1997 Volvo Award winner in clinical studies. Degenerative lumbar spondylolisthesis with spinal stenosis: a prospective, randomized study comparing decompressive laminectomy and arthrodesis with and without spinal instrumentation

STUDY DESIGN: This prospective study analyzed the influence of transpedicular instrumented on the operative treatment of patients with degenerative spondylolisthesis and spinal stenosis. OBJECTIVES: To determine whether the addition of transpedicular instrumented improves the clinical outcome and fusion rate of patients undergoing posterolateral fusion after decompression for spinal stenosis with concomitant degenerative spondylolisthesis. SUMMARY OF BACKGROUND DATA: Decompression is often necessary in the treatment of symptomatic patients who have degenerative spondylolisthesis and spinal stenosis. Results of recent studies demonstrated that outcomes are significantly improved if posterolateral arthrodesis is performed at the listhesed level. A meta-analysis of the literature concluded that adjunctive spinal instrumentation for this procedure can enhance the fusion rate, although the effect on clinical outcome remains uncertain. METHODS: Seventy-six patients who had symptomatic spinal stenosis associated with degenerative lumbar spondylolisthesis were prospectively studied. All patients underwent posterior decompression with concomitant posterolateral intertransverse process arthrodesis. The patients were randomized to a segmental transpedicular instrumented or noninstrumented group. RESULTS: Sixty-seven patients were available for a 2-year follow-up. Clinical outcome was excellent or good in 76% of the patients in whom instrumentation was placed and in 85% of those in whom no instrumentation was placed (P = 0.45). Successful arthrodesis occurred in 82% of the instrumented cases versus 45% of the noninstrumented cases (P = 0.0015). Overall, successful fusion did not influence patient outcome (P = 0.435). CONCLUSIONS: In patients undergoing single-level posterolateral fusion for degenerative spondylolisthesis with spinal stenosis, the use of pedicle screws may lead to a higher fusion rate, but clinical outcome shows no improvement in pain in the back and lower limbs.     

Anterior cervical decompression and arthrodesis for the treatment of cervical spondylotic myelopathy. Two to seventeen-year follow-up

We reviewed the cases of 108 patients with cervical spondylotic myelopathy who had been managed with anterior decompression and arthrodesis at our institution. Operative treatment consisted of anterior discectomy, partial corpectomy, or subtotal corpectomy at one level or more, followed by placement of autogenous bone graft from the iliac crest or the fibula. At the latest follow-up examination, thirty-eight of the eighty-two patients who had had a preoperative gait abnormality had a normal gait, thirty-three had an improvement in gait, six had no change, four had improvement and later deterioration, and one had a worse gait abnormality. Of the eighty-seven patients who had had a preoperative motor deficit, fifty-four had complete recovery; twenty-six, partial recovery; six, no change; and one had a worse deficit. The average grade according to the system of Nurick improved from 2.4 preoperatively to 1.2 (range, 0.0 to 5.0) postoperatively. A pseudarthrosis developed in sixteen patients, thirteen of whom had had a multilevel discectomy. Only one of thirty-eight arthrodeses that had been performed with use of a fibular strut graft was followed by a non-union. An unsatisfactory outcome with respect to pain was significantly associated with pseudarthrosis (p < 0.001). The development of complications other than non-union was associated with a history of one previous operative procedure or more (p = 0.005). Recurrent myelopathy was rare, but when it occurred it was associated with a pseudarthrosis or stenosis at a new level. The strongest predictive factor for recovery from myelopathy was the severity of the myelopathy before the operative intervention--that is, better preoperative neurological function was associated with a better neurological outcome. Anterior decompression and arthrodesis with autogenous bone-grafting can be performed safely, and is associated with a high rate of neurological recovery, functional improvement, and pain relief, in patients who have cervical spondylotic myelopathy.     

