinking, loosening, failure or migration of the implant. Statistical evaluation. The results were statistically analysed using Student's t-test. RESULTS: Clinical outcome. The NDI evaluation showed that the mean value of the index improved from 44.9 pre-operatively to 26.1 and 25.9 at 1 and 2 years of follow-up, respectively, i.e. by 42.5 % in two years. The mean VAS score for neck pain changed from 5.8 pre-operatively to 3.0 and 2.7 at post-operative years 1 and 2, respectively, which is an improvement by 53.7 % in two years. The mean VAS score for radicular pain improved from 6.3 to 2.9 and 2.8 at the same intervals, which is an improvement by 53.9 % in two years. Radiographic findings. The mean height of the affected intervertebral space was 3.2 mm before and 7.4 mm after surgery and it did not change significantly thereafter. The mean range of motion at the involved segment was 4.1 degrees before and 11.1 degrees after surgery. Statistical evaluation. In assessment of both neck and radicular pain, the difference between the mean VAS score pre-operatively and that 6 weeks post-operatively was significant (t=4.4 and t=5.3, respectively; p<0.05). The difference in mean VAS scores between 6 weeks and 3 months post-operatively was not significant (t=1.69 and t=0.3, respectively; p>0.05). At the next follow-ups the mean VAS scores changed only minimally and the differences were not significant. The difference between the mean NDI before and that at 6 weeks after surgery was significant (t=11; p<0.05) and significant was also the difference between 6 weeks and 3 months after surgery (t=3.8; p<0.05). After that changes were minimal and were not significant. DISCUSSION: Currently, mobile implants are in the focus of interest amongst spinal specialists, their materials and shapes, primary implant stability, the centre of rotation, indications for replacement and correct operative techniques being discussed. The situation appears similar to that of 20 years ago when large joint replacement was being introduced, and it is the future that will show the right development. CONCLUSIONS: This two-year prospective study on patients with CADR shows very good and promising outcomes. It is evident that the implant increases the range of motion at the treated segment and reduces degenerative changes in the adjacent intervertebral spaces. On the other hand, CADR is associated with complications such as artificial disc kyphosis and heterotropic ossifications. An unequivocal requirement for a correct indication and a faultless operative technique was the conclusion drawn from a detailed analysis.
Asunto(s)
Vértebras Cervicales , Disco Intervertebral/cirugía , Implantación de Prótesis , Adulto , Femenino , Humanos , Desplazamiento del Disco Intervertebral/cirugía , Masculino , Persona de Mediana Edad , Prótesis e Implantes , Osteofitosis Vertebral/cirugíaRESUMEN
PURPOSE OF THE STUDY: Surgical treatment is preferred in our department in all patients with type II and type III dens fractures, regardless of their age, with the exception of non-displaced or completely reduced fractures in young patients. The aim of this study was to evaluate patients over 65 years of age treated by direct osteosynthesis of the dens or posterior atlanto-axial fixation and spondylodesis. MATERIAL: In the years 2001 to 2005, 28 patients aged 65 years and older were surgically treated for dens fracture. This included 13 men and 15 women between 65 and 90 years of age, with an average of 77.4 years. According to the treatment, i.e., direct dens osteosynthesis (1) or C1-C2 posterior fixation (2), two groups were evaluated, and two categories were considered by age, i.e., 65 to 74 years (8 patients) and 75 years and older (20 patients). In 23 patients, an isolated fracture of the dens was present and, in five patients, injury was part of a complex C1-C2 fracture. A Frankel grade D neurological deficit was found in three patients. METHODS: In all patients, surgical treatment by direct osteosynthesis of the dens from the anterior approach, using two cannulated screws, was preferred as the method of choice. However, in the case of distinct osteoporosis, fragmented fracture of the dens base or tear of the ligamentum transversum atlantis, we used the Harms method of posterior fusion with polyaxial screw fixation as the primary treatment, or the Magerl transarticular fixation completed with the Gallie technique from the dorsal approach. The patients were followed up at 3, 6 and 12 weeks, at 6 and 12 months, and then at one-year intervals. X-ray and clinical examinations were made at the regular follow-ups and functional radiographs were taken at 12 months following the surgery. The whole group was evaluated in the range of 18 to 84 months (average, 37.3 months). Neurological deficit was assessed on the basis of the Frankel classification. The results were analysed using the Chi-square test. RESULTS: Of 20 patients still living at the time of this evaluation, 11 underwent direct osteosynthesis and nine were treated by posterior instrumented spondylodesis. In group 