Long-term results of pedicle stabilized thoracolumbar fractures in relation to the neurological deficit

88 patients with thoracolumbar fractures and short-segment (mono or two segment) pedicle instrumentation from the years 1985-92 had a follow-up examination after an average time of 5.6 years. The 56 men and 32 women had an average age of 32.6 years at the time of injury, 24 patients primarily had a complete and 43 patients an incomplete paraplegia, 21 patients showed no neurological deficits. The operative decompression of the spinal cord and stabilization of the injured spine by short segment pedicle instrumentation led to a complete or partial remission of the neurological deficits in 93% of the patients with incomplete paraplegia. Operative stabilization allowed an early mobilization and rehabilitation of these patients. We found no tendency to an increased complication rate in patients with neurological deficits compared to patients without neurological deficits. Patients with initially incomplete paraplegia complained more often about pain than all the other patients. Despite intensive rehabilitation and retraining programs handicapped patients had obvious disadvantages regarding their further careers.     

Increased cdc2 and cdk2 kinase activity by retinoid X receptor gamma-mediated transcriptional down-regulation of the cyclin-dependent kinase inhibitor p21Cip1/WAF1 correlates with terminal differentiation of squamous cell carcinoma lines

On 90 patients with 93 unstable fractures of the thoracic spine and the thoracolumbar junction we treated by a minimal invasive procedure between may 1996 and april 1998, in 46 patients an endoscopic splitting of the diaphragm was performed. The diaphragma was dissected at its attachment at the spine and the adjoining costal base. After partial corporectomy and discectomy, a tricortical bone graft has been inserted. An additional stabilization was done by using a plate and screw system. The incision of the diaphragm was closed by suturing or using an universal endostapler. Controlling the postoperative results a complete closure of the incision was documented by X-ray and CT-scan. There was no conversion to the open procedure or postoperative infection. Splitting the diaphragma opens also the thoracolumbar junction to a minimal invasive treatment and stabilization of fractures.     

APhA drug treatment protocols: management of patients with generalized anxiety disorder.APha Psychiatric Disorders Panel

STUDY DESIGN: The multidirectional stability potential of anterior, posterior, and combined instrumentations applied at L1-L3 was studied after L2 corpectomy and replacement with a carbon-fiber implant. OBJECTIVES: To evaluate the biomechanical characteristics of short-segment anterior, posterior, and combined instrumentations in lumbar spine tumor vertebral body replacement surgery. SUMMARY OF BACKGROUND DATA: The biomechanical properties of many different spinal instrumentations have been studied in various spinal injury models. Only a few studies, however, investigate the stabilization methods in spinal tumor vertebral body replacement surgery. METHODS: Eight fresh frozen human cadaveric thoracolumbar spine specimens (T12-L4) were prepared for biomechanical testing. Pure moments (2.5 Nm, 5 Nm, and 7.5 Nm) of flexion-extension, left-right axial torsion, and left-right lateral bending were applied to the top vertebra in a flexibility machine, and the motions of the L1 vertebra with respect to L3 were recorded with an optoelectronic motion measurement system after reconditioning. The L2 vertebral body was resected and replaced by a carbon-fiber cage. Different fixation methods were applied to the L1 and L3 vertebrae. One anterior, two posterior, and two combined instrumentations were tested. Load-displacement curves were recorded and neutral zone and range of motion parameters were determined. RESULTS: The anterior instrumentation provided less potential stability than the posterior and combined instrumentations in all motion directions. The anterior instrumentation, after vertebral body replacement, showed greater motion than the intact spine, especially in axial torsion (range of motion, 10.3 degrees vs 5.5 degrees; neutral zone, 2.9 degrees vs. 0.7 degrees; P < 0.05). Posterior instrumentation provided greater rigidity than the anterior instrumentation, especially in flexion-extension (range of motion, 2.1 degrees vs. 12.6 degrees; neutral zone, 0.6 degrees vs. 6.1 degrees; P < 0.05). The combined instrumentation provided superior rigidity in all directions compared with all other instrumentations. CONCLUSIONS: Posterior and combined instrumentations provided greater rigidity than anterior instrumentation. Anterior instrumentation should not be used alone in vertebral body replacement.     

