Harrington instrumentation in fractures and dislocations of the thoracic and lumbar spine

Harrington instrumentation was used to treat 23 injuries of the thoracic and lumbar spine accompanied by neural damage encountered during an 8 1/2-year period. The indication for the use of Harrington instrumentation is instability of the thoracic or lumbar spine due to trauma, laminectomy, or both. Of the 13 patients with incomplete neural lesions in the series, 12 improved. One of these was a cauda equina lesion. No patient in the series was neurologically worse after operation, in contrast to other reported series in which laminectomy alone was done. It is concluded that Harrington instrumentation is the strongest available system of internal fixation, and the only one that permits reduction of nearly all traumatic spinal deformities at the time of operation.     

Internal fixation of the thoracic and lumbar spine using Roy-Camille plates

Thirty patients underwent fixation of the thoracic and lumbar spine from 1986 to 1990 using the Roy-Camille pedicular screw fixation system. The spine was stabilized for a variety of pathologic entities including fracture, tumor, spondylolisthesis, postlaminectomy instability, and pseudarthrosis. All but one patient obtained solid fusion based on radiographic and clinical criteria with an average follow up of 19.5 months. All patients reported subjective improvement in preoperative pain levels. There were no neurologic complications associated with the surgical procedure. Roy-Camille plate fixation appears to offer a stable surgical construct in the treatment of thoracic and lumbar spine instability.     

Experimental investigation of lumbar epidural pressure measurement

To evaluate the usefulness of lumbar intraspinal epidural pressure (ISEDP) measurements for the estimation of intracranial pressure, we studied the relationship between ISEDP and intracranial epidural pressure (ICEDP) in 25 adult mongrel dogs. ICEDP and ISEDP were measured simultaneously with Gaeltec catheter-tip pressure transducers placed in the parietal epidural space and in the lumbar epidural space. Groups 1 and 2 dogs served as normal cerebrospinal fluid condition models. Group 1 received sequential steady-state normal saline infusions (0.5, 1.0, and 1.5 ml/min) into the cisterna magna. ISEDP and ICEDP measurements exhibited a linear correlation, and ISEDP was 80 to 90% of ICEDP at any pressure level. There was no significant difference in the pressure curves obtained at the different infusion rates. Group 2 dogs were subjected to rapid pressure changes by a cisternal bolus injection. Although compliance calculated from the change in ISEDP was slightly greater than that from ICEDP at resting pressure, the compliance calculated from both ISEDP and ICEDP decreased at 20 and 30 mm Hg of ICEDP and the values became almost equivalent. Groups 3 and 4 dogs were mild and severe experimental subarachnoid models, respectively. The ISEDP and ICEDP measurements also showed a linear correlation; however, ISEDP was about 70% of ICEDP in Group 3 and about 50% of ICEDP in Group 4. Although there are varying degrees of discrepancy between ISEDP and ICEDP in the normal or subnormal pressure range and in the presence of severe spinal block, our findings suggest that ISEDP measurements can be used to estimate intracranial pressure in a clinical practice.     

Ultra-low magnetic resonance tomography of thoracic and lumbar spine osteochondrosis

The paper presents the results of tomographic studies of 119 patients with clinical manifestations of radiculopathy or radiculomyelopathy. MR tomography was performed on the Magnaview unit ("Instrumentarium", Finland) at field intensity 0.04 T. The analysis of T1- and T2-weighted sagittal tomograms providing MRT picture of osteochondrosis and various hernias shows that osteochondrosis involves several disks simultaneously while their bulging towards the vertebral canal is multiple. The severity of the hernia in some cases does not closely agree with degeneration degree or the decline of the vertebral disk height. However there is a close correlation between the size and direction of the hernia on the one hand and the clinical manifestations on the other hand.     

Surgical management of dumbbell and paraspinal tumors of the thoracic and lumbar spine

The lateral extracavitary approach was used for single-staged tumor resection in 12 patients with complex dumbbell or paraspinal tumors of the thoracic and lumbar spine. Six women and six men (age, 28-72 yr) were treated between August 1990 and January 1994. The tumors included schwannoma (6 patients), malignant meningioma (1 patient), hemangioma (1 patient), chondrosarcoma (1 patient), osteocartilaginous exostosis (1 patient), radiation-induced osteogenic sarcoma (1 patient), and metastatic renal carcinoma (1 patient). Gross total resection was achieved in 11 patients. Radical subtotal removal was performed in the remaining patient, who had a malignant osteogenic sarcoma. Concomitant spinal stabilization with internal fixation and anterior interbody strut grafting was performed on two patients. No significant perioperative complications occurred. Ten patients were alive and clinically stable at follow-up visits ranging from 14 to 55 months. Two patients died from systemic tumor dissemination during the follow-up period. The lateral extracavitary approach is useful when extensive or difficult spinal and paraspinal exposure is required. The surgical aspects of these neoplasms and the technique of lateral extracavitary approach are described in detail.     