Predictors of outcome in patients with chronic back pain and low-grade spondylolisthesis

STUDY DESIGN: Retrospective case series. OBJECTIVES: To determine the factors influencing symptom relief after uninstrumented posterolateral spinal fusion with or without decompression in adult patients with chronic back pain and previously asymptomatic low-grade isthmic spondylolisthesis. SUMMARY OF BACKGROUND DATA: The role of previously asymptomatic low-grade isthmic spondylolisthesis in chronic adult low back pain is unclear. Operative intervention in this setting is controversial. METHODS: Twenty-four consecutive adult patients with chronic low back pain and low-grade isthmic spondylolisthesis first detected during routine work-up of new onset low back pain underwent spinal fusion with or without decompression. The influence of active worker's compensation or litigation claims, radicular pain, concomitant laminectomy, age, gender, fusion to L4, intervertebral disc bulge, and pseudarthrosis were investigated. RESULTS: All 13 patients involved in worker's compensation claims or pending litigation had fair or poor results. Nine of 11 patients without such issues had good or excellent results. Although the strong association of worker's compensation with poor results made it difficult to assess the importance of other risk factors, the data suggest that good results may be more likely in patients with radiculopathy who undergo laminectomy. CONCLUSIONS: This investigation, although limited by a number of factors including small sample size and retrospective, unblinded review, suggests that active worker's compensation and litigation issues are associated strongly with poor results of operative management for chronic low back pain in adult patients with low-grade spondylolisthesis.     

Burst fractures of the second through fifth lumbar vertebrae. Clinical and radiographic results

Fifty-five patients who had sustained a burst fracture of the lumbar spine were followed for a mean of seventy-nine months (range, twenty-four to 192 months) after the injury. Thirty patients had been managed non-operatively with a short period of bed rest followed by protected mobilization. The remaining twenty-five patients had been managed operatively: eight, with posterior arthrodesis with long-segment hook-and-rod fixation; eight, with posterior arthrodesis with short-segment transpedicular fixation; six, with posterior arthrodesis and instrumentation followed by anterior decompression and arthrodesis; and three, with anterior decompression and arthrodesis. Thirty-six patients had been neurologically intact at the time of presentation and had remained so throughout the follow-up period. No neurological deterioration or symptoms of late spinal stenosis were seen. Isolated partial single-nerve-root deficits resolved regardless of the method of treatment. Patients who had had a complete single or a multiple-nerve-root paralysis seemed to have benefited from anterior decompression. Although the anatomical results as seen on the most recent radiographs were superior for the group that had been managed operatively with long posterior fixation or anterior and posterior arthrodesis, the most recent pain scores and the functional outcomes were similar for all treatment groups. At the latest follow-up evaluation, some loss of spinal alignment was noted in the patients who had been managed with short transpedicular fixation; the alignment at the most recent follow-up examination was comparable with that in the patients who had been managed non-operatively. For the patients who had had non-operative treatment, we were unable to predict the deformity at the time of follow-up on the basis of the initial diagnostic radiographs. The clinical outcome was not related to the deformity at the latest follow-up evaluation. On the basis of the results of our study, we recommend non-operative treatment for patients who do not have neurological dysfunction or who have an isolated partial nerve-root deficit at the time of presentation. For patients who have a multiple-nerve-root paralysis, anterior decompression is indicated.     

Operative treatment of malunion of a fracture of the proximal aspect of the humerus

We retrospectively reviewed the medical records, operative reports, and preoperative and postoperative radiographs of thirty-nine patients who had been managed operatively for malunion of a fracture of the proximal aspect of the humerus. The malunions were categorized according to the presence of osseous abnormalities, including malposition of the greater or lesser tuberosity (type I; twenty-eight patients), incongruity of the articular surface (type II; twenty-six patients), and malalignment of the articular segment (type III; sixteen patients). Soft-tissue abnormalities, such as soft-tissue contracture, a tear of the rotator cuff, and impingement, were also recorded. At an average of forty-four months (range, twelve to fifty-three months) postoperatively, the patients were assessed for pain relief, the range of motion of the shoulder, and the ability to perform activities of daily living. The result was satisfactory for twenty-seven patients (69 per cent) and unsatisfactory for the remaining twelve (31 per cent) at the latest follow-up evaluation. Of the twenty-seven patients who had a satisfactory result, twenty-six (96 per cent) had had complete operative correction of all osseous and soft-tissue abnormalities. Of the twelve patients who had an unsatisfactory result, four had had complete operative correction of these abnormalities (p < 0.0001). Twenty-six patients (67 per cent) had incongruity of the glenohumeral joint at the time of presentation. Twenty-three of these patients had the incongruity corrected with prosthetic arthroplasty (twenty-two) or arthrodesis of the glenohumeral joint (one); the result was satisfactory for seventeen (74 per cent). In contrast, the result was unsatisfactory for all three patients in whom the incongruity had not been corrected at the time of the operation (p = 0.01). Eleven patients had malposition of the greater or lesser tuberosity but a congruent joint surface preoperatively. Ten patients in this group were managed with either osteotomy of the tuberosity or acromioplasty, and nine of them had a satisfactory result at the latest follow-up evaluation. The result was unsatisfactory for one patient who was managed with only correction of a soft-tissue contracture (that is, no treatment of the malposition) (p = 0.05). Both osseous and soft-tissue abnormalities were identified as the cause of pain and stiffness in patients who had malunion of a fracture of the proximal aspect of the humerus. We concluded that operative management of these patients is successful only if all osseous and soft-tissue abnormalities are corrected at the time of the operation.     