Vertebral pseudarthrosis in the osteoporotic spine

STUDY DESIGN: Radiologic and operative findings of intravertebral cleft in the osteoporotic spine were investigated and the pathomechanism discussed. OBJECTIVES: To clarify the pathologic features of the intravertebral cleft. SUMMARY OF BACKGROUND DATA: Intravertebral "vacuum" cleft is one of the common radiographic findings in the osteoporotic spine. It is thought that the cleft is a rare lesion of an ununited fracture, or pseudarthrosis. Evidential findings of the disease, however, have never been reported. METHODS: Simple bone grafting was performed in five cases (average age, 76.8 years) of thoracolumbar intravertebral cleft in osteoporotic spine in patients who had been suffering from prolonged pain of the back or leg. Preoperative radiologic evaluation using flexion-extension radiograph and magnetic resonance imaging was performed in all patients. At operation, the cleft and the components of the structure were macroscopically and microscopically observed. The fluid content in the cleft was biochemically analyzed. RESULTS: In all patients, preoperative flexion-extension radiographs showed intravertebral instability at the location of the clefts that indicated gas density in three cases and water density in two cases. Magnetic resonance imaging showed that, for the most part, the cleft was low intensity on the T1-weighted image and high intensity on the T2-weighted scans, regardless of the radiographic findings. At operation, abnormal movement was observed at the cleft of the affected body, which was covered with hypertrophic membrane. The serous fluid within the cleft was aspirated before the excision of soft tissue. The thick membrane was excised and showed that the cleft was lined by smooth fibrocartilaginous tissue and the great degree of motion between the fracture ends that is consistent with the pathologic appearance of pseudarthrosis. CONCLUSIONS: The unstable cleft in the affected vertebral body of the osteoporotic spine with magnetic resonance findings of low intensity on the T1-weighted scans and high intensity on the T2-weighted scans suggests that the cleft is a false joint lined by fibrocartilaginous tissue with notable movement consistent with pseudarthrosis.     

Anterior instrumentation in the management of thoracolumbar burst fractures

Anterior instrumentation in the treatment of thoracolumbar fractures has progressed significantly during the past 2 decades. These fixation systems have evolved to meet the anatomic, biomechanical, and imaging challenges associated with internal fixation of the thoracolumbar spine. The evolution of these devices will be reviewed, and from this, the indications and surgical techniques necessary for the safe and effective use of the device will be discussed. This study also reports the authors' initial clinical experience using the Z plate anterior thoracolumbar plating system in the treatment of thoracolumbar burst fractures. The study consists of 12 consecutive adult patients who underwent a 1-stage anterolateral decompressive and stabilization procedure for burst fractures from T9-L3. The indications for surgery included neurologic deficits, deformity, progressive kyphosis, and late pain. Ten of the 12 patients maintained their postoperative sagittal alignment or a significant portion of their kyphosis reduction. Two patients with severe kyphotic deformities greater than 50 degrees lost 10 degrees and 20 degrees of their reduction at last followup. All 3 patients with neurologic deficits recovered. There were no neurologic or perioperative complications. Eleven of the 12 patients obtained a good or excellent functional outcome. Anterior arthrodesis using instrumentation stabilization after a 1-stage anterolateral decompression and reduction procedure can yield successful clinical results in the treatment of thoracolumbar burst fractures.     