1, pseudoarthrosis of the dens or fibrous callus developed in one patient (9.1 %) and a line of fracture was evident in one patient of group 2 (11.1 %), which was not significant (p<0.05). However, a statistically significant difference in mortality was found when the two age categories were compared (p>0.05), with 0 % in the younger and 40 % in the older category. The overall mortality within 6 weeks of injury was 28.6 %. Mortality in group 1 and group 2 was 21.4 % and 35.7 %, respectively; this difference was not statistically significant (p<0.05). DISCUSSION: We use conservative treatment only in the patients who are able to stand up and move soon after injury. If this is not feasible, we prefer surgical treatment with the same aim achieved as soon as possible without rigid external fixation. In this study, surgery was associated with an acceptable number of minor complications due to poor bone quality or health state of the patient. The higher mortality in the higher age category was obviously related to generally poorer health of these patients. CONCLUSION: Surgical treatment can significantly improve the quality of life in elderly patients who have suffered a fracture of the dens. The surgical technique should be chosen to take bone quality, degenerative changes of the spine and overall health of the patient into consideration. Mortality after surgery is not related to the technique selected but to patient's age. Elderly patients with neurological deficit usually die due to co-morbidity, regardless of the therapy used.
Asunto(s)
Vértebras Cervicales/cirugía , Fijación Interna de Fracturas , Apófisis Odontoides/lesiones , Fracturas de la Columna Vertebral/cirugía , Fusión Vertebral , Anciano , Anciano de 80 o más Años , Femenino , Fijación Interna de Fracturas/métodos , Humanos , MasculinoRESUMEN
PURPOSE OF THE STUDY: To evaluate a group of 11 patients with L5 burst fractures treated by L4-S1 posterior instrumented spinal fusion without reconstruction of the anterior column. MATERIAL: The group included seven men and four women aged between 14 and 66 years (average, 37.5 years), followed for 12 to 36 months (average, 18 months). Ten patients were treated by posterior instrumented spinal fusion at the L4-S1 level, and one with an associated injury to L3 underwent L2-L4-S1 posterior instrumented spinal fusion. The spinal column was inspected in eight patients in whom neurological symptoms or significant stenosis were present. METHODS: On admission, the evaluation of post-traumatic radiographs included measurements of the angle between the L4 lower and the S1 upper end-plates, the angle between the upper and lower end-plates of L5 and height of the anterior and posterior rims of the L5 vertebral body. CT scans were assessed for a relative narrowing of the spinal canal. The patient's neurological status was also evaluated. At 3, 6, 12, 24 and 36 months of follow-up, radiographs, neurological findings and subjective complaints were assessed. RESULTS: On comparison of pre-operative values with those 3 months after surgery, the differences were on average 3.6 degrees for L4-S1 lordosis, 2.5 degrees for the angle between the upper and lower end-plates of L5, and 1 mm for the height of the anterior rim; there was no difference in posterior rim height. Eight patients had the same values at the latest as at 3- month follow-up. Three patients with broken screws showed the loss of L4-S1 lordosis by 4 to 13 degrees (average, 9 degrees). Neither the angle between the upper and lower end-plates of L5, nor vertebral body height were changed. The narrowing of the spinal canal by vertebral body fragments ranged from 0 to 60 % (average, 35 %) of canal space. On admission, neurological findings were normal in two patients and involved nerve root syndrome in five patients. In four patients it was not possible to assess their neurological status. At he latest follow-up, ten patients were free from peripheral neurological lesions, one still had lumbar radicular syndrome, two patients reported mild or moderate lumbosacral pain and seven patients were without complaints. Subjective complaints could not be assessed in two patients because of their mental state. An early post-operative complication included wound dehiscence in one patient (9 %) and, in three patients, broken screws in S1 were recorded as late complications. DISCUSSION: Only a few references referring to a relatively low number of patients with L burst fractures treated by surgery were found in the literature. Most of the authors report limitations of reduction and good clinical outcomes. CONCLUSIONS The posterior instrumented spinal fusion of L5 alone is sufficient for the treatment of most L5 burst fractures. Early removal of the fixator is indicated in active patients. Often good clinical outcomes are in contradiction with radiological findings. The possibilities of spinal canal decompression by ligamentotaxis at this level of injury are limited. When significant spinal stenosis is present, laminectomy or hemilaminectomy is necessary to achieve decompression of the spinal canal.
