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ABSTRACT: Occipitocervical fixation and spondylodesis is indicated in various cases of occipitocervical instability. The aim of this retrospective study was to evaluate the results of occipitocervical fixation at our institutions.
Between 1997 and 2007, a total of 57 patients underwent occipitocervical fixation (OC) there were 25 men and 32 women, from four to 77 years of age, with an average of 58.7 years. The patients were allocated to two groups according to the method of OC fixation used: tying wires or cables (group 1) screw-rod or screw-plate systems (group 2). Indications for OC fixation included trauma in 15, rheumatoid arthritis (RA) in 28, destruction due to psoriasis in one, tumour in eight, and congenital anomalies of the cervico-cranial junction in five patients. In five patients with tumour, OC fixation was completed with a transoral or transmandibular procedure. The C0-T 1 or C0-T 2 segments were fixed in 22 patients, C0-C2 segments in 14, C0-C3 segments in six, C0-C4 segments in two, C0-C5 segments in eight and C0-C6 segments in five patients.
In atlanto-occipital dislocation, comminuted fractures of the ;atlas or similar injuries, C0-C1-C2 segments were fused in congenital anomaly, the C0-to-lower cervical spine was fixed, with C1 being avoided. The RA patients were treated by fixation of the C0 to T1 or T2 segments. The atlas was fixed by the screw method of Goel, the C2 joint by that of Judet, or stable fusion of the two vertebrae was carried out by the Magerl transarticular technique. For the middle and lower cervical spine, lateral mass screw fixation by the Magerl method was used, and from C7 caudally the vertebrae were fixed transpedicularly. Occasionally, in small children in particular, a Ransford frame fixed with wires or cables was used. In principle, an extent of fixation as small as possible was employed. The patients were evaluated at a final follow-up ranging between 12 and 132 months after the primary surgery (average, 42.7 months). Indications for surgery and the method and extent of instrumentation were recorded. The evaluation included pain and neurological deficit assessment, radiographic evidence of the stability of fixation and bone union and intra-operative and early and late post-operative complications.
Of the 57 patients, bone fusion was the objective of surgery in 52. Further five patients died of associated injuries or serious medical complications shortly after the operation. Of the remaining 47, bone union was achieved in 44 patients (93.6%). Pseudoarthrosis developed in three patients who, however, because of a higher age and minimal complaints did not require revision surgery. In terms of bone union, there was no difference between a short (C0-C2) and a long (C0-CX or C-T) fixation. No differences among fixation materials were found. The differences in percent bone union after spondylodesis between the tying-wire and screw-rod fixation systems were not statistically significant (p > 0.05). In the patients treated for RA, psoriasis or congenital anomaly, the Nurick scale score significantly improved at 2 years after surgery (p < 0.05). In comparison with the others, the RA patients had a significantly higher number of complications (p < 0.05). The patients treated for tumour showed a significant difference between the pre- and post-operative VAS values (p < 0.05).
Of the patients with RA, psoriasis or congenital anomaly, 57.6% showed post-operative improvement in the Nurick scale score by 1-2 but never more than by 2. A decrease in pain intensity and neurological findings was recorded in 88.2% of the patients. This is in agreement with the results published in the international literature. In the patients treated for trauma, a high proportion (53.3%) had neurological deficit, which is unusually high for craniocervical injuries. This can be explained by the fact that OC fixation is used only in the most serious injuries. Of five patients with neurological deficit of Frankel grade A or B, three died and two required mechanical ventilation. Less serious neurological findings of Frankel grade C or D in three patients improved to a normal condition.
Rigid OC fixation is a very effective method for the treatment of craniocervical junction instability. The currently used implants allow us to achieve high stability and efficiency of bone union. Regardless of the instrumentation used, fusion is achieved in more than 90%, and clinical improvement in more than 80% of the patients.
Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca 12/2009; 76(6):479-86. · 1.63 Impact Factor
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ABSTRACT: In this case study, three patients are presented who had incomplete cauda equina syndrome following elective lumbar spine surgery for degenerative disease. In all patients, the neurological symptoms developed due to post-operative arachnoiditis. Its aetiology, pathogenesis and diagnostics are discussed, as well as the methods of prevention and therapy which are still limited and often not beyond experimentation.
Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca 12/2009; 76(6):505-8. · 1.63 Impact Factor
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ABSTRACT: PURPOSE OF THE STUDY To evaluate retrospectively a group of patients with hyperextension injury to the cervical spine who were treated at the Department of Spinal Surgery of the University Hospital in Motol, Prague, between 2003 and 2006. MATERIAL The group comprised 22 patients, 17 men (77 %) and five women (23 %) in the age range of 35 to 81 years, with an average of 59.5 years. All patients had, in association with the injury, neurological deficit of varying degree. METHODS All patients underwent X-ray and magnetic resonance imaging examination and received methylprednisolone according to the National Acute Spinal Cord Injury Study (NASCIS) 2 trial. Eleven patients had urgent surgery within 24 hours of injury; eight patients were operated on within an interval of 3 days to 2 months because of the seriousness of their state and multiple morbidity; and three patients were treated conservatively. Neurological deficit in terms of upper- and lower-limb mobility was evaluated by the American Spinal Injury Association (ASIA) motor score. The values obtained for the urgently operated patients and for those operated on after a time interval were compared by Wilcoxons two-sample test. The other aspects evaluated included trauma aetiology, level of spinal cord injury, manner of treatment, and intra-operative and post-operative complications. RESULTS The most frequent cause of injury was a low-height fall (13 patients; 59 %); car accidents ranked second (9 patients; 41 %). In five patients (22.7 %) ebriety was found. Eighteen patients had no skeletal injury (81.8 %). Four patients (18.2 %). Four patients (18.2 %) suffered fractures of articular or spinous processes, but the anterior column skeleton was intact in all. The segment most frequently affected by myopathy was C3-C4, then C4-C5 and C5-C6. Decompression was carried out to the extent of myopathy; and in the adjacent segments only if significant stenosis was present. In both subgroups of surgically treated patients (urgent and delayed management), comparisons of the ASIA scores at the time of injury and at one-year follow-up showed no significat improvement in post-operative mobility, as evaluated by Wilcoxons two-sample test at a level of significance a = 5 %. No intra-operative or post-operative complications, except for early death, were recorded. In all patients the wound healed by first intention and no loosening of instrumentation was foud on follow-ups at the out-patient departments. DISCUSSION Although the greatest narrowing of the spinal canal due to spondylosis occurs at the C5-C6 segment, the C4-C5 segment sustained most injuries. Although some relevant papers report no significant difference in improved neurological deficit between patients treated surgically and those undergoing conservative therapy, we prefer surgical management, in most of the cases from the anterior approach, which allows us to remove dorsal osteophytes and perform careful decompression to prevent damage to nerve structures and to preserve those which are still intact. There was no significant difference in the outcome between urgent and delayed trauma management, which is unusual amongst other injuries associated with neurological lesions and this indicates that the timing of surgery must be strictly individual and should be carried out at a time when operative benefit outweighs operative burden. The surgical treatment used should, in the first place, lead to early recuperation and rehabilitation. CONCLUSIONS Hyperextension injuries of the cervical spine are usually associated with serious neurological deficit. A correct algorithm of examination will result in good treatment outcomes. However, these injuries require a therapy that is long-lasting and difficult, with a need for cooperation of anaesthesiologists, spinal surgeons, physical therapists and, last but not least, psychologists. Key words: cervical spine, hyperextension injury, spondylosis, myelopathy.
Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca 05/2009; 76(2):128-32. · 1.63 Impact Factor
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ABSTRACT: To present the results of an independent mono-centric prospective study on patients with a mobile ProDisc-C implant. This cervical artificial disc replacement (CADR), which is one of the options for avoiding cervical spine fusion, was evaluated during two-years follow-up.
A total of 61 patients underwent CADR with a ProDisc-C in one or two segments at the Department of Spinal Surgery of the University Hospital in Motol, Prague, in the period from October 2004 to May 2006. Of these, 39 were included in the study and followed up for 2 years at least. Except for one patient, one segment was replaced in all patients.
The surgical procedure recommended by the manufacturer (Synthes, USA) was used throughout the study. Clinical evaluation. Each patient was examined before and immediately after surgery, and followed up at 6 and 12 weeks, and 6, 12 and 24 months. At each follow-up the patient answered the questionnaire which included the Neck Disability Index (NDI) and Visual Analoque Scale (VAS) assessment for neck and radicular pain, analgesic use and the patient's satisfaction. Radiographic examination. Radiographs were taken in antero-posterior and lateral projection, and on bending films in flexion, extension and lateral flexion on both sides. The height of the intervertebral space of the involved segment and motion of the replaced and adjacent discs in flexion and extension were measured. The radiographs were examined for potential sinking, loosening, failure or migration of the implant. Statistical evaluation. The results were statistically analysed using Student's t-test.
Clinical outcome. The NDI evaluation showed that the mean value of the index improved from 44.9 pre-operatively to 26.1 and 25.9 at 1 and 2 years of follow-up, respectively, i.e. by 42.5 % in two years. The mean VAS score for neck pain changed from 5.8 pre-operatively to 3.0 and 2.7 at post-operative years 1 and 2, respectively, which is an improvement by 53.7 % in two years. The mean VAS score for radicular pain improved from 6.3 to 2.9 and 2.8 at the same intervals, which is an improvement by 53.9 % in two years. Radiographic findings. The mean height of the affected intervertebral space was 3.2 mm before and 7.4 mm after surgery and it did not change significantly thereafter. The mean range of motion at the involved segment was 4.1 degrees before and 11.1 degrees after surgery. Statistical evaluation. In assessment of both neck and radicular pain, the difference between the mean VAS score pre-operatively and that 6 weeks post-operatively was significant (t=4.4 and t=5.3, respectively; p<0.05). The difference in mean VAS scores between 6 weeks and 3 months post-operatively was not significant (t=1.69 and t=0.3, respectively; p>0.05). At the next follow-ups the mean VAS scores changed only minimally and the differences were not significant. The difference between the mean NDI before and that at 6 weeks after surgery was significant (t=11; p<0.05) and significant was also the difference between 6 weeks and 3 months after surgery (t=3.8; p<0.05). After that changes were minimal and were not significant.
Currently, mobile implants are in the focus of interest amongst spinal specialists, their materials and shapes, primary implant stability, the centre of rotation, indications for replacement and correct operative techniques being discussed. The situation appears similar to that of 20 years ago when large joint replacement was being introduced, and it is the future that will show the right development.
This two-year prospective study on patients with CADR shows very good and promising outcomes. It is evident that the implant increases the range of motion at the treated segment and reduces degenerative changes in the adjacent intervertebral spaces. On the other hand, CADR is associated with complications such as artificial disc kyphosis and heterotropic ossifications. An unequivocal requirement for a correct indication and a faultless operative technique was the conclusion drawn from a detailed analysis.
Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca 09/2008; 75(4):253-61. · 1.63 Impact Factor
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ABSTRACT: To evaluate a group of 11 patients with L5 burst fractures treated by L4-S1 posterior instrumented spinal fusion without reconstruction of the anterior column.
The group included seven men and four women aged between 14 and 66 years (average, 37.5 years), followed for 12 to 36 months (average, 18 months). Ten patients were treated by posterior instrumented spinal fusion at the L4-S1 level, and one with an associated injury to L3 underwent L2-L4-S1 posterior instrumented spinal fusion. The spinal column was inspected in eight patients in whom neurological symptoms or significant stenosis were present.
On admission, the evaluation of post-traumatic radiographs included measurements of the angle between the L4 lower and the S1 upper end-plates, the angle between the upper and lower end-plates of L5 and height of the anterior and posterior rims of the L5 vertebral body. CT scans were assessed for a relative narrowing of the spinal canal. The patient's neurological status was also evaluated. At 3, 6, 12, 24 and 36 months of follow-up, radiographs, neurological findings and subjective complaints were assessed.
On comparison of pre-operative values with those 3 months after surgery, the differences were on average 3.6 degrees for L4-S1 lordosis, 2.5 degrees for the angle between the upper and lower end-plates of L5, and 1 mm for the height of the anterior rim; there was no difference in posterior rim height. Eight patients had the same values at the latest as at 3- month follow-up. Three patients with broken screws showed the loss of L4-S1 lordosis by 4 to 13 degrees (average, 9 degrees). Neither the angle between the upper and lower end-plates of L5, nor vertebral body height were changed. The narrowing of the spinal canal by vertebral body fragments ranged from 0 to 60 % (average, 35 %) of canal space. On admission, neurological findings were normal in two patients and involved nerve root syndrome in five patients. In four patients it was not possible to assess their neurological status. At he latest follow-up, ten patients were free from peripheral neurological lesions, one still had lumbar radicular syndrome, two patients reported mild or moderate lumbosacral pain and seven patients were without complaints. Subjective complaints could not be assessed in two patients because of their mental state. An early post-operative complication included wound dehiscence in one patient (9 %) and, in three patients, broken screws in S1 were recorded as late complications.
Only a few references referring to a relatively low number of patients with L burst fractures treated by surgery were found in the literature. Most of the authors report limitations of reduction and good clinical outcomes. CONCLUSIONS The posterior instrumented spinal fusion of L5 alone is sufficient for the treatment of most L5 burst fractures. Early removal of the fixator is indicated in active patients. Often good clinical outcomes are in contradiction with radiological findings. The possibilities of spinal canal decompression by ligamentotaxis at this level of injury are limited. When significant spinal stenosis is present, laminectomy or hemilaminectomy is necessary to achieve decompression of the spinal canal.
Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca 05/2008; 75(2):123-8. · 1.63 Impact Factor
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ABSTRACT: Surgical treatment is preferred in our department in all patients with type II and type III dens fractures, regardless of their age, with the exception of non-displaced or completely reduced fractures in young patients. The aim of this study was to evaluate patients over 65 years of age treated by direct osteosynthesis of the dens or posterior atlanto-axial fixation and spondylodesis.
In the years 2001 to 2005, 28 patients aged 65 years and older were surgically treated for dens fracture. This included 13 men and 15 women between 65 and 90 years of age, with an average of 77.4 years. According to the treatment, i.e., direct dens osteosynthesis (1) or C1-C2 posterior fixation (2), two groups were evaluated, and two categories were considered by age, i.e., 65 to 74 years (8 patients) and 75 years and older (20 patients). In 23 patients, an isolated fracture of the dens was present and, in five patients, injury was part of a complex C1-C2 fracture. A Frankel grade D neurological deficit was found in three patients.