Fractures of the thoracolumbar spine. Late results of dorsal instrumentation and its consequences

Between January 1989 and July 1992, 76 patients with thoracolumbar fractures were operatively treated at the Department of Trauma Surgery, Hannover Medical School. After a mean of more than 3 years, 56 of 62 patients (90%) still alive who had their implants removed were examined. According to the ASIF classification 33 patients sustained type A fractures, 13 type B and 10 type C. Three patients with incomplete paraplegia returned to normal; in one case of complete paraplegia no change occurred. In 40 cases the dorsal instrumentation was combined with transpedicular cancellous bone grafting. The mean operative time totaled 3 h. In this series, two complications (3.6%) were observed: one iatrogenic vertebral arch fracture without consequences and one deep infection. Compared to the preoperative status, our follow-up examinations demonstrated permanent physical and social sequelae; the percentage of individuals able to do physical labor was reduced by half (22 to 11 patients) whereas the share of unemployed or retired patients doubled (4 to 8 patients). At the time of follow-up examination only 21 of 42 patients continued in sports. The assessment of complaints and functional outcome with the "Hannover Spinal Trauma Score" reflected a significant difference (P < 0.001) between the status before injury (96.6/100 points) and at the time of follow-up (71.4/100 points). The radiographic assessment in the lateral plane (Cobb technique) demonstrated a significant (P < 0.001) mean restoration from an initial angle of -15.6 degrees (kyphosis) to +0.4 degree (lordosis). Serial postoperative radiographic follow-up showed progressive loss of correction; at follow-up examination we found a mean of 10.1 degrees (P < 0.001). Compared to the preoperative deformity a mean improvement of 6.1 degrees to an average of -9.7 degrees at follow-up examination was noted. The addition of transpedicular cancellous bone grafting did not decrease the loss of correction. CT scans after implant removal were performed in 9 cases: only 3 of 9 patients showed evidence of intervertebral fusion. No correlation could be found between ASIF classification and radiographic outcome. However, the preoperative wedge angle of the vertebral body correlated significantly with the postoperative loss of reduction. Due to disappointing results after dorsal stabilization with transpedicular cancellous bone grafting we recommend a combined procedure with dorsal stabilization and ventral fusion in cases of complete or incomplete burst injury of the vertebral body.     

The lordotic effect of the OSI frame on operative adolescent idiopathic scoliosis patients

STUDY DESIGN: A prospective evaluation of adolescent idiopathic scoliosis patients undergoing operative treatment on the Orthopedic Systems Incorporated (OSI; Jackson) frame. OBJECTIVES: To investigate prospectively thoracic, thoracolumbar, and lumbar sagittal alignments in patients with adolescent idiopathic scoliosis who undergo an instrumented posterior spinal fusion on the OSI frame. SUMMARY OF BACKGROUND DATA: In several studies, it has been shown that patient positioning on various operative frames is an important component of ultimate lumbar sagittal alignment. However, these studies have all concentrated on the lumbar spine, and no sagittal plane alignment data in adolescent idiopathic scoliosis patients have been reported in the thoracic and thoracolumbar junction as it relates to intraoperative positioning, correction maneuvers and correlative postoperative results. METHODS: Thirty-nine patients with operative adolescent idiopathic scoliosis treated with an instrumented posterior spinal fusion on the OSI frame were prospectively evaluated. Standing preoperative, intraoperative, and postoperative long-cassette lateral radiographs were reviewed with regional and segmental Cobb measurements of the thoracic, thoracolumbar junction, and lumbar spine obtained. RESULTS: Thoracic kyphosis (T1-T12) measured +34 degrees before surgery, +28 degrees during surgery, and +30 degrees after surgery, Thus, a statistically significant decrease was noted in thoracic kyphosis secondary to prone positioning on the OSI frame ( P < 0.05). Thoracolumbar spine measurements from T10 to L2 also showed a lordotic trend from +2 degrees before surgery, to -4 degrees during surgery, to -8 degrees after surgery, which was also statistically significant (P < 0.05). Total lumbar lordosis from T12 to S1 remained relatively unchanged from -60 degrees before surgery, to -59 degrees during surgery, to -60 degrees after surgery. However, segmental lumbar lordosis measured from T12 to the lowest instrumented vertebra showed a statistically significant increase in lordosis from -17 degrees before surgery, to -19 degrees during surgery, to -23 degrees after surgery (P < 0.05). Those patients in whom lumbar pedicle screws were used (vs. hooks alone) had the greatest increase in lumbar instrumented lordosis. CONCLUSIONS: Performing adolescent idiopathic scoliosis correction on the OSI frame tends to decrease thoracic kyphosis, increase thoracolumbar lordosis, and increase segmental instrumented lumbar lordosis, while it maintains total lumbar lordosis.     