Asunto(s)
Vértebras Lumbares/lesiones , Fracturas de la Columna Vertebral/cirugía , Fusión Vertebral , Adolescente , Adulto , Anciano , Femenino , Humanos , Vértebras Lumbares/diagnóstico por imagen , Vértebras Lumbares/cirugía , Masculino , Persona de Mediana Edad , Radiografía , Fracturas de la Columna Vertebral/diagnóstico por imagenRESUMEN
PURPOSE OF THE STUDY: Although great advances have been made in both radiological diagnosis and antibiotic therapy of microbial infections, the treatment of spinal infections remains a major clinical challenge. Many of the patients affected are referred to spinal units with long delays. The general population is ageing and the number of immunocompromised patients, as well as the number of operative procedures for spinal disorders are increasing. The aim of our study was to evaluate the clinical presentations of spinal infections, options for their diagnosis, indications for treatment and their risk factors and the results of surgery. MATERIAL AND METHODS: The group of 112 patients evaluated after the treatment of spinal infection comprised 63 men and 49 women at an average age of 59.4 years (range, 17 to 84). The average follow-up was 3.2 years (range, 6 months to 8 years). Of these, 82 patients had primary hematogenous infection, 29 had post-operative infection,and one had an infected gun shot wound. Thirty-six patients showed neurological deficit and six were paraplegic. The diagnostic methods included FBC, CRP and EST tests, examination of blood cultures, aspirates and biopsy samples from the infected site, bone scintigraphy, MRI and CT scanning. Indications for surgery included an infection not responding to conservative treatment,with existing or impending spinal instability, and with or without neurological deficit. The surgical management involved transpedicular drainage of the abscess, wound debridement from the posterior approach and instrumented spondylodesis. Surgery which included spinal decompression with radical excision of infected tissue was augmented with posterolateral instrumented fusion and/or anterior stabilization, as indicated. RESULTS: Of the 112 patients treated, seven died of uncontrollable sepsis after surgery; the remaining 105 were followed up. Another four patients died of causes unrelated to the spinal problem treated within 12 months. All patients recovered except for two in whom the infection persisted, but 13 required more than one surgical procedure. One patient with CSF leakage failed to heal after five interventions. The most frequently isolated infectious agents were Staphylococus aureus, Staphylococus epidermidis and E. coli. Of the 33 patients with neurological deficit, 24 improved by one or two Frankel grades. The neurological status of six paraplegic patients did not improve, but their functional findings did after stabilization of the spine. Clinical evaluation showed 47 (44.7 %) very good, 40 (38 %) good, eight (7.6 %) unchanged and 10 (9.5 %) poor outcomes. CONCLUSION: Early diagnosis is a prerequisite for good treatment outcomes. Clinical examination, results of laboratory tests, and scintigraphy and MRI findings play the key role. When progressing osteolysis is suspected, a CT scan is necessary. Debridement should be as radical as possible, but always in compliance with the patient's health state. At an advanced stage of disease, spinal stabilization is important because it allows us to remove infected tissue. Intravenous and then oral antibiotic therapy at 2 to 4 and 6 to 12 weeks of follow-up is mandatory. The management of spinal infections is a complex process requiring good multidisciplinary cooperation.