Analysis and treatment of poor outcomes following in situ arthrodesis in adolescent spondylolisthesis

In situ lumbosacral arthrodesis in the treatment of adolescent spondylolisthesis was evaluated in 39 patients. The clinical outcome an average of 4.7 years later was considered excellent or good in 82% of the cases based on their pain and gait. The quality of the fusion mass correlated with outcome. Those patients with the most severe kyphosis (slip angle) had the greatest chance of a poor result. Four patients required reoperation for pseudarthrosis or symptomatic compression of the cauda equina. Three of these were successfully treated with repeat arthrodesis or decompression with sacroplasty or both.     

Mid-tarsal and tarsometatarsal arthrodesis for primary degenerative osteoarthrosis or osteoarthrosis after trauma

We report the long-term results of arthrodesis of the mid-tarsal and tarsometatarsal joints, performed for osteoarthrosis after dislocation with or without a fracture (seventeen patients [seventeen feet]), for primary degenerative osteoarthrosis (twenty-one patients [twenty-two feet]), or for inflammatory arthritis (two patients [two feet]). All forty patients (forty-one feet) had a severe loss of function because of pain. The average age of the patients who had primary degenerative osteoarthrosis was sixty years (range, twenty-seven to seventy-five years) and that of the patients who had post-traumatic osteoarthrosis was forty years (range, twenty-three to sixty-seven years); the two patients who had inflammatory arthritis were forty-four and seventy years old. Thirty-seven patients (thirty-eight feet; 93 per cent) were satisfied with the results of the procedure after an average duration of follow-up of six years (range, two to seventeen years). Union was achieved after 176 (98 per cent) of the 179 attempted arthrodeses, and only one of the three non-unions necessitated an operative repair. A skin slough developed in two patients, one of whom needed operative débridement. Five patients noted at least one prominent metatarsal head postoperatively, but none of these patients needed débridement because of abnormal callus formation. A stress fracture of the second metatarsal developed in three patients, but all three fractures responded to immobilization of the foot. An incisional neuroma developed in three patients, but none of these patients needed additional treatment. We believe that patients who have a severe loss of function due to osteoarthrosis of the mid-tarsal or tarsometatarsal joints can be managed successfully with tarsometatarsal or mid-tarsal arthrodesis, or both.     

High resting energy expenditure in normal-weight bulimics and its normalization with control of eating behaviour

Combined anterior and posterior fusion with posterior instrumentation may be indicated in the treatment of select cases of L5-S1 spondylolisthesis. The instrumentation, however, is expensive and usually bulky, occasionally requiring removal. In an effort to avoid these problems, an L5-S1 paralaminar screw technique was developed for posterior stabilization after an L5-S1 anterior interbody fusion. The technique involves the placement of cortical screws from the base of the articular process of S1 to the pedicle of L5. This study evaluates the anatomic applications and clinical results of this technique. The relationship between the screw and L5 nerve root was examined using five cadaveric specimens with olisthesis of 0, 25, 50, and 75%. This work demonstrates that the screws can only be inserted safely if an L5-S1 olisthesis of at least 25% is present. If < 25%, the screws will either impinge on or directly injure the L5 nerve root. In the clinical study, the outcomes of 20 patients who had an isthmic spondylolisthesis of 25-81% and were treated with partial reduction, L5-S1 anterior interbody fusion, and L5-S1 posterior paralaminar screw fixation were reviewed. Nineteen patients had adequate posterior stabilization to completely heal an L5-S1 anterior interbody fusion without loss of the correction. In one patient, a pseudarthrosis occurred secondary to poor surgical technique of both anterior and posterior fusions. This patient required an additional L4-S1 posterior fusion 9 months later and had a good clinical outcome. No other complications due to screw placement occurred. We conclude that this procedure can be used safely and reliably for the posterior stabilization of L5-S1 after stable anterior L5-S1 interbody fusion in residual slips of at least 25%. Prerequisites are proper patient compliance and low weight. Compared with other posterior instrumentation systems, this screw fixation is inexpensive and does not require implant removal. The disadvantages of the method are the degree of difficulty of the procedure and the limited clinical application to cases of L5-S1 spondylolisthesis with corrected residual slips of 25 to 50-60%. The procedure is technically demanding and should be limited to those surgeons who are comfortable with the method.     