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.     

New anterior instrumentation for the management of thoracolumbar and lumbar scoliosis. Application of the Kaneda two-rod system

STUDY DESIGN: The Kaneda multisegmental instrumentation is a new anterior two-rod system for the correction of thoracolumbar and lumbar spine deformities. This system consists of a vertebral plate and two vertebral screws for individual vertebral bodies and two semirigid rods to interconnect the vertebral screws. Clinical results of 25 thoracolumbar and lumbar scoliosis patients treated with this new instrumentation were analyzed. OBJECTIVES: To evaluate the efficacy of the new anterior instrumentation in correction and stabilization of thoracolumbar and lumbar scoliosis. SUMMARY OF BACKGROUND DATA: Since Dwyer first introduced the concept of anterior spinal instrumentation and fusion for scoliosis, anterior surgery has gradually gained acceptance. In 1976, a useful modification for the anterior spinal instrumentation, which reportedly provided means of lordosation and vertebral body derotation, was described. However, some authors reported a high tendency of the implant breakage, loss of correction, progression of the kyphosis, and pseudoarthrosis as the major complications. To overcome the disadvantages of Zielke instrumentation, the authors have developed a new anterior spinal instrumentation (two-rod system) for the management of thoracolumbar and lumbar scoliosis. METHODS: Anterior correction and fusion using Kaneda multisegmental instrumentation was performed in 25 patients with thoracolumbar or lumbar scoliosis. The average follow-up period was 3 years, 1 month (range, 2 years to 4 years, 7 months). There were 20 patients with idiopathic scoliosis (13 adolescents and seven adults) and five patients with other types of scoliosis, including congenital and other etiologies. All patients had correction of scoliosis by fusion within the major curve, and for 16 of the 25 patients, the most distal end vertebra was not included in the fusion (short fusion). Radiographic evaluations were performed to analyze frontal and sagittal alignments of the spine. RESULTS: The average correction rate of scoliosis was 83%. Over the instrumented levels, the correction rate was 90%. Preoperative kyphosis of the instrumented levels of 7 degrees was corrected to 9 degrees of lordosis. Sagittal lordosis of the lumbosacral area beneath the fused segments averaged 51 degrees before surgery and was reduced to 34 degrees after surgery. The trunk shift was improved from 25 mm before surgery to 4 mm at final follow-up evaluation. The average improvement in the lower end vertebra tilt-angle was 97% in those patients whose lower end vertebra was included in the fusion and 83% in patients whose lower end vertebra was not included in the fusion. Apical vertebral rotation showed an average correction rate of 86%. At final follow-up evaluation, all patients demonstrated solid fusion without implant-related complications. There was 1.5 degrees of frontal plane and 1.5 degrees of sagittal plane correction loss within the instrumented area at final follow-up evaluation. CONCLUSIONS: New anterior two-rod system showed excellent correction of the frontal curvature and sagittal alignment with extremely high correction capability of rotational deformities. Furthermore, correction of thoracolumbar kyphosis to physiologic lordosis was achieved. This system provides flexibility of the implant for smooth application to the deformed spine and overall rigidity to correct the deformity and maintain the fixation without a significant loss of correction or implant failure compared with conventional one-rod instrumentation systems in anterior scoliosis correction.     