Asunto(s)
Infecciones Bacterianas/cirugía , Enfermedades de la Columna Vertebral/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
PURPOSE OF THE STUDY: Cervical spine injuries in young adults are usually caused by high-energy trauma. However, a typical injury to the cervical spine can also occur in older patients, in whom it is often associated with the presence of osteoporosis and relatively low-energy trauma, similarly to distal radial or proximal femoral fractures, or fractures of the thoracolumbar spine. The aim of this study was to evaluate a group of elderly patients with cervical spine injuries treated at our department. MATERIAL: In the period from 2001 to 2005, 66 patients older than 65 years were treated for cervical spine injury at the Department of Spinal Surgery of the Motol University Hospital in Prague. Of these, the 53 patients treated surgically, and followed up longer than 6 months after surgery, were evaluated in detail in this retrospective study. They included 30 men and 23 women at an average age of 75.5 years (range, 65-92 years). METHODS: Conservative therapy was used to treat stable injuries to both the upper and the lower spine that were without risk of the development of secondary instability or deformity and that were not associated with neurological deficit. Surgery was performed in primary unstable injuries of the upper and lower spine or in injuries involving the risk of secondary instability or deformity, and also in all injuries associated with neurological deficit, when the patient's health state allowed for it. The final retrospective evaluation was made at 6 to 78 (average, 31.3) months after the primary operation. The evaluation included trauma etiology, type and level of injury, neurological findings, kind of treatment, complications and outcome. RESULTS: In our group, 56 % of the patients were men, injury occurred due to a fall in 66 % and the upper cervical spine was affected in 60 % of the patients. Most of the upper cervical spine injuries happened to the patients over 75 years, and included fractures of the dens and complex atlantoaxial fractures. Neurological deficit was found in 37.7 % of the patients treated surgically, but only 7.5 % had a deficit classified as Frankel grade A or B. Of the 13 patients treated conservatively and the 53 patients treated surgically, two (15.4 %) and 15 (28.3 %) died, respectively. DISCUSSION: The results of our study are in agreement with the relevant international literature data. Conservative treatment is used only in the patients in whom early mobilization, including standing and walking, is possible. In other patients, surgical treatment is preferred with the aim to achieve early mobilization without rigid external fixators, if possible. Surgery is carried out predominantly in patients with more serious injuries; therefore, mortality in our patients was nearly twice as high after surgery as after conservative treatment. Some surgical procedures were accompanied by minor complications usually associated with poor bone quality or poor health in general. Old patients with serious neurological deficit usually die of co-existent diseases regardless of the therapy used. CONCLUSIONS: In patients older than 65 years, injuries to the upper cervical spine are usually caused by low-energy trauma. In this age category, neurological deficit is found more often than in younger patients and is typically manifested as a central cord syndrome.
Asunto(s)
Vértebras Cervicales/lesiones , Fracturas de la Columna Vertebral/cirugía , Anciano , Anciano de 80 o más Años , Vértebras Cervicales/cirugía , Femenino , Humanos , MasculinoRESUMEN
According to the available sources, no case of total spondylectomy of C2 with preservation of roots, preservation of vertebral arteries and a short fixation without occipitocervical fusion has been so far described in the literature. We decided to perform a radical surgery in a man, now 27 y. o., with solitary metastasis of thyroid adenocarcinoma. In the first step, we applied the posterior surgical approach. The patient was placed prone on a standard operating table with a support of head fixed by adhesive plaster, with the upper cervical spine slightly bent forward. We made a mid-line incision, extending from the external occipital protuberance to the C7 spinous process, controlled bleeding and exposed the C0-C4 section. Subsequently, the entire posterior epistropheus was resected, including most of the pedicles and the entire articular processes for C2-C3 articulation. Both the C2 roots were preserved, however, we had to control quite a profuse bleeding from the venous plexus around the left root. During dissection, the dural sac was damaged in the region of the attachment of the left root, which was treated by suture and covered with Tissucol fibrin sealant. Screws 4.0 mm thick, were inserted into the lateral masses of the atlas after Harms and 4.0mm screws into the C3 and C4 articular processes. On both sides, the screws were connected with 3.2 mm rods, and a transverse stabilizer was then applied to fix the two sides together. Cancellous bone grafts were harvested from the iliac crest and a massive posterolateral and posterior fusion of C1-C4 was performed. The second operation was performed after 21 days. Transoral transmandible approach without tongue