Adding posterior lumbar interbody fusion to pedicle screw fixation and posterolateral fusion after decompression in spondylolytic spondylolisthesis

STUDY DESIGN: This is a retrospective study analyzing 76 patients treated by decompression, pedicle screw instrumentation, and fusion for spondylolytic spondyiolisthesis with symptomatic spinal stenosis. OBJECTIVES: To verify the advantages of adding posterior lumbar interbody fusion to the usual posterolateral fusion with pedicle screw instrumentation. SUMMARY OF BACKGROUND DATA: Stabilization after decompression of spondylolytic spondylolisthesis is difficult because of a lack of fusional bone bases, gap between the transverse process bases, and incompetent anterior disc support. Posterior lumbar interbody fusion offers anterior support, reduction, and a broad fusion base. METHODS: Forty patients were treated with posterolateral fusion, and 36 were treated with additional posterior lumbar interbody fusion. They were compared for union, reduction of the deformity, and clinical results. RESULTS: The patients were followed up for more than 2 years. Nonunion was observed in three patients who underwent posterolateral fusion (7.5%), and no cases of nonunion was found in patients who underwent posterior lumbar interbody fusion. Reduction of slippage was 28.3% in those who underwent posterolateral fusion and 41.6% in those who had posterior lumbar interbody fusion (P = 0.05). In the posterolateral fusion group, eight patients (20%) had recurrence of deformity, with loss of reduction more than 50%. Hardware failures occurred in two patients who had posterolateral fusion. There was no major neurologic complications in both groups. Both groups had satisfactory results in more than 90% of patients, with marked improvement of claudication. However, subjective improvement of back pain by Kirkaldy-Willis criteria revealed differences in the excellent results. An excellent result was reported by 45% in the posterolateral fusion group and by 75% in posterior lumbar interbody fusion group. CONCLUSIONS: The addition of posterior lumbar interbody fusion to posterolateral fusion after a complete decompression and pedicle screw fixation is a recommended procedure for the treatment of spondylolytic spondylolishesis with spinal stenosis.     

Stress fracture of the tibia after arthrodesis of the ankle or the hindfoot

We studied twelve patients who had a stress fracture of the tibia and one patient who had a stress fracture of the fibula after arthrodesis of the ankle or the foot. A second stress fracture subsequently developed in two patients. All but two patients were managed non-operatively, and the fractures healed uneventfully. One patient who was managed operatively had a below-the-knee amputation to treat a painful non-union of a tibial fracture, and the other had interlocking intramedullary nailing for a displaced fracture. All but one of the arthrodesis sites had fused before the stress fracture occurred. All of the stress fractures that occurred after arthrodesis of the ankle were in the middle and distal aspects or the distal aspect of the tibia, while those that occurred after triple arthrodesis were in the distal aspect of the fibula or the medial malleolus. Although six of the thirteen patients still had uncorrected alignment and deformity after the arthrodesis, optimum alignment after the arthrodesis did not preclude the occurrence of a stress fracture. We conclude that stress fracture must be considered in the differential diagnosis of pain months or even years after solid fusion at the site of an ankle or triple arthrodesis.     

The clinical use of fine needle aspiration cytology for diagnosis and management of children with neuroblastic tumours