Acute abdomen. When to operate immediately and when to observe

BACKGROUND: Seat belt type injury of thoracolumbar spine is an uncommon injury characterized by disruption of the posterior elements of the spine. The fracture has long been treated conservatively, but progressive kyphotic deformity developed frequently. METHODS: From January, 1991 through December, 1992, 10 cases of seat belt type injury of the thoracolumbar spine were encountered at our hospital with an incidence of 8% in overall spinal fractures. Of these patients, eight patients were male and two were female, average age 30.7 years old. The causes included motor-vehicle accident in five patients, fall from height in four, and stricken by a falling electric pole in one. None of the victims of motor vehicle accidents wore seat belt. All of them received open reduction, posterior internal fixation and posterior fusion. RESULTS: After follow-up for an average of 42.2 months, the average kyphotic angulation was 5.7 degrees. Back pain and function of these patients were all rated good. None of them suffered from neurologic deficit. One patient with breakage of transpedicular screws was encountered during follow-up, but there was no complaint. CONCLUSIONS: In treating seat belt type injuries of spinal column, benefits of operation outweigh the risks. Besides, the clinical result is satisfactory and more aggressive surgical approach should be encouraged.     

Residual intersegmental spinal mobility following limited pedicle fixation of thoracolumbar spine fractures with the fixateur interne

The Fixateur Interne has been proposed for limited pedicle fixation of thoracolumbar spine fractures with the assumption that motion in the nontraumatized spinal segments could be maintained. To date, no data exist that both localize and quantitate spinal mobility about the fractured vertebra. Voluntary maximum lateral flexion and extension radiographs were obtained on patients with unstable thoracolumbar spine fractures at a minimum of 2 years after Fixateur Interne instrumentation (implant was removed after 1 year). Residual intersegmental motion was measured at levels adjacent to both the vertebra fracture and the fixation. Fifty-nine patients were reviewed, and the posterior vertebral body angle demonstrated a mean total sagittal motion of 2.98 degrees. Cephalad and caudal to the fractured vertebra, a mean of 1.34 degrees and 3.08 degrees, respectively, of residual motion was noted; cephalad and caudal to the previously instrumented segment a mean of 3.22 degrees and 6.88 degrees, respectively, was measured. The authors conclude that residual mobility is most evident at the caudal end of the instrumented segment, removed from the fractured vertebra. The level with end plate disruption becomes essentially ankylosed, with or without a fusion.     

Treatment of nonunion of the humerus using the Ilizarov external fixator

Ilizarov's method of monofocal compression was used in 30 humeri with a diaphyseal pseudarthrosis. Twenty-one patients had previous surgery but had loosening of the osteosynthesis material. Nine patients initially were treated with a hanging cast, resulting in interfragmentary distraction. Fourteen nonunions were hypertrophic, and 16 were atrophic, of which six were infected. A complete circular frame was used only in the first nine patients, whereas the remaining 21 patients were treated with the modified semicircular fixator. Union was obtained in all but two patients, with an average consolidation time of 4.5 months (range, 2.5-10 months). No patient required additional bone grafting. Apart from superficial pin tract infection seen in most of the patients, three had a minor temporary sensory neurologic problem. Four patients experienced a second fracture after removal of the fixator that required a second application of an Ilizarov frame. Although similar results with regard to union are reported after plate osteosynthesis, there was no radial nerve palsy or deep infection in this series, indicating that the treatment by the Ilizarov technique is associated with less complications. The authors' findings suggest that the Ilizarov method is a reliable treatment for humeral nonunions, even after multiple previous operations or in the event of infection.     