splitting was applied. The patient was placed supine on a standard operating table with a support of neck, the head was fixed by adhesive plaster and slightly bent back, and tracheostomy was inserted. An arched incision through the middle of the red lip was made, extending 2 cm straight caudally and arching across the chin and neck, in the midline. On the caudal end we made a transverse inverted T incision. Subsequently, we exposed and osteotomised the mandible using the midline Z-type incision. In order to identify the space between the anterior arch of C1 and the C4 vertebral body, the Synframe retractor was inserted with one blade opening the mouth by pressure on the upper teeth and two blades pressing the tongue caudally. Then an inverted U incision through the mucosa of pharynx was made to identify paravertebral muscles. Caspar retractor was used to separate the muscles and expose C1-C3 laterally, including transversal processes with vertebral arteries. No pathological changes were manifested on the skeleton. First we removed the middle portion of the C2 vertebral body where we did not find any tumour, only sclerotic remodelling. Subsequently, we reamed the lower middle portion of the anterior arch of C1, extracted the dens and cut off the alar ligaments and the apical ligament of dens. The entire dens was then removed. Then we continued on the right side, in the intact part and extracted part of C2 in the region of the atlantoaxial joint, including the rest of the pedicle, and the anterior portion of the transversal process up to the vertebral artery. The posterior part of the transversal process was carefully rotated around the artery and also removed. All parts were extremely hard, sclerotic. The same procedure was followed on the left side where we found a 7 x 10 mm gelatinous greyish tumour in the lateral part of C2 below the atlantoaxial joint. Other parts were again sclerotic. Liquorrhea appeared again from dissection around the C2 root on the left side, the source of which we could not clearly identify. We filled the site of the probable hole with Tissucol fibrin sealant. Between the notch in the lower part of the anterior arch of C1 and the upper end plate of the C3 vertebral body we seated a shaped SynMesh cage with sharp edges providing a very good fixation. No additional fixation was needed. Again we harvested cancellous bone grafts from the iliac crest and placed them on the sides of the cage and at the front between the anterior arch of the atlas and the C3 vertebral body. Subsequently, the muscles were approximated and the mucous tissue of the pharynx repaired. The mandible was fixed by two Miniplate System plates and supported by a dental plate. Total spondylectomy of C2 with preservation of vertebral arteries and roots stabilized only by a short fixation is an extreme surgical procedure suitable only for exceptional cases of young patients with a good bone quality. With regard to potential complications it is of vital importance to consider carefully such operation and consult the proposed therapy with the patient.
Asunto(s)
Adenocarcinoma/secundario , Adenocarcinoma/cirugía , Vértebras Cervicales/cirugía , Procedimientos Ortopédicos/métodos , Neoplasias de la Columna Vertebral/secundario , Adulto , Humanos , Masculino , Neoplasias de la Columna Vertebral/cirugía , Neoplasias de la Tiroides/patologíaRESUMEN
PURPOSE OF THE STUDY: Spinal injuries in children are rare and account for a low proportion of all childhood injuries. Due to anatomical and biomechanical properties of the growing spine, there are great differences between spinal injury in childhood and adulthood. Because of higher mobility and elasticity of the spine and a lower body mass in children, spinal injuries are not frequent and represent only 2 to 5 % of all spinal injuries. In this retrospective study, the effectiveness of conservative and surgical treatment of injured spines in children is evaluated in a 10-year period. MATERIAL: All patients from birth to the completed 18th year of age treated in our departments between 1996 and 2005 were included in this study. The patients, evaluated in three age categories (0-9, 10-14, 15-18), were allocated to two groups according to the method of treatment used (conservative or surgical). The information on patients treated conservatively was drawn from medical records; the surgically treated patients were invited for a check-up. METHODS: We used conservative treatment in patients with stable spinal injury who had no neurological deficit and in patients with neurological deficit but without apparent injury to the skeleton. Surgery was indicated in patients with unstable spinal injury and in those with neurological deficit and apparent injury to the skeletal structures. Injuries to the cervical spine were treated conservatively using a Philadelphia collar or a halo-vest in more serious cases. For treatment of injury to the thoracolumbar spine, the Magnuson method was preferred, together with rest in bed until subsidence of acute pain, followed by application of a vest and active rehabilitation to strengthen postural muscles. When surgery was used, the procedure was selected on a strictly individual basis in patients under 12; in older patients it was carried out according to the adult treatment protocol. RESULTS: During 1996 through 2005, we treated a total of 15 646 patients with injury to the skeleton, aged 0 to 18 years. The spine was affected in 571 cases, which is 3.6 %. We used conservative treatment in 528 (92.5 %) and surgery in 43 (7.5 %) children. The period between surgery and evaluation ranged from 6 to 120 months (average, 46.3 months) in the patients treated conservatively, and from 6 to 66 months (average, 27 months) in the surgically treated patients. The group of patients treated conservatively consisted of 292 boys (55. 