Surgical treatment of deformities of the thoracic and lumbar spine by posterior spinal osteotomy

From 1987 to 1993, we performed spinal osteotomy with posterior closing-wedge using a single-operation technique in 20 patients with kyphosis. Spinal deformity resulted from mal union after spinal injury in 13 patients and from ankylosing spondylarthritis in 7. Mean duration of the procedure was 4 h 15 min (range 2 h 30 min to 7 h) for mal union and 3 hours (2 h 30 to 4 h) for ankylosing spondylarthritis. Intraoperative blood loss was estimated at 1.8 liters (0.5-4) and 1 liter (0.5-1.5) respectively. Osteotomy was performed at L3 in all cases of spondylarthritis with a mean 30 degrees correction (24-37 degrees) which was maintained after 5 to 18 months follow-up (mean 10 months). For mal union, the mean angular correction was better and more stable after 3 to 84 months (mean 23 months) for the thoracic or thoraco-lumbar segments than for the lumbar spine. Functional results were excellent or good for 11 patients, acceptable for 1 and poor for 1. Three patients with recurrent radiculalgia with mal union were cured after the operation while the neurological status of the paraplegic patients remained unchanged. There were no fatal complications nor neurological or vascular complications among the 20 patients. There were 4 complications in patients with an abnormal callus including 3 mechanical complications and one deep infection. For spondylarthritis, there were no complications at maximum follow-up.     

Transpedicular stabilization in spinal and vertebral column injuries in thoracic and lumbar spine segments

The authors present their own experience in application of transpedicular internal stabilization of the thoracic and lumbar spine. Clinical analysis was carried out in a group of 12 patients after vertebral column and spinal trauma managed surgically in the Department of Neurosurgery in Poznań between 1.06.95 and 31.12.96. Age of patients ranged from 19 to 56 years (mean age 35.08 +/- 13.04 yrs.). The level of vertebral fracture was as follows: thoracic (2 cases), thoraco-lumbar (6 cases) and lumbar (4 cases). Three patients were completely paraplegic. All patients underwent posterior or posterolateral surgical approach. The fractured parts of bones, translocated into vertebral canal were removed and nervous structures were decompressed. Transpendicular stabilization was performed after the decompression. Improvement of neurological condition was observed in 8 patients.     

Percutaneous biopsy of the thoracic and lumbar spine: transpedicular approach under fluoroscopic guidance

BACKGROUND: Merkel cell carcinoma (MCC) is a rare, aggressive, cutaneous neoplasm. The primary form of initial treatment is wide surgical excision. The use of Mohs micrographic surgery as the primary form of treatment in MCC has been controversial. The course of MCC is often aggressive, with early metastasis, widespread disease, and death. Despite the poor prognosis, spontaneous regression has occasionally been reported. OBJECTIVE: We describe the clinical course of two patients with Merkel cell carcinoma who underwent treatment with Mohs micrographic surgery for the primary MCC. Metastases were excised in the first case and spontaneously regressed in the second. Both patients are without clinical disease at the time of this report. METHODS: Histopathology, clinical records, and the current literature are reviewed. RESULTS: One patients was without recurrence of MCC for 13 years of follow-up. The other patient experienced clinical spontaneous remission after nodal spread of the disease, with no recurrence for 18 months after clinical remission and 24 months after surgery. CONCLUSION: The treatment of Merkel cell carcinoma with Mohs micrographic surgery (MMS) has been successful for the control of primary skin disease, and is at least comparable to wide excision. Spontaneous regression may occur in the course of this usually relentless and aggressive disease. The explanation for spontaneous regression of MCC is unknown.     

Myelolipoma of the thoracic spine

We describe a myelolipoma of the thoracic spine in a patient with gradual and progressive myelopathy. MR imaging showed this predominately fatty lesion to be extradural in location.     

The postoperative lumbar spine: evaluation of epidural scar over a 1-year period

BACKGROUND: Results of antituberculous chemotherapy for Mycobacterium avium complex disease remain disappointing. Pulmonary resection during an early stage of the disease, therefore, may be beneficial to patients whose disease is localized and who can tolerate a resectional operation. METHODS: Thirty-three patients with localized M avium complex disease underwent 33 pulmonary resections between 1979 and 1996. There were 17 males and 16 females, with a mean age of 50 years (range, 30 to 69 years). Lobectomy was performed in 26 patients, pleuropneumonectomy in 1, segmentectomy in 5, and wedge resection in 1. RESULTS: There was no operative mortality. After pulmonary resection, 31 (94%) patients attained sputum-negative status. Bronchopleural fistula occurred in one patient who underwent a right upper lobectomy. There were two late deaths. A patient with bronchopleural fistula died of respiratory failure two years postoperatively. Another patient died of an unknown cause 12 years postoperatively. Of the 31 patients with negative sputum status postoperatively, only 2 patients (6%) had relapse at 1 and 9 years after operation. CONCLUSIONS: We recommend that patients with this disease be considered for pulmonary resection as early as possible.     