In all patients, surgical treatment by direct osteosynthesis of the dens from the anterior approach, using two cannulated screws, was preferred as the method of choice. However, in the case of distinct osteoporosis, fragmented fracture of the dens base or tear of the ligamentum transversum atlantis, we used the Harms method of posterior fusion with polyaxial screw fixation as the primary treatment, or the Magerl transarticular fixation completed with the Gallie technique from the dorsal approach. The patients were followed up at 3, 6 and 12 weeks, at 6 and 12 months, and then at one-year intervals. X-ray and clinical examinations were made at the regular follow-ups and functional radiographs were taken at 12 months following the surgery. The whole group was evaluated in the range of 18 to 84 months (average, 37.3 months). Neurological deficit was assessed on the basis of the Frankel classification. The results were analysed using the Chi-square test.
Of 20 patients still living at the time of this evaluation, 11 underwent direct osteosynthesis and nine were treated by posterior instrumented spondylodesis. In group 1, pseudoarthrosis of the dens or fibrous callus developed in one patient (9.1 %) and a line of fracture was evident in one patient of group 2 (11.1 %), which was not significant (p<0.05). However, a statistically significant difference in mortality was found when the two age categories were compared (p>0.05), with 0 % in the younger and 40 % in the older category. The overall mortality within 6 weeks of injury was 28.6 %. Mortality in group 1 and group 2 was 21.4 % and 35.7 %, respectively; this difference was not statistically significant (p<0.05).
We use conservative treatment only in the patients who are able to stand up and move soon after injury. If this is not feasible, we prefer surgical treatment with the same aim achieved as soon as possible without rigid external fixation. In this study, surgery was associated with an acceptable number of minor complications due to poor bone quality or health state of the patient. The higher mortality in the higher age category was obviously related to generally poorer health of these patients.
Surgical treatment can significantly improve the quality of life in elderly patients who have suffered a fracture of the dens. The surgical technique should be chosen to take bone quality, degenerative changes of the spine and overall health of the patient into consideration. Mortality after surgery is not related to the technique selected but to patient's age. Elderly patients with neurological deficit usually die due to co-morbidity, regardless of the therapy used.
Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca 04/2008; 75(2):99-105. · 1.63 Impact Factor
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ABSTRACT: Although great advances have been made in both radiological diagnosis and antibiotic therapy of microbial infections, the treatment of spinal infections remains a major clinical challenge. Many of the patients affected are referred to spinal units with long delays. The general population is ageing and the number of immunocompromised patients, as well as the number of operative procedures for spinal disorders are increasing. The aim of our study was to evaluate the clinical presentations of spinal infections, options for their diagnosis, indications for treatment and their risk factors and the results of surgery.
The group of 112 patients evaluated after the treatment of spinal infection comprised 63 men and 49 women at an average age of 59.4 years (range, 17 to 84). The average follow-up was 3.2 years (range, 6 months to 8 years). Of these, 82 patients had primary hematogenous infection, 29 had post-operative infection,and one had an infected gun shot wound. Thirty-six patients showed neurological deficit and six were paraplegic. The diagnostic methods included FBC, CRP and EST tests, examination of blood cultures, aspirates and biopsy samples from the infected site, bone scintigraphy, MRI and CT scanning. Indications for surgery included an infection not responding to conservative treatment,with existing or impending spinal instability, and with or without neurological deficit. The surgical management involved transpedicular drainage of the abscess, wound debridement from the posterior approach and instrumented spondylodesis. Surgery which included spinal decompression with radical excision of infected tissue was augmented with posterolateral instrumented fusion and/or anterior stabilization, as indicated.
Of the 112 patients treated, seven died of uncontrollable sepsis after surgery; the remaining 105 were followed up. Another four patients died of causes unrelated to the spinal problem treated within 12 months. All patients recovered except for two in whom the infection persisted, but 13 required more than one surgical procedure. One patient with CSF leakage failed to heal after five interventions. The most frequently isolated infectious agents were Staphylococus aureus, Staphylococus epidermidis and E. coli. Of the 33 patients with neurological deficit, 24 improved by one or two Frankel grades. The neurological status of six paraplegic patients did not improve, but their functional findings did after stabilization of the spine. Clinical evaluation showed 47 (44.7 %) very good, 40 (38 %) good, eight (7.6 %) unchanged and 10 (9.5 %) poor outcomes.
Early diagnosis is a prerequisite for good treatment outcomes. Clinical examination, results of laboratory tests, and scintigraphy and MRI findings play the key role. When progressing osteolysis is suspected, a CT scan is necessary. Debridement should be as radical as possible, but always in compliance with the patient's health state. At an advanced stage of disease, spinal stabilization is important because it allows us to remove infected tissue. Intravenous and then oral antibiotic therapy at 2 to 4 and 6 to 12 weeks of follow-up is mandatory. The management of spinal infections is a complex process requiring good multidisciplinary cooperation.
Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca 11/2007; 74(5):305-17. · 1.63 Impact Factor
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ABSTRACT: Cervical spine injuries in young adults are usually caused by high-energy trauma. However, a typical injury to the cervical spine can also occur in older patients, in whom it is often associated with the presence of osteoporosis and relatively low-energy trauma, similarly to distal radial or proximal femoral fractures, or fractures of the thoracolumbar spine. The aim of this study was to evaluate a group of elderly patients with cervical spine injuries treated at our department.
In the period from 2001 to 2005, 66 patients older than 65 years were treated for cervical spine injury at the Department of Spinal Surgery of the Motol University Hospital in Prague. Of these, the 53 patients treated surgically, and followed up longer than 6 months after surgery, were evaluated in detail in this retrospective study. They included 30 men and 23 women at an average age of 75.5 years (range, 65-92 years).
Conservative therapy was used to treat stable injuries to both the upper and the lower spine that were without risk of the development of secondary instability or deformity and that were not associated with neurological deficit. Surgery was performed in primary unstable injuries of the upper and lower spine or in injuries involving the risk of secondary instability or deformity, and also in all injuries associated with neurological deficit, when the patient's health state allowed for it. The final retrospective evaluation was made at 6 to 78 (average, 31.3) months after the primary operation. The evaluation included trauma etiology, type and level of injury, neurological findings, kind of treatment, complications and outcome.
In our group, 56 % of the patients were men, injury occurred due to a fall in 66 % and the upper cervical spine was affected in 60 % of the patients. Most of the upper cervical spine injuries happened to the patients over 75 years, and included fractures of the dens and complex atlantoaxial fractures. Neurological deficit was found in 37.7 % of the patients treated surgically, but only 7.5 % had a deficit classified as Frankel grade A or B. Of the 13 patients treated conservatively and the 53 patients treated surgically, two (15.4 %) and 15 (28.3 %) died, respectively.
The results of our study are in agreement with the relevant international literature data. Conservative treatment is used only in the patients in whom early mobilization, including standing and walking, is possible. In other patients, surgical treatment is preferred with the aim to achieve early mobilization without rigid external fixators, if possible. Surgery is carried out predominantly in patients with more serious injuries; therefore, mortality in our patients was nearly twice as high after surgery as after conservative treatment. Some surgical procedures were accompanied by minor complications usually associated with poor bone quality or poor health in general. Old patients with serious neurological deficit usually die of co-existent diseases regardless of the therapy used.