3 %) and 236 girls (44.7 %); of these 219 (41.5 %) were in the 0-9 year category, 251 (47.5 %) were between 10 and 14 years and 58 (11 %) were 15 to 18 years old. The average age in this group was 10.2 years. The most frequent cause of injury was a fall (277; 52.2 %), then sports activity or games (86; 16.3 %), car accidents (34; 6.4 %) and diving accidents (30; 5.7 %). Pedestrians were injured on 25 occasions (4.7 %) and other causes of injury were recorded in 76 patients (14.4 %). In all age categories, injury to the thoracic spine was most frequent (340; 64.4 %). Three and more vertebrae were injured (multi-segment injury) in 124 patients (23.5 %). The thoracolumbar spine was affected in 22 patients (4.2 %), and lumbar vertebrae were injured in 28 patients (5.3 %). Injury to the cervical spine, both upper and lower, was least frequent, including four (0.8 %) and 10 (1.9 %) patients, respectively. None of the patients in this group showed neurological deficit. The surgically treated group included 29 (67.4 %) boys and 14 (32.6 %) girls; two (4.7 %) children were between 0 and 9 years, nine (20.9 %) between 10 and 14 years, and 32 (74.7 %) between 15 and 18 years, with an average of 15.1 years for the whole group. The frequent causes of injury were car accidents and falls in 21 (48.8 %) and 14 (32.6 %) children, respectively. Other causes were infrequent. The upper cervical spine was operated on in five (11.6 %), lower cervical spine in eight (18.6 %), thoracic spine in 13 (30.2 %), thoracolumbar spine in five (11.6 %) and lumbar vertebrae in 12 (27.9 %) patients. Thirty-six (83.7 %) patients had fractures, five had dislocated fractures (11.6 %) and two (4.7 %) had a dislocation. Of the 43 children in this group, neurological deficit was recorded in nine (20.9 %); this included a complete spinal cord lesion, an incomplete spinal cord lesion and a nerve root lesion in three, five and one patient, respectively. DISCUSSION: The results of this study confirm, in the majority of aspects, the conclusions of previously published papers. In some of the characteristics described above, however, our results are different, which can be explained by some specific features of care for injured children in the Czech Republic. CONCLUSIONS: Childhood spinal injuries account for only 2 to 5 % of all spinal injuries and for 3.6 % of all skeletal injuries in children. Particularly at the age of 11 to 12 years, they differ significantly from spinal injuries in adults and therefore require different therapeutic approaches. The cervical spine is affected most often in younger children, while the thoracolumbar spine in older children. Multi-segment injuries are typical in the childhood spine, particularly in smaller children. Typically, children show SCIWORA and a more rapid improvement of neurological deficit than adults. Conservative treatment is preferred; surgery before 12 years of age is strictly individual, while after 12 years therapy is similar to that used in adults.
Asunto(s)
Traumatismos Vertebrales , Adolescente , Niño , Preescolar , Femenino , Humanos , Masculino , Traumatismos Vertebrales/diagnóstico , Traumatismos Vertebrales/cirugía , Traumatismos Vertebrales/terapiaRESUMEN
The patient, a 52-year-old male foreign citizen working as a construction worker, was attacked by his coworker who had fired a drive stud, 70 mm long, with reverse hooks from a powered gun at him; the stud pierced the worker's spine at the scapular level. The patient was taken to the nearest surgical ward. On the basis of clinical presentation and X-ray of the thoracic spine, the diagnosis of penetrating injury to the spinal column at the 7th thoracic vertebra level was made. Subsequently, the patient was admitted to the intensive care unit of our department. On admission the patients showed slight paresis of the right lower extremity and hypesthesia of the right thigh, but no other neurological deficit. After preoperative examination, the patient was operated on within six hours of the injury. Intraoperatively, a 3-mm-thick stud, piercing the T7 vertebral arch, was found on the left side, lateral to the T7 spinous process. After partial resection of the arch around the stud, the spinal canal was inspected. The stud passed paramedially on the right side through the dura mater and the centre of the spinal cord into the body of the 7th thoracic vertebra. The stud was gently removed. Subsequently, some sanguineous liquor appeared. The dura mater was sutured and the wound was closed layer by layer. The postoperative period was uneventful, and the patient was allowed to stand up on day 2. The drain was removed on day 4. Healing by first intention took place. At 6 weeks after surgery slight neurological deficit still remained. Key words: spinal penetrating injury, spinal gunshot injury.