Anatomy of the lumbar spine

The macroscopic courses of the posterior primary rami in the lumbar spine are described and illustrated from fresh cadaver dissections.     

Percutaneous biopsy of the thoracic spine

The aspartate aminotransferase gene (AspAT, EC 2.6.1.1) of an extremely thermophilic bacterium, Thermus thermophilus HB8, was cloned and sequenced, and its gene product was overproduced. The purified T. thermophilus AspAT was stable up to about 80 degrees C at neutral pH. T. thermophilus AspAT was strictly specific for acidic amino acid substrates, such as aspartate, glutamate, and the respective keto acids. The gene coding for T. thermophilus AspAT showed that it comprised 1,155 bp with a high G+C content (70 mol%), and encoded a 385-residue protein with a molecular weight of 42,050. The amino acid sequence of T. thermophilus AspAT deduced from its gene showed about 15, 46, and 29% homology with those from Escherichia coli, Bacillus sp. YM-2, and Sulfolobus solfataricus, respectively. When the amino acid sequence of T. thermophilus AspAT was compared with that of E. coli AspAT, the number of Cys was found to have decreased from 5 to 1, that of Asn from 23 to 9, that of Gln from 16 to 8, and that of Asp from 20 to 13, all of which are known to be relatively labile at high temperatures. Conversely, the number of Pro was increased from 15 to 25, Arg from 22 to 32, and Glu 27 to 37. As shown by the E. coli AspAT structure, there was a marked tendency for the extra prolyl residues to be located around the surface of the molecule. This was quite different from that in the case of RecA protein, which shows an increased number of prolyl residues in the interior of its molecule. Different strategies of different proteins as to prolyl contribution to thermostability have been suggested. Despite the high degree of conservation of active-site residues, Arg292 in E. coli AspAT, which interacts with the distal carboxylate of the substrate, was not found in T. thermophilus AspAT. Arg89 may complement the function of Arg292.     

Kinematics of the pelvic girdle and the thoracic and lumbar segments in the course of the lateral inclinations and rotations of the spine

Physiological displacements of the trunk are the addition of these of the pelvic girdle and thoracic and lumbar spine segments. For a long time (3), this conjunction had been noticed but without numbered precisions. The purpose of this communication is to appreciate quantitatively, from a series of 16 subjects, the respective share of each components during lateral bending movements in the frontal plan and movements of rotation in the transverse plan. It results from this work that the pelvic girdle presents as reduced amplitude (4 degrees) in lateral bending on the other hand, displacement predominate to the level of thoracic spine (50 degrees). In rotation pelvic displacements are very important (30 degrees), while the spine so thoracic that lumbar has a weak participation (inferior to 5 degrees). Moderated abduction of hips increases by significant manner the motility of the pelvic girdle.     

Effects of thoracic vs. lumbar epidural anaesthesia on systemic haemodynamics and coronary circulation in sevoflurane anaesthetized dogs

BACKGROUND: Although many investigators reported changes in coronary circulation during thoracic epidural anaesthesia (TEA), no previous studies have attempted to compare it with lumbar epidural anaesthesia (LEA) concerning coronary circulation. Our aim was to compare effects of TEA on systemic haemodynamics and coronary circulation with those of LEA in anaesthetized dogs. METHODS: In dogs receiving 1.5% sevoflurane, 2% lidocaine (0.1 ml kg-1) was injected into the epidural space via an epidural catheter inserted at either the T7-T8 (TEA group, n = 8) or L5-L6 (LEA group, n = 8) interspace, and the same dose was repeated again 30 min later. RESULTS: Heart rate and maximum left ventricular dP/dt decreased in the TEA group but were unchanged in the LEA group. Decreases in mean arterial pressure were found for both groups, and they were more substantial in the TEA than in the LEA group. Decreases in left ventricular minute work index were found for both groups, and they tended to be more substantial in the TEA than in the LEA group. Coronary perfusion pressure and blood flow decreased in both groups. Calculated coronary vascular resistance increased in the TEA group but was unchanged in the LEA group. CONCLUSION: The most significant difference between TEA and LEA concerning coronary circulation was characterized by an increase in coronary vascular resistance in the TEA group, which was not present in the LEA group. The increase in coronary vascular resistance caused by TEA may be explained by a coronary vasoconstriction caused by a lower myocardial oxygen demand.     