In patients older than 65 years, injuries to the upper cervical spine are usually caused by low-energy trauma. In this age category, neurological deficit is found more often than in younger patients and is typically manifested as a central cord syndrome.
Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca 07/2007; 74(3):189-94. · 1.63 Impact Factor
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ABSTRACT: According to the available sources, no case of total spondylectomy of C2 with preservation of roots, preservation of vertebral arteries and a short fixation without occipitocervical fusion has been so far described in the literature. We decided to perform a radical surgery in a man, now 27 y. o., with solitary metastasis of thyroid adenocarcinoma. In the first step, we applied the posterior surgical approach. The patient was placed prone on a standard operating table with a support of head fixed by adhesive plaster, with the upper cervical spine slightly bent forward. We made a mid-line incision, extending from the external occipital protuberance to the C7 spinous process, controlled bleeding and exposed the C0-C4 section. Subsequently, the entire posterior epistropheus was resected, including most of the pedicles and the entire articular processes for C2-C3 articulation. Both the C2 roots were preserved, however, we had to control quite a profuse bleeding from the venous plexus around the left root. During dissection, the dural sac was damaged in the region of the attachment of the left root, which was treated by suture and covered with Tissucol fibrin sealant. Screws 4.0 mm thick, were inserted into the lateral masses of the atlas after Harms and 4.0mm screws into the C3 and C4 articular processes. On both sides, the screws were connected with 3.2 mm rods, and a transverse stabilizer was then applied to fix the two sides together. Cancellous bone grafts were harvested from the iliac crest and a massive posterolateral and posterior fusion of C1-C4 was performed. The second operation was performed after 21 days. Transoral transmandible approach without tongue splitting was applied. The patient was placed supine on a standard operating table with a support of neck, the head was fixed by adhesive plaster and slightly bent back, and tracheostomy was inserted. An arched incision through the middle of the red lip was made, extending 2 cm straight caudally and arching across the chin and neck, in the midline. On the caudal end we made a transverse inverted T incision. Subsequently, we exposed and osteotomised the mandible using the midline Z-type incision. In order to identify the space between the anterior arch of C1 and the C4 vertebral body, the Synframe retractor was inserted with one blade opening the mouth by pressure on the upper teeth and two blades pressing the tongue caudally. Then an inverted U incision through the mucosa of pharynx was made to identify paravertebral muscles. Caspar retractor was used to separate the muscles and expose C1-C3 laterally, including transversal processes with vertebral arteries. No pathological changes were manifested on the skeleton. First we removed the middle portion of the C2 vertebral body where we did not find any tumour, only sclerotic remodelling. Subsequently, we reamed the lower middle portion of the anterior arch of C1, extracted the dens and cut off the alar ligaments and the apical ligament of dens. The entire dens was then removed. Then we continued on the right side, in the intact part and extracted part of C2 in the region of the atlantoaxial joint, including the rest of the pedicle, and the anterior portion of the transversal process up to the vertebral artery. The posterior part of the transversal process was carefully rotated around the artery and also removed. All parts were extremely hard, sclerotic. The same procedure was followed on the left side where we found a 7 x 10 mm gelatinous greyish tumour in the lateral part of C2 below the atlantoaxial joint. Other parts were again sclerotic. Liquorrhea appeared again from dissection around the C2 root on the left side, the source of which we could not clearly identify. We filled the site of the probable hole with Tissucol fibrin sealant. Between the notch in the lower part of the anterior arch of C1 and the upper end plate of the C3 vertebral body we seated a shaped SynMesh cage with sharp edges providing a very good fixation. No additional fixation was needed. Again we harvested cancellous bone grafts from the iliac crest and placed them on the sides of the cage and at the front between the anterior arch of the atlas and the C3 vertebral body. Subsequently, the muscles were approximated and the mucous tissue of the pharynx repaired. The mandible was fixed by two Miniplate System plates and supported by a dental plate. Total spondylectomy of C2 with preservation of vertebral arteries and roots stabilized only by a short fixation is an extreme surgical procedure suitable only for exceptional cases of young patients with a good bone quality. With regard to potential complications it is of vital importance to consider carefully such operation and consult the proposed therapy with the patient.
Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca 05/2007; 74(2):79-90. · 1.63 Impact Factor
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ABSTRACT: Spinal injuries in children are rare and account for a low proportion of all childhood injuries. Due to anatomical and biomechanical properties of the growing spine, there are great differences between spinal injury in childhood and adulthood. Because of higher mobility and elasticity of the spine and a lower body mass in children, spinal injuries are not frequent and represent only 2 to 5 % of all spinal injuries. In this retrospective study, the effectiveness of conservative and surgical treatment of injured spines in children is evaluated in a 10-year period.
All patients from birth to the completed 18th year of age treated in our departments between 1996 and 2005 were included in this study. The patients, evaluated in three age categories (0-9, 10-14, 15-18), were allocated to two groups according to the method of treatment used (conservative or surgical). The information on patients treated conservatively was drawn from medical records; the surgically treated patients were invited for a check-up.
We used conservative treatment in patients with stable spinal injury who had no neurological deficit and in patients with neurological deficit but without apparent injury to the skeleton. Surgery was indicated in patients with unstable spinal injury and in those with neurological deficit and apparent injury to the skeletal structures. Injuries to the cervical spine were treated conservatively using a Philadelphia collar or a halo-vest in more serious cases. For treatment of injury to the thoracolumbar spine, the Magnuson method was preferred, together with rest in bed until subsidence of acute pain, followed by application of a vest and active rehabilitation to strengthen postural muscles. When surgery was used, the procedure was selected on a strictly individual basis in patients under 12; in older patients it was carried out according to the adult treatment protocol.
During 1996 through 2005, we treated a total of 15 646 patients with injury to the skeleton, aged 0 to 18 years. The spine was affected in 571 cases, which is 3.6 %. We used conservative treatment in 528 (92.5 %) and surgery in 43 (7.5 %) children. The period between surgery and evaluation ranged from 6 to 120 months (average, 46.3 months) in the patients treated conservatively, and from 6 to 66 months (average, 27 months) in the surgically treated patients. The group of patients treated conservatively consisted of 292 boys (55. 3 %) and 236 girls (44.7 %); of these 219 (41.5 %) were in the 0-9 year category, 251 (47.5 %) were between 10 and 14 years and 58 (11 %) were 15 to 18 years old. The average age in this group was 10.2 years. The most frequent cause of injury was a fall (277; 52.2 %), then sports activity or games (86; 16.3 %), car accidents (34; 6.4 %) and diving accidents (30; 5.7 %). Pedestrians were injured on 25 occasions (4.7 %) and other causes of injury were recorded in 76 patients (14.4 %). In all age categories, injury to the thoracic spine was most frequent (340; 64.4 %). Three and more vertebrae were injured (multi-segment injury) in 124 patients (23.5 %). The thoracolumbar spine was affected in 22 patients (4.2 %), and lumbar vertebrae were injured in 28 patients (5.3 %). Injury to the cervical spine, both upper and lower, was least frequent, including four (0.8 %) and 10 (1.9 %) patients, respectively. None of the patients in this group showed neurological deficit. The surgically treated group included 29 (67.4 %) boys and 14 (32.6 %) girls; two (4.7 %) children were between 0 and 9 years, nine (20.9 %) between 10 and 14 years, and 32 (74.7 %) between 15 and 18 years, with an average of 15.1 years for the whole group. The frequent causes of injury were car accidents and falls in 21 (48.8 %) and 14 (32.6 %) children, respectively. Other causes were infrequent. The upper cervical spine was operated on in five (11.6 %), lower cervical spine in eight (18.6 %), thoracic spine in 13 (30.2 %), thoracolumbar spine in five (11.6 %) and lumbar vertebrae in 12 (27.9 %) patients. Thirty-six (83.7 %) patients had fractures, five had dislocated fractures (11.6 %) and two (4.7 %) had a dislocation. Of the 43 children in this group, neurological deficit was recorded in nine (20.9 %); this included a complete spinal cord lesion, an incomplete spinal cord lesion and a nerve root lesion in three, five and one patient, respectively.