Autogenous iliac crest bone graft. Complications and functional assessment

Functional outcomes and complications experienced by adult patients who underwent iliac crest bone grafting were evaluated to assess the effect of bone grafts on patient function. In addition to retrospective chart reviews, patients completed the Sickness Impact Profile and a detailed questionnaire on pain. One hundred ninety-two patients met study inclusion criteria. Major complications were recorded in four (2.4%) patients in whom infections developed requiring readmission. Thirty-seven (21.8%) patients had minor complications. One hundred nineteen of 170 patients were available for followup; of these 119 patients, 87 (73.1%) returned completed questionnaires. Thirty-three of 87 (37.9%) patients reported pain 6 months postoperatively. The incidence of pain decreased with time, with 16 of 87 (18.7%) patients continuing to report pain more than 2 years postoperatively. Proportionately more spine patients reported pain at all time points. The mean Sickness Impact Profile score for patients completing questionnaires was nine, suggesting most patients were functioning well 2 years postoperatively. The morbidity of iliac crest grafting remains substantial. Pain symptoms in this study sample seemed to last longer in more patients than earlier series have indicated. Minimizing muscle dissection around donor sites and the advent of bone graft substitutes may help alleviate these problems.     

Surgery of the upper cervical spine in rheumatoid arthritis. Indications and results apropos of 28 cases

PURPOSE OF THE STUDY: The goal of this study was to precise indications and surgical techniques for stabilisation with or without decompression of the upper cervical spine instability in rheumatoid arthritis. MATERIAL AND METHODS: 28 patients presenting upper cervical spine disease have been reviewed (mean age 57 years). These patients had been suffering from severe diffuse arthritis during an average of 14.5 years. The anterior atlanto-axial dislocation was most frequent (25 times), 1 posterior dislocation and 2 vertical dislocations. Odontoid lysis was noted 19 times. A subluxation of the lower cervical spine was present in 12 patients. SURGICAL TECHNIQUE: C1-C2 arthrodesis was performed 12 times (9 times with a loop wire and 3 isthmo-pedicular screws C2-C1), occipito-cervical arthrodesis with plates 16 times. Operative traction was necessary 5 times. The associated surgical gestures included 3 times a laminectomy, 2 times an enlargement of the occipital foramen, 1 section of the Arnold nerve. In 2 patients was associated a fixation of the lower cervical spine. RESULTS: With an average of 27 months follow-up, functional results (classified according to Ranawat's criteria) were satisfactory in 14 patients, improved in 7 patients, unchanged in 4 and bad in 3. The reduction of the anterior displacement in 25 patients was complete 11 times, partial 17 times and null 3 times. The reduction of the vertical displacement was complete once, partial 3 times. Arthrodesis fusion was obtained in 19 cases, 5 times it was a fibrous union and 4 pseudarthrosis occurred, all with C1-C2 loop wire. The rate of complications was high: 2 infections on bone site grafting requiring reoperation, 2 infections with secondary septicemia after lack of reduction. DISCUSSION AND CONCLUSION: Occipito-cervical arthrodesis is necessary as soon as the patient presents neurological signs. When there is an anterior dislocation associated with vertical dislocation, if there is posterior dislocation in case of osteoporosis of the posterior C1-C2 arc, or destabilisation of the lower cervical spine. C1-C2 arthrodesis is suggested when there is no important neurological signs, when displacement is limited to a pure anterior dislocation and in young patient with good bone quality.     

Transpedicular stabilization in fractures of the thoracolumbar spine. II

Proceeding from the literature survey and on the basis of his own experience the author presents a current concept review of the problems of the transpedicular stabilization in fractures of the thoracolumbar spine. Individual chapters are devoted to the biomechanics and transpedicular screw placement, classification of implants and to the transpedicular operations on the injured vertebral body. Based on both his own experience and survey of the literature the author recommends the following: in order to increase the stability of osteosynthesis to place transpedicular screw in anteromedial direction (Magerl approach) close to the anterior cortex of the vertebral body or (in case of osteoporosis) to perforate it by tip of the screw. in fractures with the compression of vertebral body (mainly in case of burst fractures) to perform transpedicular reduction and cancellous bone grafting after Daniaux and Dick. Out of the implants so far used the author considers the best Fixateur interne (Dick) allowing facultless reduction as well as a longterm stabilization of the fracture.     