Physical measurements of the lumbar spine

This article describes measurement of lumbar function. The simplest range of motion devices are compared with the progressive, more complex computerized devices for range and strength testing. The author presents his own opinion as to the place of these devices in both research and clinical practices. The economics of accurate physical testing is compared to the clinical realities of current payment systems.     

Anterior transpedicular fixation of the lower thoracic and lumbar spine. Experimental verification using a new direction finder

Currently, no anterior spinal implant provides a strong bone-screw interface because of the cancellous characteristics of the vertebral body. A more secure anchorage could be obtained by anterior transpedicular screw fixation. Four hundred transpedicular screws located between T7 and L5 were placed using the newly developed direction finder. Measurements were obtained directly from radiographs of the cadaveric specimens. In 10 cases (2.5%), the screws crossed the medial pedicle border, but never by more than 1.4 mm. A lateral protrusion was noted in another 41 screws (10%), with no protrusion greater than 2.2 mm. Encroachments beyond the superior or inferior border were not observed. The mean angle of the screws at each level measured between 7 and 19 in the transverse plane and between 2 and 4.5 in the sagittal plane. This technique should be reserved for vertebrae without significant arthritic changes. The rare screw with minimal infraction through the medial or lateral pedicle wall should not cause any vascular or neural compromise. The anterior transpedicular screw technique appeared relatively safe (88%) and encouraged the development of the new plate system for anterior spinal stabilization.     

Ultrasonography-guided identification of the lumbar epidural space

The study was designed to assess the reliability of sonographic evaluation in the prediction of the depth of the lumbar epidural space. Forty males, scheduled for epidural anesthesia for surgical repair of inguinal hernia, were prospectively studied. Patients were placed in a sitting position and sagittal scanning of the lumbar spine was performed with a 5-MHz transducer over the fourth or fifth interspace in order to identify the deeper hyperechogen interface, which represents the landmark between the ligamentum flavum and the epidural space. Ultrasound depth was measured and transducer removed. A Tuohy needle 18 G was then introduced percutaneously according to the standard technique and a rubber slide placed over it, so that it depth of insertion could be accurately measured. The potential for using ultrasounds for prediction of the distance from skin to epidural space was analyzed using a simple linear regression analysis; p values < 0.05 were considered significant. Mean values of ultrasound depth and needle depth were respectively 51 mm (SD 6.3) and 50.9 mm (SD 6.2); the correlation coefficient was 0.99. Ultrasound scanning of the lumbar spine provides an accurate measurement of the depth of the epidural space, which can facilitate the performance of the epidural anaesthesia and may decrease the complication rate, particularly in those patients in which anatomic landmarks are obscured.     

Methods of transfemoral lumbar epidural venography in the diagnosis of lumbar disc herniation

This article outlines several ways of achieving adequate visualization of the epidural venous plexus in the diagnosis of lumbar disc herniation. Preference is expressed for simultaneous injection of contrast medium via two catheters selecttively introduced into the lateral sacral segmental veins or into the left and right internal iliac veins. For visualization of the epidural veins, the investigator has a choice of over 20 different procedures. The position of choice of the catheter tip(s) can vary during the examination, dependent on diagnostic problems or technical catheterization problems. Epidural venography should be regarded as a very accurate, relatively simple method of demonstrating disc herniations in the lumbar region. This method is especially recommendable in cases that are clinically suspect but have a negative or dubious caudogram. The risk of complications is very small. It is also a good method for azygography. It is possible to perform the examination on outpatients.     

MR imaging of congenital anomalies of the thoracic veins

Congenital anomalies of the thoracic veins are infrequent but important developmental abnormalities. Thoracic venous anomalies can be classified as systemic or pulmonary. Systemic venous anomalies are often incidental findings, whereas pulmonary venous anomalies are more likely to manifest with cyanosis and to be associated with congenital cardiac abnormalities, especially atrial septal defect. Magnetic resonance (MR) imaging provides excellent delineation of the abnormal vessels and associated cardiac defects. Conventional spin-echo (SE) techniques show blood flow as a signal void and are sufficient for demonstrating the aberrant venous anatomy in most cases. Gradient-echo images show flowing blood as high signal intensity and are useful for clarifying the course of anomalous veins when vessel walls are difficult to visualize on SE images. Phase-contrast images are valuable for ascertaining the direction of blood flow and thus provide a physiologic method of distinguishing the vertical vein of anomalous pulmonary venous return from a left superior vena cava. MR imaging is useful for delineating both the thoracic venous and accompanying intracardiac anomalies and is a valuable, complementary technique to echocardiography, angiography, and computed tomography in the evaluation of patients with these abnormalities.