Thirty-seven ankles in twenty-four patients were treated at our institution between July 1, 1974, and December 31, 1996, for atraumatic osteonecrosis of the talus. This group represents 2 per cent of the 1056 patients who were managed for osteonecrosis during this period. There were twenty-one women and three men, and their mean age was forty years (range, twenty-six to sixty-two years) at the time of the diagnosis. Thirteen (54 per cent) of the twenty-four patients had bilateral involvement. Sixteen patients (67 per cent) had a disease that affects the immune system, including systemic lupus erythematosus (thirteen patients), scleroderma (one), insulin-dependent diabetes mellitus (one), and multiple sclerosis (one). Four patients had a history of regular alcohol use, and four patients had a history of moderate smoking. One patient had a protein-S deficiency, one patient had had a renal transplant, and one patient had a history of asthma. Two patients had no identifiable risk factors for osteonecrosis [corrected]. Fifteen patients (63 per cent) had involvement of other large joints. The mean duration of symptoms before the patients were seen was 5.4 months (range, two months to two years). The mean ankle score at the time of presentation was 34 points (range, 2 to 75 points), according to the system of Mazur et al. A radiographic review revealed that, according to the system of Ficat and Arlet, eight ankles had stage-III or IV disease of the talus at presentation. The remaining twenty-nine ankles had stage-II disease. The osteonecrosis was seen in the posterolateral aspect of the talar dome (zones III and IV on the sagittal images and zones II, III, and IV on the coronal images) in twenty-two of the twenty-three ankles for which magnetic resonance images were available. The osteonecrosis was seen in the anteromedial aspect of the talar dome (zones I and II on the sagittal images and zone I on the coronal images) in the remaining ankle. Bone scans, which were available for eleven ankles, revealed increased uptake in the talus. All patients were initially managed non-operatively with restricted weight-bearing, an ankle-foot orthosis, and use of analgesics; two ankles responded to this regimen. Thirty-two ankles that remained severely symptomatic were treated with core decompression, which was useful in the treatment of precollapse (stage-II) disease. Twenty-nine of these ankles had a fair-to-excellent clinical outcome a mean of seven years (range, two to fifteen years) postoperatively; the remaining three ankles had an arthrodesis after the core decompression failed. Three ankles were treated initially with an arthrodesis for postcollapse (stage-III or IV) disease. All six of the ankles that had an arthrodesis fused, at a mean of seven months (range, five to nine months) postoperatively. When patients who have a history of osteonecrosis are seen because of pain in the ankle, the diagnosis of osteonecrosis of the talus should be considered. Early detection may allow the ankle to be treated non-operatively or with core decompression and thus reduce the need for arthrodesis. We also believe that when a patient has osteonecrosis of the talus, the hips should be screened with use of standard radiography or magnetic resonance imaging, or both.     

Posterolateral fusion for radicular pain in isthmic spondylolisthesis

Reported is the outcome for 25 patients in whom spondylolisthesis with radicular pain was treated by posterolateral fusion alone (Group A). These outcomes are compared with those obtained in 23 other patients with the same symptomatology and spondylolisthesis treated by root release and posterolateral fusion (Group B). Most patients had Grade I or II isthmic spondylolisthesis. Results were assessed functionally and radiographically with an average followup of 32 months. Posterolateral fusion in situ provided excellent or good results in 88% of patients according to the modified classification of Stauffer and Coventry. In Group A, radicular pain at exertion disappeared in 92% of patients, and radicular pain at rest disappeared in 88%. In Group B, radicular pain at exertion disappeared in 65% of patients, and radicular pain at rest disappeared in 70%. There was no significant statistical difference between the 2 groups. Resection of the loose lamina and root decompression do not seem to be mandatory. The overall fusion rate was 81%. Instrumentation in case of instability and the use of allografts are advised.     

Total-body skeletal muscle mass: evaluation of 24-h urinary creatinine excretion by computerized axial tomography

We retrospectively reviewed the results of operative decompression for peroneal nerve palsy in thirty-one patients who had been managed between 1980 and 1990. All patients had been managed non-operatively for at least two months after they had initially been seen. Intraoperatively, we found epineurial fibrosis and bands of fibrous tissue constricting the peroneal nerve at the level of the fibular head and at the proximal origin of the peroneus longus muscle. At a mean of thirty-six months (range, twelve to seventy-two months) postoperatively, thirty (97 per cent) of the thirty-one patients reported subjective and functional improvement and were able to discontinue the use of the ankle-foot orthosis. In contrast, only three of nine patients who had been managed non-operatively reported subjective and functional improvement (p < 0.01). Peroneal nerve palsy does not always resolve spontaneously; if it is left untreated, the loss of dorsiflexion of the ankle and persistent paresthesias can result in severe functional disability. Therefore, if non-operative measures do not lead to improvement within two months, we believe that operative decompression should be considered.     