Effect of a bicycle safety program and free bicycle helmet distribution on the use of bicycle helmets by elementary school children

A retrospective follow-up study was performed on 40 patients, in which tuberculous spondylitis was treated conservatively between 1969 and 1985 with orthotic supports for an average of 16 months (range, 10-30 months) and with anti-tuberculous agents. All had persistent back pain, but none had neurological deficits. The mean follow-up period was 17 years (range, 10-26 years). Diagnosis was confirmed histopathologically. The spinal segments involved ranged from T5 to L5. The kyphotic angle was calculated according to Cobb. At final follow-up, 22 patients were pain free, 11 had occasional pain, 6 complained of pain in the morning, and 1 had chronic pain and needed frequent analgesics. Solid bony union was found in 75% of patients. The kyphotic deformity occurred in the thoracic spine with a mean angle of 20 degrees (range, 13-28 degrees) and in the lumbar spine with a mean angle 12 degrees (range, 5-26 degrees). The long-term follow-up of conservative treatment showed only slightly increased kyphosis. Conservative treatment is an alternative to surgical intervention in cases with kyphosis < 35 degrees.     

Circulating factors as markers and mediators of endothelial cell dysfunction in preeclampsia

3 different types of complex spinal trauma are defined: Type I means a multilevel contiguous or non contiguous unstable injury, type II is described as a spinal injury with concomitant thoracic or abdominal lesion, type III stands for the coincidence of spinal injury and polytrauma. Overlapping of different types occurs. Type I: The incidence amounts according a german multicenter study to about 2.5%. Multilevel injuries need to be stabilized for a long distance from posterior. With a thorough analysis the segments to be fused are determined. Type II: The leading thoracic injury is a lung contusion which occurs in up to 50% of the cases. A CT scan of the thorax during the first diagnostic screening is recommended. Early reduction and stabilization from posterior should be aimed at. During the first two weeks anterior procedures are contraindicated. Abdominal injuries are to be found in 3-4% of all spinal injuries. All organs could be affected. A typical constallation is the "seat-belt syndrome" with lesions of the upper abdominal organs and a flexiondistraction injury of the upper lumbar spine. The main problem is to make the diagnosis of both components initially. Most of the patients may be treated in one operation by first taking care of the abdominal injury and than stabilizing the spine. The prognosis of this combination is favorable. Type III: In 17-18% of all polytraumatized patients lesions of the spine are to be diagnosed. From these only one third need surgical care. From 680 patients with operatively treated fractures of the thoracolumbar junction 6.2% were polytraumatized according to the multicenter study mentioned above. The risk of missing a spinal injury in polytrauma totals approximately 20%. Surgical stabilization should be performed in the primary phase (day-1-surgery). Additional injuries, potentially time consuming operations with a high blood loss sometimes necessitate a different approach. Non stabilized spinal injuries apparently do not have the same negative effect on the whole organism as long bone fractures. In the early phase of treatment on the C-spine only anterior procedures and on the thoracolumbar spine only posterior techniques should be applied.     

Initial heme uptake from albumin by short-term cultured rat hepatocytes is mediated by a transport mechanism differing from that of other organic anions