Asunto(s)
Cuerpos Extraños/cirugía , Traumatismos Vertebrales/cirugía , Heridas Penetrantes/cirugía , Humanos , Masculino , Persona de Mediana EdadRESUMEN
PURPOSE OF THE STUDY: The anterior approach to the thoracic and lumbar spine is used with increasing frequency for various indications. With the advent of prosthetic intervertebral disc replacement, its use has become even more frequent and has often been associated with serious complications. The aim of this study was to evaluate vascular complications in patients who underwent anterior spinal surgery of the thoracic and lumbar spine. MATERIAL: We performed a total of 531 operations of the thoracolumbar spine from the anterior approach. In 12 cases, after exposure of the body of the first or second thoracic vertebrae, we employed the Smith-Robinson technique to expose the cervical spine. We used sternotomy in six, posterolateral thoracotomy in 209, the pararectal retroperitoneal approach in 239, anterolateral lumbotomy in 58 and the transperitoneal approach in seven patients. The aim of surgery was somatectomy in 190 patients and discectomy in 341 patients. Sternotomy and transperitoneal approaches were carried out by a thoracic or vascular surgeon and all the other procedures were done by the first author. The indications for spinal surgery included an accident in 171, tumor in 56, spondylodiscitis in 43 and a degenerative disease in 261 patients. METHODS: All patients indicated for anterior spinal surgery were examined by conventional radiography in two projections, and this was completed by CT sagittal and frontal reconstructions of the affected region. Most patients also underwent MR imaging. The Smith-Robinson approach was used for exposure of T1 or T2. Sternotomy was indicated for treatment of T2-T4 and also T1 in the patients with a short, thick neck. Access to T3-L1 was gained by posterolateral thoracotomy, in most cases performed as a minimally invasive transpleural procedure. For access to the lumbar spine we usually used the retropleural approach from a pararectal incision or lumbotomy. We preferred the pararectal retroperitoneal approach in L2-S1 degenerative disease, L5 fractures, and L5-S1 spondylodiscitis. We carried out lumbotomy in patients with trauma, tumors and L1-L4 spondylodiscitis. The transperitoneal approach from lower middle laparotomy was used only in tumors at L5 or L4. For treatment of trauma and degenerative disease of the lumbar spine we preferred less invasive procedures, and for tumors and spondylodiscitis we used more extensive exposure because of the difficult terrain. The patients were followed up for 2 to 96 months (average, 31.4 months) after anterior spinal surgery. RESULTS: In 12 patients treated by the Smith-Robinson procedure and in six patients undergoing sternotomy, neither early nor late signs of any injury to major blood vessels or internal organs were recorded. The 209 patients with posterolateral thoracotomy were also free from any signs of vascular injury, but trauma to the thoracic duct was recorded in one case. We found injury to major blood vessels in three patients in the group treated by the pararectal retroperitoneal procedure. In the total of 531 anterior spinal surgery procedures this accounts for 0.56 %; of the 304 lumbar operations and 239 pararectal retroperitoneal operations it is 0.99 % and 1.26 %, respectively. In one patient the vascular injury was associated with trauma to the ureter. DISCUSSION: In our group of 531 patients we found a higher risk of vascular injury when the L4-L5 segment was treated, when less invasive surgery was used or when spinal anatomy was altered due to tumor or spondylodiscitis. All the complications were recorded in the first 250 patients. It should be emphasized that, because in five patients, the planned anterior spondylodesis would have been associated with high risk due to altered anatomy of the bifurcation of the aorta, these patients were treated by dorsal instrumented spondylodesis. We also avoided the anterior approach for revision spinal surgery and used the posterior approach instead. Vascular complications were treated in cooperation with a vascular or cardiac surgeon. In the most serious case, if a sophisticated cardiosurgical technique had not been immediately available, the patient would probably have died. CONCLUSIONS: The technique of anterior approach is safe only in the hands of experienced spinal surgeons with long experience. In institutions where anterior spinal surgery is not a routine method it is advisable to involve a vascular or cardiac surgeon. However, the most important point is to know when not to operate.
Asunto(s)
Vasos Sanguíneos/lesiones , Complicaciones Intraoperatorias , Vértebras Lumbares/cirugía , Procedimientos Ortopédicos/efectos adversos , Adolescente , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Procedimientos Ortopédicos/métodos , Vértebras Torácicas/cirugíaRESUMEN
Unilateral dislocation is a trauma typical of the cervical spine. Case reports on unilateral dislocation of the thoracic or lumbar vertebrae can be found in the relevant literature only rarely and they often describe this condition associated with multiple trauma or combined injuries. Although unilateral dislocation is an unstable injury with rotation involved, injury to the spinal cord or spinal nerve roots is not common. Diagnosis is based on radiographic and CT examination. Therapy includes open reduction and instrumented spondylodesis of the injured segment. The cases of two patients with unilateral dislocations in the thoracic and the lumbar spine, respectively, treated at the Department of Spinal Surgery, Motol Teaching Hospital in Prague, are reported here.