Use of an intramedullary hip-screw compared with a compression hip-screw with a plate for intertrochanteric femoral fractures. A prospective, randomized study of one hundred patients

One hundred elderly patients who had an intertrochanteric femoral fracture were randomized to treatment with a compression hip-screw with a plate (fifty patients) or a new intramedullary device, the intramedullary hip-screw (fifty patients). All patients were followed prospectively for one year or until death. A detailed assessment of the functional status and the plain radiographs of the hip was performed one, three, six, and twelve months postoperatively. The two treatment groups were strictly comparable. The operative time needed to insert the intramedullary hip-screw was significantly greater than that needed to insert the compression hip-screw with the plate (p = 0.02), but use of the intramedullary hip-screw was associated with less estimated intraoperative blood loss (p = 0.011). The prevalence of perioperative complications, such as bronchopneumonia, cardiac failure, and urinary tract infection, was comparable in the two treatment groups. There were one intraoperative fracture of the femoral shaft and two intraoperative fractures of the greater trochanter in the group managed with the intramedullary hip-screw. One patient had pulling-out of the compression hip-screw on the seventh postoperative day. Four patients had a trochanteric wound hematoma, without infection, after insertion of an intramedullary hip-screw. All but one of the fractures healed. The one non-union, which was in a patient who had a compression hip-screw, was treated with a hemiarthroplasty. The mortality rate was similar in the two treatment groups. The patients who had an intramedullary hip-screw had, on the average, significantly better mobility at one (p < 0.0001) and three months (p = 0.0013) postoperatively. This difference was no longer seen at six and twelve months, although the patients who had an intramedullary hip-screw still had significantly better walking ability outside the home at those time-periods (p = 0.05). The compression hip-screw was removed from two patients because of pain in the mid-portion of the thigh, which had begun after consolidation of the fracture. Fourteen patients who had an intramedullary hip-screw had cortical hypertrophy at the level of the tip of the nail at twelve months postoperatively. Cortical hypertrophy was significantly related to the use of two interlocking screws (p = 0.02). Six of these patients also had pain in the mid-portion of the thigh, and the nail had been locked with two screws in five of them. Three of the six patients had the hardware removed because of the pain, and the symptoms resolved. A seventh patient had pain without cortical hypertrophy. The intramedullary hip-screw device was associated with significantly less sliding of the lag-screw and subsequent shortening of the limb in the region of the thigh (p = 0.012 and 0.019, respectively); these differences were more pronounced when the unstable fractures in the two treatment groups were compared (p < 0.001).     

Occipitocervical fusion with a five-millimeter malleable rod and segmental fixation

Although occipitocervical fusion is frequently used for instability of the upper cervical spine and the occipitocervical articulation, most currently used techniques have one or more of the following disadvantages: the necessity for sublaminar wires, the use of occipital screws, a fixed angle of instrumentation, or the necessity for routine postoperative halo immobilization. Moreover, many reported techniques are associated with a high rate of nonunion or instrumentation failure. We present our experience with a technically simple method of obtaining rigid occipitocervical arthrodesis using a 5-mm malleable rod that is fixed to the skull by a pair of wires passed through four suboccipital burr holes. Segmental spinal fixation is achieved with Wisconsin interspinous wires and is occasionally supplemented with sublaminar wires. Supplemental autogenous bone graft is used in all cases. A cervical collar is routinely used for postoperative immobilization. The results of treatment were retrospectively reviewed in 16 patients with an average age of 49.4 years (range, 9-69). Mean follow-up was 24 months (range, 12-36 mo). The indication for fusion was instability of the occiput-C1-C2 complex as a result of Chiari malformation, rheumatoid disease, skull base tumor resection, basilar invagination, ankylosing spondylitis, Down's syndrome, cervical laminectomy, and trauma. The average number of levels fused was 5.4 (range, O-C3 to O-T3). Successful occipitocervical arthrodesis was achieved in all but one of the surviving patients. The single patient with a pseudarthrosis was successfully managed with supplemental bone grafting and halo immobilization. There were two deaths from medical complications in chronically ill patients. Other complications included one postoperative instrumentation loosening, one myocardial infarction, and one superficial occipital decubitus. In conclusion, rodding and segmental interspinous wiring is an effective, technically simple method of obtaining rigid occipitocervical fixation, which obviates the need for bulky orthoses.     