Twenty-eight proximal phalangeal fractures secondary to low-velocity gunshot wounds in 27 patients treated by stable fixation were retrospectively reviewed. Definitive fixation was performed within 1 week of injury. Fractures were stabilized with either a plate, intramedullary spacer, or a combination of both. When necessary, supplemental fixation was achieved with cerclage wires or interfragmentary screws. Twenty fractures with bone loss or comminution were primarily supplemented with iliac crest bone graft. After surgery, the fingers were splinted in 90 degrees of metacarpophalangeal (MP) flexion. An aggressive supervised therapy program was initiated within 24 hours of surgery. The average length of follow-up care was 9 months (range, 3-29 months). Primary union was achieved in all fractures. The average range of motion was 83 degrees for the MP joint and 66 degrees for the proximal interphalangeal joint. The average total active motion (TAM) for the involved digits was 200 degrees (range, 65 degrees-250 degrees). Fractures without intra-articular extension had a significantly better average TAM (213 degrees) than did those with intra-articular extension (169 degrees; p = .05). Primary bone grafting did not adversely effect the final TAM. There were no infections. Early stable fracture fixation of these injuries achieved union, alignment, and early rehabilitation with no appreciable increase in morbidity.     

Perioperative complications of anterior procedures on the spine

We reviewed the operative and hospital records of 447 patients in order to determine the rates of perioperative complications associated with an anterior procedure on the thoracic, thoracolumbar, or lumbar spine. The anterior procedures were performed to treat spinal deformity or for débridement or decompression of the spinal canal. The diagnostic groups that we studied included idiopathic scoliosis in adolescents or young adults (100 patients), scoliosis in mature adults (sixty-three patients), kyphosis (sixty-one patients), neuromuscular scoliosis (sixty patients), fracture (forty-seven patients), a revision procedure (thirty-nine patients), congenital scoliosis (thirty-six patients), tumor (nineteen patients), vertebral osteomyelitis or discitis (eight patients), and miscellaneous (fourteen patients). Complications occurred in 140 (31 per cent) of the 447 patients and were classified as major or minor. Forty-seven patients (11 per cent) had at least one major complication and 109 (24 per cent) had at least one minor complication. Two patients died, both from pulmonary complications after the operation. The most common type of major complication was pulmonary; the most common type of minor complication was genito-urinary. The adolescent or young adult patients who had idiopathic scoliosis had the lowest rate of complications, and the patients who had neuromuscular scoliosis had the highest. An age of more than sixty years at the time of the operation was associated with a higher risk of complications. The duration of the procedures involving a thoracic approach was shorter than that of those involving a thoracolumbar or lumbar approach; however, the rate of complications was not significantly different among the three approaches. Vertebrectomies took longer to perform and were associated with a greater estimated blood loss than discectomies; however, there was no significant difference in the rate of complications between the two types of procedures. The patients who had a fracture or a tumor lost more blood than those from the other diagnostic groups. Blood loss increased as the duration of the operation increased for all procedures. Combined anterior and posterior procedures performed during the same anesthesia session were associated with a higher rate of major complications than were procedures that were staged. A logistical regression analysis showed that the variables that increased the risk of a major complication were an estimated blood loss of more than 520 milliliters and an anterior and posterior procedure performed sequentially under the same anesthesia session. This analysis also demonstrated that the diagnosis of idiopathic scoliosis in adolescents or young adults was associated with a reduced risk of major complications. Compared with other major operations, an anterior procedure on the thoracic, thoracolumbar, or lumbar spine performed for the indications mentioned in this study is relatively safe.     

Talonavicular arthrodesis for the painful adult acquired flatfoot

Twenty-seven consecutive patients with posterior tibial tendon insufficiency were treated with talonavicular arthrodesis as the primary stabilizing procedure. Twenty-six patients were followed a minimum of 12 and an average of 27 months. Twenty-four patients had either no pain or pain only after heavy usage. Eleven patients were completely satisfied with postoperative foot function, 13 were satisfied, with minor reservations, and 2 were satisfied, with major reservations. Results were rated as excellent in 10 patients, good in 14 patients, and fair in 2 patients. Successful arthrodesis was achieved in all patients, although one patient required two additional bone grafts. Progressive arthrosis in adjacent joints was noted in five patients, four of whom had arthrosis preoperatively. No deterioration of foot position was seen in any patient with follow-up as long as 5 years. An isolated talonavicular arthrodesis seems to offer patients with this disorder both reliable pain improvement and lasting stability.