Asunto(s)
Luxaciones Articulares/cirugía , Vértebras Lumbares/lesiones , Traumatismos Vertebrales/cirugía , Vértebras Torácicas/lesiones , Adulto , Humanos , Luxaciones Articulares/diagnóstico , Vértebras Lumbares/diagnóstico por imagen , Masculino , Radiografía , Fusión Vertebral , Traumatismos Vertebrales/diagnóstico por imagen , Vértebras Torácicas/diagnóstico por imagenRESUMEN
PURPOSE OF THE STUDY: The complex anatomy of the cervicothoracic junction region makes a reliable assessment of plain radiographs in lateral projection difficult or even impossible, which may result in failure to detect fracture or other pathology in this region of the spine. The aim of this study was to evaluate the patients with spinal disorders in the region of the seventh cervical to the third thoracic vertebrae treated at our department. MATERIAL: During the period from November 2001 to June 2004, 34 patients with disorders of the C7-T3 region were treated surgically at the Department of Spinal Surgery, Motol Teaching Hospital, which accounted for 2.1% of the 1537 patients treated for spinal diseases in this period. Instability of the cervicothoracic junction was caused by tumors in 15 and by injury in 14 patients. Other diagnoses included deformity associated with rheumatoid arthritis (RA) in two patients, spondylodiscitis in one, and hemivertebral deformity at C7 and T1, each in one patient. The group included 16 women and 18 men between 8 and 75 years, with the mean of 52.3 years (after excluding the two children with hemivertebral deformity aged 8 and 9 years, respectively). The trauma subgroup had a significantly lower mean age (43.6 years) than the tumor subgroup (59.9 years). METHODS: We placed the patients in three groups according to the etiology of cervicothoracic junction disorder, namely, 1. tumors and spondylodiscitis; 2. injuries; 3. others. Group 1 included 16 patients, 15 with tumors and one with spondylodiscitis. Two patients were treated by dorsal stabilization, one by ventral stabilization and the rest underwent combined surgery. Of 14 patients in group 2, three were treated from the posterior approach, six from the anterior approach and five by the combined approach. All group 3 patients underwent surgery from the posterior approach, with two patients being treated without instrumentation. RESULTS: Of the 34 patients, only 33 were included; one was lost to follow-up soon after the operation. In group 1, no excellent, five very good, five satisfactory and two unsatisfactory outcomes were recorded. No intraoperative complications such as injury to the major vessels or nerve structures occurred; in one patient, profuse bleeding from arteries supplying a metastatic tumor had to be arrested. Late complications included loosening of the dorsal instrumentation in two patients, who required repeat operations. In group 2, there were six excellent, four good, two satisfactory and one poor outcomes. Late complications in one patient included loosening of the ventral instrumentation, followed by repeat surgery. Group 3 showed two excellent and two satisfactory outcomes; the latter were in the RA patients. Late complications involved one loosening of the dorsal instrumentation requiring repeat surgery. No injury to the major vessels or nerve structures was recorded in either group 2 or group 3. No deep infection was recorded in any of the three groups. DISCUSSION: The results of our evaluation are in agreement with those of other authors and, similarly to them, we had to deal with the difficult issues of diagnosis. Currently, we prefer, in addition to conventional X-ray examination, CT scans including sagittal and frontal reconstruction, recently completed with magnetic resonance imaging, in all patients with cervicothoracic junction disorders. This policy allows us to avoid delays in making correct diagnosis and to provide conditions for effective treatment. In stabilization from the posterior approach we use rod-screw fixation that, in the majority of cases, is not combined with thoracic fixation. Previously, we have inserted screws in the articular processes at the C7 level, but now we prefer transpedicular fixation. Complicated anterior surgical procedures, such as complete or partial sternotomy, are always performed with the assistance of a thoracic surgeon. A noticeably high number of patients with neurological deficit was seen also in our group. Postoperative care is always provided in cooperation with the spinal unit of our hospital. Intensive inter-disciplinary cooperation has an important role in that our patients have a minimum of complications in comparison with the literature data. CONCLUSIONS: Injuries and diseases of the spine at the cervicothoracic junction present a complex issue with a high potential for mistakes and complications. The principle of success lies in a high-quality X-ray examination, CT scans with sagittal and frontal reconstruction, and magnetic resonance imaging of the region affected. The complex anatomy of that region requires demanding surgical procedures, which can be performed only by a highly qualified and specialized team with appropriate facilities.