Robinson anterior cervical discectomy and arthrodesis for cervical radiculopathy. Long-term follow-up of one hundred and twenty-two patients

We evaluated the results of the Robinson method of anterior cervical discectomy and arthrodesis with use of autogenous iliac-crest bone graft, at one to four levels, in 122 patients who had cervical radiculopathy. A one-level procedure was done in sixty-two of the 122 patients; a two-level procedure, in forty-eight; a three-level procedure, in eleven; and a four-level procedure, in one. The average duration of clinical and roentgenographic follow-up was six years (range, two to fifteen years). The average age was fifty years (range, twenty-five to seventy-eight years). Preoperatively, 118 patients had pain in the arm, fifty-five had weakness of one or more motor roots, and seventy-seven had sensory loss. At the time of follow-up, eighty-one patients had no pain in the neck, twenty-six had mild pain in the neck, nine had moderate pain in the neck, four had mild radicular pain, and two had a combination of mild radicular pain and moderate pain in the neck. One hundred and eight patients had no functional impairment, and fourteen had a slight limitation of function during the activities of daily living. Nine of eleven patients who had symptoms related to a change at one level cephalad or caudad to the site of a previous arthrodesis had another operative procedure. Lateral roentgenograms of the cervical spine, made in flexion and extension, showed a pseudarthrosis at twenty-four of 195 operatively treated segments. Sixteen of the patients who had a pseudarthrosis were symptomatic, but only four had sufficient pain to warrant revision. The risk of pseudarthrosis was significantly greater after a multiple-level arthrodesis than after a single-level arthrodesis (p < 0.01). At the time of the most recent follow-up, fifty-three of the fifty-five patients who had had a motor deficit had had a complete recovery, and the two remaining patients had had a partial recovery. Seventy-one of the seventy-seven patients who had had a sensory loss had regained sensation. None of the patients had an increased neurological deficit postoperatively. Our results suggest that the Robinson anterior cervical discectomy and arthrodesis with an autogenous iliac-crest bone graft for cervical radiculopathy is a safe procedure that can relieve pain and lead to resolution of neurological deficits in a high percentage of patients.     

Isthmic spondylolisthesis in symptomatic and asymptomatic subjects, epidemiology, and natural history with special reference to disk abnormality and mode of treatment

Observations during the past 35 years on operative and conservative treatment of adult and young patients with isthmic spondylolisthesis, demonstrate the main indications of fusion are pain and risk of further progression of the slip. At one time, posterior fusion was recommended. Posterolateral fusion in situ was adopted in 1975, and during the past ten years anterior fusion combined with reduction and transpedicular fixation has been performed in severe slips. Surgery was mainly indicated to alleviate pain or to prevent further progression of the slip. It seems possible to alter the natural course of the disease by operation, but it is difficult to prove the connection between the radiographic findings and the pain. The epidemiologic study shows that the prevalence of spondylolisthesis in Finland is 6%, but there are no significant differences between these subjects and controls without spondylolisthesis. Symptomatic patients may have pain, however, even after a long observation time. Prevention of the slip is difficult because, statistically, 90% of the slip has already occurred when the patient is first seen. Posterolateral fusion in situ is the method of choice, especially for most young patients. Anterior fusion is indicated if the slip is greater than 40%-50%. Reduction of the slip is indicated in exceptional cases only.     

Transport in a grooved perfusion flat-bed bioreactor for cell therapy applications

We retrospectively reviewed the cases of seventy-two consecutive patients who had a lumbar discectomy, between 1950 and 1983, when they were sixteen years of age or younger. There were forty boys and thirty-two girls. At the time of the lumbar discectomy, twelve patients (17 per cent) also had a spinal arthrodesis. The mean duration of follow-up was 27.8 years (range, twelve to forty-five years). Twenty patients (28 per cent) had one reoperation or more, with the first reoperation performed at a mean of 9.7 years after the initial discectomy. Fourteen patients had one reoperation, four had two reoperations, one had three, and one had five. Fifty-two patients (72 per cent) did not need a reoperation. At the time of the latest follow-up, forty-eight (92 per cent) of the fifty-two patients either had no pain or had occasional pain related to strenuous activity and fifty-one (98 per cent) could participate in daily activities with no or mild limitations. Survivorship analysis showed that the overall probability that a patient would not need a reoperation was 80 per cent at ten years and 74 per cent at twenty years after the initial operation. With the numbers available for study, we could not show that age, gender, or an arthrodesis performed at the time of the initial operation were risk factors for a reoperation. We could not detect a difference, with respect to pain or the level of activity, between the patients who had had an arthrodesis at the initial operation and those who had not or between those who had a coexisting structural abnormality of the lumbar spine and those who did not.     