The results of this study confirm, in the majority of aspects, the conclusions of previously published papers. In some of the characteristics described above, however, our results are different, which can be explained by some specific features of care for injured children in the Czech Republic.
Childhood spinal injuries account for only 2 to 5 % of all spinal injuries and for 3.6 % of all skeletal injuries in children. Particularly at the age of 11 to 12 years, they differ significantly from spinal injuries in adults and therefore require different therapeutic approaches. The cervical spine is affected most often in younger children, while the thoracolumbar spine in older children. Multi-segment injuries are typical in the childhood spine, particularly in smaller children. Typically, children show SCIWORA and a more rapid improvement of neurological deficit than adults. Conservative treatment is preferred; surgery before 12 years of age is strictly individual, while after 12 years therapy is similar to that used in adults.
Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca 11/2006; 73(5):313-20. · 1.63 Impact Factor
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ABSTRACT: The patient, a 52-year-old male foreign citizen working as a construction worker, was attacked by his coworker who had fired a drive stud, 70 mm long, with reverse hooks from a powered gun at him; the stud pierced the worker's spine at the scapular level. The patient was taken to the nearest surgical ward. On the basis of clinical presentation and X-ray of the thoracic spine, the diagnosis of penetrating injury to the spinal column at the 7th thoracic vertebra level was made. Subsequently, the patient was admitted to the intensive care unit of our department. On admission the patients showed slight paresis of the right lower extremity and hypesthesia of the right thigh, but no other neurological deficit. After preoperative examination, the patient was operated on within six hours of the injury. Intraoperatively, a 3-mm-thick stud, piercing the T7 vertebral arch, was found on the left side, lateral to the T7 spinous process. After partial resection of the arch around the stud, the spinal canal was inspected. The stud passed paramedially on the right side through the dura mater and the centre of the spinal cord into the body of the 7th thoracic vertebra. The stud was gently removed. Subsequently, some sanguineous liquor appeared. The dura mater was sutured and the wound was closed layer by layer. The postoperative period was uneventful, and the patient was allowed to stand up on day 2. The drain was removed on day 4. Healing by first intention took place. At 6 weeks after surgery slight neurological deficit still remained. Key words: spinal penetrating injury, spinal gunshot injury.
Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca 11/2006; 73(5):353-5. · 1.63 Impact Factor
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ABSTRACT: The anterior approach to the thoracic and lumbar spine is used with increasing frequency for various indications. With the advent of prosthetic intervertebral disc replacement, its use has become even more frequent and has often been associated with serious complications. The aim of this study was to evaluate vascular complications in patients who underwent anterior spinal surgery of the thoracic and lumbar spine.
We performed a total of 531 operations of the thoracolumbar spine from the anterior approach. In 12 cases, after exposure of the body of the first or second thoracic vertebrae, we employed the Smith-Robinson technique to expose the cervical spine. We used sternotomy in six, posterolateral thoracotomy in 209, the pararectal retroperitoneal approach in 239, anterolateral lumbotomy in 58 and the transperitoneal approach in seven patients. The aim of surgery was somatectomy in 190 patients and discectomy in 341 patients. Sternotomy and transperitoneal approaches were carried out by a thoracic or vascular surgeon and all the other procedures were done by the first author. The indications for spinal surgery included an accident in 171, tumor in 56, spondylodiscitis in 43 and a degenerative disease in 261 patients.
All patients indicated for anterior spinal surgery were examined by conventional radiography in two projections, and this was completed by CT sagittal and frontal reconstructions of the affected region. Most patients also underwent MR imaging. The Smith-Robinson approach was used for exposure of T1 or T2. Sternotomy was indicated for treatment of T2-T4 and also T1 in the patients with a short, thick neck. Access to T3-L1 was gained by posterolateral thoracotomy, in most cases performed as a minimally invasive transpleural procedure. For access to the lumbar spine we usually used the retropleural approach from a pararectal incision or lumbotomy. We preferred the pararectal retroperitoneal approach in L2-S1 degenerative disease, L5 fractures, and L5-S1 spondylodiscitis. We carried out lumbotomy in patients with trauma, tumors and L1-L4 spondylodiscitis. The transperitoneal approach from lower middle laparotomy was used only in tumors at L5 or L4. For treatment of trauma and degenerative disease of the lumbar spine we preferred less invasive procedures, and for tumors and spondylodiscitis we used more extensive exposure because of the difficult terrain. The patients were followed up for 2 to 96 months (average, 31.4 months) after anterior spinal surgery.
In 12 patients treated by the Smith-Robinson procedure and in six patients undergoing sternotomy, neither early nor late signs of any injury to major blood vessels or internal organs were recorded. The 209 patients with posterolateral thoracotomy were also free from any signs of vascular injury, but trauma to the thoracic duct was recorded in one case. We found injury to major blood vessels in three patients in the group treated by the pararectal retroperitoneal procedure. In the total of 531 anterior spinal surgery procedures this accounts for 0.56 %; of the 304 lumbar operations and 239 pararectal retroperitoneal operations it is 0.99 % and 1.26 %, respectively. In one patient the vascular injury was associated with trauma to the ureter.
In our group of 531 patients we found a higher risk of vascular injury when the L4-L5 segment was treated, when less invasive surgery was used or when spinal anatomy was altered due to tumor or spondylodiscitis. All the complications were recorded in the first 250 patients. It should be emphasized that, because in five patients, the planned anterior spondylodesis would have been associated with high risk due to altered anatomy of the bifurcation of the aorta, these patients were treated by dorsal instrumented spondylodesis. We also avoided the anterior approach for revision spinal surgery and used the posterior approach instead. Vascular complications were treated in cooperation with a vascular or cardiac surgeon. In the most serious case, if a sophisticated cardiosurgical technique had not been immediately available, the patient would probably have died.
The technique of anterior approach is safe only in the hands of experienced spinal surgeons with long experience. In institutions where anterior spinal surgery is not a routine method it is advisable to involve a vascular or cardiac surgeon. However, the most important point is to know when not to operate.
Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca 05/2006; 73(2):92-8. · 1.63 Impact Factor
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ABSTRACT: Unilateral dislocation is a trauma typical of the cervical spine. Case reports on unilateral dislocation of the thoracic or lumbar vertebrae can be found in the relevant literature only rarely and they often describe this condition associated with multiple trauma or combined injuries. Although unilateral dislocation is an unstable injury with rotation involved, injury to the spinal cord or spinal nerve roots is not common. Diagnosis is based on radiographic and CT examination. Therapy includes open reduction and instrumented spondylodesis of the injured segment. The cases of two patients with unilateral dislocations in the thoracic and the lumbar spine, respectively, treated at the Department of Spinal Surgery, Motol Teaching Hospital in Prague, are reported here.
Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca 02/2005; 72(5):317-21. · 1.63 Impact Factor
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ABSTRACT: The complex anatomy of the cervicothoracic junction region makes a reliable assessment of plain radiographs in lateral projection difficult or even impossible, which may result in failure to detect fracture or other pathology in this region of the spine. The aim of this study was to evaluate the patients with spinal disorders in the region of the seventh cervical to the third thoracic vertebrae treated at our department.
During the period from November 2001 to June 2004, 34 patients with disorders of the C7-T3 region were treated surgically at the Department of Spinal Surgery, Motol Teaching Hospital, which accounted for 2.1% of the 1537 patients treated for spinal diseases in this period. Instability of the cervicothoracic junction was caused by tumors in 15 and by injury in 14 patients. Other diagnoses included deformity associated with rheumatoid arthritis (RA) in two patients, spondylodiscitis in one, and hemivertebral deformity at C7 and T1, each in one patient. The group included 16 women and 18 men between 8 and 75 years, with the mean of 52.3 years (after excluding the two children with hemivertebral deformity aged 8 and 9 years, respectively). The trauma subgroup had a significantly lower mean age (43.6 years) than the tumor subgroup (59.9 years).
We placed the patients in three groups according to the etiology of cervicothoracic junction disorder, namely, 1. tumors and spondylodiscitis; 2. injuries; 3. others. Group 1 included 16 patients, 15 with tumors and one with spondylodiscitis. Two patients were treated by dorsal stabilization, one by ventral stabilization and the rest underwent combined surgery. Of 14 patients in group 2, three were treated from the posterior approach, six from the anterior approach and five by the combined approach. All group 3 patients underwent surgery from the posterior approach, with two patients being treated without instrumentation.
Of the 34 patients, only 33 were included; one was lost to follow-up soon after the operation. In group 1, no excellent, five very good, five satisfactory and two unsatisfactory outcomes were recorded. No intraoperative complications such as injury to the major vessels or nerve structures occurred; in one patient, profuse bleeding from arteries supplying a metastatic tumor had to be arrested. Late complications included loosening of the dorsal instrumentation in two patients, who required repeat operations. In group 2, there were six excellent, four good, two satisfactory and one poor outcomes. Late complications in one patient included loosening of the ventral instrumentation, followed by repeat surgery. Group 3 showed two excellent and two satisfactory outcomes; the latter were in the RA patients. Late complications involved one loosening of the dorsal instrumentation requiring repeat surgery. No injury to the major vessels or nerve structures was recorded in either group 2 or group 3. No deep infection was recorded in any of the three groups.
The results of our evaluation are in agreement with those of other authors and, similarly to them, we had to deal with the difficult issues of diagnosis. Currently, we prefer, in addition to conventional X-ray examination, CT scans including sagittal and frontal reconstruction, recently completed with magnetic resonance imaging, in all patients with cervicothoracic junction disorders. This policy allows us to avoid delays in making correct diagnosis and to provide conditions for effective treatment. In stabilization from the posterior approach we use rod-screw fixation that, in the majority of cases, is not combined with thoracic fixation. Previously, we have inserted screws in the articular processes at the C7 level, but now we prefer transpedicular fixation. Complicated anterior surgical procedures, such as complete or partial sternotomy, are always performed with the assistance of a thoracic surgeon. A noticeably high number of patients with neurological deficit was seen also in our group. Postoperative care is always provided in cooperation with the spinal unit of our hospital. Intensive inter-disciplinary cooperation has an important role in that our patients have a minimum of complications in comparison with the literature data.
Injuries and diseases of the spine at the cervicothoracic junction present a complex issue with a high potential for mistakes and complications. The principle of success lies in a high-quality X-ray examination, CT scans with sagittal and frontal reconstruction, and magnetic resonance imaging of the region affected. The complex anatomy of that region requires demanding surgical procedures, which can be performed only by a highly qualified and specialized team with appropriate facilities.
Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca 02/2005; 72(4):213-20. · 1.63 Impact Factor
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ABSTRACT: Purulent arthritis of the facet joint is a rare affection. It occurs most commonly by hematogenous spread of microorganisms and the initiating agent is in most cases Staphylococcus aureus. Diagnosis is made predominantly by means of MRI and hemocultures, or culture of pus aspirated from the abscess with a needle. Conservative therapy consists in a long-term administration of antibiotics. In case of insufficient response to the treatment or development of a neurological deficit, the patient is indicated for surgical revision, drainage and, if necessary, for decompression of nerve structures. In addition to sepsis, a severe complication of the purulent arthritis of the facet joint is propagation of the abscess epidurally, intradurally or foraminally with the risk of the onset of neurological deficit. In their case series the authors present four cases of purulent arthritis of the facet joint diagnosed and treated at the Department of Spinal Surgery of the University Hospital in Motol, Prague.
Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca 02/2005; 72(6):387-9. · 1.63 Impact Factor
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ABSTRACT: Combined fractures of the atlas and epistropheus account for 3 % of all acute injuries to the cervical spine. In relation to all C1 and C2 injuries this is 43 % and 16 %, respectively. The aim of this study is to evaluate a group of patients with combined C1-C2 fractures and to suggest an effective therapeutic procedure.
In the years 1996 to 2003, a total of 16 patients with trauma to the atlantoaxial complex were treated at the Orthopedic Department of the Third Faculty of Medicine, Charles University, Prague (1996-2001) and the Department of Spinal Surgery of the University Hospital in Motol, Prague (2001-2003). These injuries included a combined fracture of the dens (Anderson and D'Alonzo type II) and of the atlas posterior arch in six patients, a type II dens fracture combined with Jefferson fracture in two patients, a type III fracture of the dens with a lateral mass fracture in two patients, hangman's fracture with posterior arch fracture in three patients, a type II fracture of the dens with anterior arch fracture in one patient, a fracture of the C2 body with Jefferson fracture in one patient and a fracture of the C2 body with fracture of the lateral mass in one patient. Two patients were treated conservatively and 14 underwent surgery. On admission neurological deficit was found in five patients.
Fourteen patients were operated on. Direct osteosynthesis of the dens, with motion in the atlantoaxial complex preserved, was performed in five patients. Seven patients underwent C1-C2 fixation that, in one, involved the C1-C3 segments; five patients were treated by Harms fixation with polyaxial screws from the posterior approach, two by the Magerl or Gallie techniques and one patient required occipito-cervical fixation of C0-C2. The patient with a hangman's fracture combined with fracture of the atlas posterior arch was treated by discectomy of C2-C3, tricortical graft from the iliac crest and plate application. The patients used Philadelphia collars for 6 to 12 weeks according to the type of injury and their bone quality.
Three patients (two undergoing direct osteosynthesis of the dens and one with occipito-cervical fixation) reported intermittent upper neck pain that required taking analgesics. The patient treated by occipito-cervical fixation repeatedly complained of restriction of rotational head movement by about 50 %. Radiograms of the cervical spine in both flexion and extension taken at 12- to 14-week follow-up all showed stable C0-C1 and C1-C2 segments. In the five patients undergoing direct osteosynthesis of the dens, complete bony union was found on X-ray and CT examination by 6 to 24 weeks postoperatively. Similarly, full instrumented fusion was achieved by 12 to 24 weeks postoperatively in the seven patients treated by dorsal fixation. The patient with anterior C2-C3 fixation showed, on X-ray images, a completely remodeled segment at 24 weeks after surgery. There was one intraoperative complication involving management of profuse bleeding from the venous plexus along the greater occipital nerve. No other complications related to the surgical procedure were recorded and no injury to the spinal cord, nerve roots or the vertebral artery was observed. None of the patients experienced any deterioration of neurological findings during the early postoperative period. One patient had to undergo resuturing of the operative wound from the posterior approach, because of subcutaneous necrosis that had failed to heal. No instrumentation failure or infection, regarded as late complications, were recorded.
At our Department we prefer early operative treatment involving spondylodesis in the shortest segment possible, with special emphasis on preserving rotational C1-C2 movement. Therefore, in some cases, we use only temporary stabilization with removal of instrumentation after 3 to 4 months. In this group the most frequent fractures were those combined with type II fractures of the dens. In such cases we always prefer direct osteosynthesis of the dens or, if this is not possible, the Harms technique of C1-C2 fixation, possibly only temporary. We believe, in agreement with Guilot and Fesser, that a potential failure of conservative therapy may result in a longer convalescent period and that patients should always be informed about these issues. In contrast to Guilot and Fesser we treat combined hangman's fractures from the anterior approach, by discectomy, tricortical graft and plate application.
Combined atlantoaxial fractures are serious, life-threatening injuries which, because of their diversity, require an individual approach to each patient. Early surgery is recommended with increasing frequency, particularly in the cases with persisting dislocation or instability. At the same time it is necessary to ensure that motion restriction of the cervical spine be minimal.
Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca 02/2005; 72(2):105-10. · 1.63 Impact Factor
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ABSTRACT: The Harms technique of stabilizing C1-C2 by fixation with polyaxial screws and rods is a further option for atlantoaxial fixation from the dorsal approach. Harms and Melcher published this method in 2001, but the operation had first been performed by Harms in August 1997. The aim of this study is to evaluate the first results and try to assign the Harms C1-C2 fixation an appropriate standing in the in broad range of options for stabilization of the atlantoaxial complex.
Between December 2002 and January 2004 we carried out the Harms fixation of C1-C2 on 22 patients admitted to the Department of Spine Surgery, Motol University Hospital, 2nd Medical Faculty in Prague. Out of these, 18 patients were included in this study, 10 men and 8 women between 23 and 84 years of age (average, 55.4 years) followed-up longer than 6 months. In 14 patients we used the Harms technique as a permanent fixation of C1-C2 in order to achieve atlantoaxial arthrodesis and, in four patients, we applied it only for a period of 4 to 6 months without the use of bone grafts or their substitutions. We employed the permanent fixation to treat the following conditions: fracture of the atlas in three patients, type IIA comminuted fracture of the dens base in three patients, fracture of C2 categorized as "other" in two patients, atlantoaxial vertical instability in one patient with rheumatoid arthritis, malunion of the fractured dens in one patient, and complicated trauma to C1-C2 in four patients. The temporary fixation was used for type III displaced fractures of the dens in two and fixed atlantoaxial rotatory dislocations also in two cases. Only one patient showed signs of Frankel C neurological deficit on admission, the rest were without neurological findings.
All screws were inserted under an image intensifier always in lateral projection. First we retracted the greater occipital nerve in a caudal direction towards C2 with a fine raspatory and, using an awl, marked the entry point in the C1 lateral mass; a pilot hole, reaching through the anterior cortical bone, was made with a 2.5 mm drill. It followed a straight or slightly convergent trajectory in an anterior-posterior direction and parallel to the plane of the C1 posterior arch in the sagittal direction. Individual anatomical variations in the atlantoaxial complex of every patient were respected. The hole was tapped through the entire vertebral body, with the exception of osteoporous bone in which only the posterior cortical bone was treated with a screw tap. At this stage profuse bleeding usually arose from dissection around the epidural venous plexus along the C1-C2 joint. This was effectively controlled by a quick insertion of a screw and compression of the venous plexus with the screw head. To control bleeding by bipolar electrocautery is difficult and is always associated with a risk of nerve injury. Screws 3.5 mm thick, with polyaxial heads, were inserted bicortically into the lateral mass of C1. Subsequently, the intervertebral C2-C3 joint was localized and its medial border in the spinal canal was palpated. The entry point for placement of a C2 pedicle screw was marked with an awl at the point of intersection at a distance of 2 mm from the medial border and 5 mm from the caudal border of the C2 articular process. Under an X-ray intensifier in lateral projection, a hole was drilled approximately parallel to the screws inserted in C1, i. e., at an angle of 20 to 30 degrees cranially, up to and through the anterior cortical bone. In the transversal plane, the screws were situated in a convergent direction at an angle of 20 to 25 degrees. After all screws had been inserted, we reduced the antlantoaxial complex in the correct anatomical position by manipulating the patient's head or by directly adjusting the screws. Connecting 3.0-mm rods were then applied and fastened by cap nuts or inner nuts according to the instrumentation used.
Operative time ranged from 35 to 155 min, with an average of 81 min. Intra-operative blood loss ranged from 50 to 1500 ml, with an average of 560 ml. The X-ray intensifier was used for a period of 0.4 to 2.6 min, with an average of 0.9 min. A total of 36 screws were inserted in the atlas; their length ranged from 16 to 34 mm (average, 30.6 mm). All screws were positioned correctly in the C1 lateral mass; two screws did not reach up to the anterior cortical bone and one protruded over it, but without causing clinical problems. Thirty-six screws were inserted in the axis. Their length ranged from 28 to 36 mm (average, 31.7) mm). Twenty-seven screws were correctly applied through the isthmus into the C2 anterior cortical bone, three were too short to reach it and five were placed too close to the vertebral artery canal. Of these, two protruded into the artery canal, but without clinical consequences. One screw inserted too medially passed into the spinal canal, but this also was without clinical response. Of the 36 screws inserted in C2, three (8.3 %) were malpositioned. Bony fusion at C1-C2 was the goal of this operation in 14 patients. At 6 weeks post-operatively, it was achieved in two patients, at 12 weeks in 12 patients and at 6 months in all 14 patients. The C1-C2 segment was stable at 12 weeks in all 18 treated patients. Four patients reported restriction of motion in rotation by 10 to 25 % after removal of the instrumentation.
Operative time, longer at the beginning than with the Magerl technique, gradually shortened to between 45 and 60 min. Similar trends were seen when intra-operative blood loss and X-ray exposure were evaluated. Using the Harms and Melcher procedure we saved the greater suboccipital nerve. In contrast to these authors, however, we did not resect the atlantoaxial joint. Solid fusion was achieved in all our patients. Of the total of 72 screws inserted, only three (4.2 %) were assessed as malpositioned; however, when related to the 36 screws inserted in C2, this was 8.3 %, which indicates that insertion of screws in C2 was more difficult. We did not observe any clinical consequences in any of these cases.
The Harms fixation of C1-C2 is a very effective technique for stabilizing the atlantoaxial complex. It enables us to provide temporary fixation without damage to atlantoaxial joints and to reduce the vertebrae after the screws and rods had been inserted, which is unique. These advantages compensate for a higher cost of the implant.
Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca 02/2005; 72(1):22-7. · 1.63 Impact Factor
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ABSTRACT: In contrast to the thoracolumbal spine, the cervical spine bears a lower biomechanical load and, therefore, anterior stabilization of a fracture is a definitive procedure in the majority of cases. What remains the matter of choice is screw fixation in the body of the vertebra involved. This may be either monocortical or bicortical. In this study, we evaluate a group of patients in whom fractures of the lower cervical spine were treated using the CSLP monocortical system (Synthes).
We included 68 patients in whom complete radiographic data were available and the surgery was performed more than 6 months earlier. This group comprised 49 men and 19 women with the mean age of 37.6 years and range of 12 to 79 years. In the first stage, all patients were operated on from the anterior approach. In 11 (16.2%) patients with type B or C injury, according to the AO classification, the procedure was completed by dorsal stabilization. The definite indication for surgery was any involvement of nerve structures or open fractures; kyphosis greater than 15 degrees, reduction by more that 50% of the proximal edge of the vertebral body, narrowing of the spinal canal by more than 50%, multiple wedge fractures and disc and ligament injuries associated with instability were considered conditional indications.
Any locked dislocation was reduced manually under X-ray guidance in the shortest possible time. Subluxations or fractures of the vertebral body were reduced by positioning the patient's body on the operating table. The standard procedure for subluxation management was distraction of the segment by applying a Caspar's distractor and subsequent microscopic discectomy up to the posterior longitudinal ligament. A tricortical bone graft was collected from the iliac crest. After its implantation, the distractor was released and the segment was fixed by a CSLP system (Synthes) with monocortical screws 14 mm long, usually used in a 2 + 2 configuration. In locked dislocation, in addition, the discission of the posterior longitudinal ligament and inspection of the dural sac were performed, and completed by dorsal stabilization with hook plates or a Cervifix fixator (Synthes) in one procedure under anesthesia. When the body of the vertebra was fractured, either partial or subtotal excision of it was carried out according to the type of fracture or when displaced fragments protruded into the spinal canal. A tricortical graft taken from the iliac crest was larger than in the treatment of subluxation but a plate was applied as in monosegmental fixation. In addition, the graft was fixed with special screws that had a porous surface and holes in the shank. Dorsal stabilization with hook plates or a Cervifix fixator was used for severe instability in type B or C injury.
The normal range of cervical spine motion (flexion, extension, inclination, rotation) was found in 44 patients. Slightly limited movement (75% to 90% normal motion) was in 17 patients and seven were affected more seriously (50% to 75% normal motion). Of the 19 patients with neurological deficit, 13 showed improvement by 1, 2 or 3 grades of Frankel's classification in seven, four and two patients, respectively. The first signs of bone remodeling between the graft and covering plate, usually at the distal graft border, were found in 16 patients at 6 weeks and in the remaining 52 patients at 12 weeks. By 6 months postoperatively, all patients showed complete healing and incorporation of the tricortical graft. The cranial screws broke in one case (1.5%) but this had no effect on the treatment outcome. No complication related to the surgical procedure occurred intraoperatively.
The very good results achieved with the use of the CSLP monocortical system in this study (98.5% fusion without broken screws or plates) are in agreement with relevant data reported in the Czech and foreign literature. The principal condition is a careful preparation of both the endplates of vertebral bodies and the graft. After insertion, this should stay in place without any tendency to extrude. If the graft is too long, it imposes an increased load on plates or screws that consequently act ventrally.
Our experience and literature data suggest that the CSLP monocortical system is fully capable to stabilize the lower cervical spine after injury, supposing all procedures described above are completed. In more serious trauma and type B or C instability, the additional dorsal instrumented fusion is indicated.
Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca 01/2003; 70(4):226-32. · 1.63 Impact Factor
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ABSTRACT: The primary reduction and stabilization of all types of injury to the thoracolumbar spine is currently performed from the posterior approach by an internal, transpedicular fixator. The exceptions are type A fractures, according to the AO classification, that can primarily be treated from the anterior approach. The aim of the study was to assess the effect of BAS-O bioceramic granules, inserted by transpedicular approach, on the development of post-operative kyphosis of the segments injured.
Between 1997 and 2001 we treated anterior spinal column fractures, using bioceramic granules in combination with an internal fixator, in 53 patients (40 men, 13 women: age 26 to 69 years; average, 42.3 years) at the Department of Orthopedics and Traumatology of the Third Faculty of Medicine and FNKV in Prague. However, only 42 patients (33 men, 9 women; age 28 to 67 years; average, 41.6 years) who had had the metal fixator removed more than six months previously were included in the study. The fixator was removed in the range of 10 to 24 months after the primary operation. The sample was divided into two groups; one with bioceramic material inserted in the body of the damaged vertebra (20 patients) and the other bioceramic granules implanted in both the vertebral body and the intervertebral space (22 patients).
In all the patients, the standard procedure included transpedicular application of Schanz's screws and an USS FS fixator (Synthes). If necessary, distraction of the segment injured and the correction of lordosis were carried out. Further transpedicular procedures to treat the anterior spinal column were as follows: If the vertebral body was injured without destruction to the intervertebral disc, a bent elevator was inserted through the vertebral foramen and the intervertebral joints were reduced. At the same time, a cavity for application of bioceramic granules was created. These were inserted, using a funnel and a pusher, in the anterior part of the injured body. If the fracture involved a destroyed intervertebral disc, the disc was removed, the vertebral end plate of the adjacent vertebra was perforated and bioceramic granules were inserted in both the vertebral body and intervertebral space. Subsequently, spongeous bone grafts were harvested from the ilium and massively applied to the previously decorticated transverse and articular processes.
In the group of patients who had bioceramic granules inserted in only the vertebral body, the kyphotic angle was on average 10.36 degrees after injury and 2.86 degrees after surgery; therefore, a correction by 13.22 degrees was achieved. At 3 and 6 months after surgery, the kyphotic angle was 2.71 degrees and 2.68 degrees, respectively; at 3 and 6 months after fixator removal, it was 0.67 degree in both instances. In the group of patients with bioceramic granules implanted in both the vertebral body and intervertebral space, the kyphotic angle was on average 9.16 degrees after injury and 4.26 degrees after, surgery; therefore, a correction by 13.43 degrees was achieved. At 3 and 6 months after surgery, the kyphotic angle was -4.11 degrees and -4.00 degrees, respectively; at 3 and 6 months after fixator removal, it was 2.38 degrees and 2.44 degrees, respectively.
Our results revealed differences between the patients who had bioceramic granules inserted in only the vertebral body and those who had them also in the intervertebral space. At 6 months after surgery, the first group showed the loss of correction per two segments to be 3.53 degrees on the average, whereas the second group had a loss of 6.70 degrees, i.e., twice as high. This may be explained by a more serious damage to the intervertebral disc in the latter group. Only small differences between the groups were found in the kyphotic angle at both 6 months after surgery and 3 to 6 months after fixator removal. This implied that, in both groups, the loss of correction occurred in the period up to 3 months after removal of the fixator.
Bioceramic granules provide material for replacement of osseous tissue in the body of the vertebra as well as conditions necessary for bone restructuring. The loss of correction per segment is lower by about half in patients treated with bioceramic granules than in those who received a spongeous bone grafts.
Acta chirurgiae orthopaedicae et traumatologiae Cechoslovaca 02/2002; 69(5):288-94. · 1.63 Impact Factor