Monteggia fractures in adults

The records concerning ten consecutive years of experience with Monteggia fractures in adult patients at a level-one trauma center were retrospectively reviewed. Forty-eight patients who had been followed for a minimum of two years (average, 6.5 years; range, two to fourteen years) were identified. There were twenty-five women and twenty-three men, and the average age was fifty-two years (range, eighteen to eighty-eight years). According to the classification of Bado, there were seven type-I, thirty-eight type-II, one type-III, and two type-IV injuries. Twenty-six patients (68 percent) who had a Bado type-II fracture had an associated fracture of the radial head; ten of these patients also had a fracture of the coronoid process as a single large fragment. The ulna was fixed with a tension band-wire construct supplemented with screws in three patients (all of whom had a Bado type-II fracture). An ulnar diaphyseal fracture was fixed with an intramedullary Steinmann pin in one patient. The remaining patients had fixation with a plate and screws. The fracture of the radial head was treated with either complete or partial excision of the fragments in twelve patients (with replacement with a silicone prosthesis in two), open reduction and internal fixation in ten patients, and no intervention in four patients. Nine patients, all of whom had a Bado type-II fracture, needed a reoperation within three months after the initial operation; five had revision of a loose ulnar fixation device, three had resection of the radial head, and one had removal of a wire that had migrated from the radial head into the elbow articulation. Other important complications included proximal radioulnar synostosis in three patients, ulnar malunion in three, posterolateral rotatory instability of the ulnohumeral joint in one, and instability of the distal radioulnar joint in one. At the most recent follow-up examination, which was performed after all of the reoperations and reconstructive procedures had been done, the average score according to the system of Broberg and Morrey was 86 points (range, 15 to 100 points). The result was excellent for eighteen patients, good for twenty-two, fair for two, and poor for six. Six of the eight patients who had an unsatisfactory (fair or poor) result had had a Bado type-II fracture with a concomitant fracture of the radial head. These unsatisfactory results were related to a malunited fracture of the coronoid process in two patients, a proximal radioulnar synostosis in one, a malunited fracture of the coronoid process and a proximal radioulnar synostosis in one, a malunion of the ulna in one, and painfully restricted rotation of the forearm after operative fixation of a comminuted fracture of the radial head in one. The other two unsatisfactory results were in a patient who had had a Bado type-I fracture and in one who had had a Bado type-IV fracture. The results of the present series are much better than those reported in most earlier studies, suggesting that stable anatomical fixation of the ulnar fracture (including associated fracture fragments of the coronoid process) with a plate and screws inserted with use of current techniques of fixation leads to a satisfactory result in most adults who have a Monteggia fracture. The posterior (Bado type-II) fracture is the most common type of Monteggia fracture in adults. Problems with the elbow related to fractures of the coronoid process and the radial head, which are common with Bado type-II Monteggia fractures, remain the most challenging elements in the treatment of these injuries.     

Treatment of infection with débridement and retention of the components following hip arthroplasty

Forty-two patients (forty-two hips) who had an infection following a hip arthroplasty were managed with open débridement, retention of the prosthetic components, and antibiotic therapy. After a mean duration of follow-up of 6.3 years (range, 0.14 to twenty-two years), only six patients (14 per cent) -- four of nineteen who had had an early postoperative infection and two of four who had had an acute hematogenous infection -- had been managed successfully. Of the remaining thirty-six patients, three (7 per cent of the entire group) were being managed with chronic suppression with oral administration of antibiotics and thirty-three (79 per cent of the entire group) had had a failure of treatment. All nineteen patients who had a late chronic infection were deemed to have had a failure of treatment. Débridement had been performed at a mean of six days (range, two to fourteen days) after the onset of symptoms in the patients who had been managed successfully and at a mean of twenty-three days (range, three to ninety-three days) in those for whom treatment had failed. Débridement with retention of the prosthesis is a potentially successful treatment for early postoperative infection or acute hematogenous infection, provided that it is performed in the first two weeks after the onset of symptoms and that the prosthesis previously had been functioning well. In our experience, this procedure has not been successful when it has been performed more than two weeks after the onset of symptoms. Retention of the prosthesis should not be attempted in patients who have a chronic infection at the site of a hip arthroplasty as this approach universally fails.