Andreas Baikousis

Reciprocal Angulation of Vertebral Bodies in the Sagittal Plane in an Asymptomatic Greek Population

Study Design. A prospective study conducted on several roentgenographic parameters of the standing sagittal profile of the spine in an asymptomatic Greek population. Objectives. To perform segmental analysis of the sagittal plane alignment of the normal thoracic, lumbar, and lumbosacral spines and to compare the findings with those derived from similar populations. Summary of Background Data. Until recently, little attention has been paid to the sagittal segmental alignment of the spine, and there are only a few studies (in French and American populations) in which radio‐graphic analysis of sagittal spinal alignment is investigated. Methods. Ninety‐nine consecutive asymptomatic Greek volunteers (38 men, 61 women), an average age of 52.7 ± 15 years old (range, 20‐79 years), were included in this prospective study, on the basis of several inclusion criteria. These volunteers were divided into six distinct age groups. The radiologic parameters, which were measured (by Cobbs method) on the lateral standing roentgenograms of the whole spine were: thoracic kyphosis (T4‐T12), lumbar lordosis (L1‐L5), total lumbar lordosis (T12‐S1), distal lumbar lordosis (L4‐S1), sacral inclination (measured from the line drawn parallel along the back of the proximal sacrum and the vertical line), pelvic tilting, vertebral body inclination, and relative segmental inclination between pairs of adjacent vertebrae. Results. Thoracic kyphosis and lumbar lordosis (T12‐S1, L1‐L5) were not gender related. Thoracic kyphosis increased with age (P < 0.001), the lumbar spine (L1‐L5) gradually became less lordotic as the thoracic kyphosis increased (P < 0.003), and total lumbar lordosis was not age related. Sacral inclination correlated strongly with both thoracic kyphosis (P < 0.002) and L1‐L5 lordosis (P < 0.001). Pelvic tilting correlated strongly with L1‐L5 lordosis (P < 0.0075), but did not correlate with thoracic kyphosis and age. Vertebral body inclination showed a narrow variability in T6‐T12 and in L4 and a wide variability in T4, T5, L1‐L3, and S1. Distal lumbar lordosis represents the 68.6% of the total lumbar lordosis. Conclusions. In the results of this study, a reliable table of reference for roentgenographic parameters in the sagittal plane of the spine was established in an asymptomatic Greek population. The parameters are similar to those used in previous studies. Thus, these data should be considered in preoperative planning and postoperative evaluation of achieved correction during restoration procedures of the spine in the sagittal plane.

Combined anterior plus posterior stabilization versus posterior short-segment instrumentation and fusion for mid-lumbar (L2-L4) burst fractures.

Study Design. Prospective randomized study. Objectives. To compare the results of the combined anterior-posterior surgery (Group A) with posterior “short-segment” transpedicular fixation (SSTF) (Group B) in mid-lumbar burst fractures. Summary of Background Data. There are no comparative randomized clinical studies on the outcome following operative treatment of mid-lumbar fractures. Methods. Forty consecutive patients with L2–L4 fresh single A3-type/AO burst fractures and load sharing score up to 6 were randomly selected to underwent either combined one-stage anterior stabilization with mesh cage and SSTF (Group A) or solely SSTF with intermediate screws in the fractured vertebra (Group B). Kyphotic Gardner angle, anterior and posterior vertebral body height (PVBHr, AVBHr), spinal canal encroachment (SCE), SF-36, VAS, and Frankel classification were used. Results. The follow-up observation averaged 46 and 48 months for Group A and B, respectively. Operative time, blood loss, and hospital stay were significant more in Group A. More surgical complications were observed in the Group A. After surgery, VAS was reduced to 4.3 and 3.6 for Group A and Group B, respectively. The SF-36 domains Role physical and Bodily pain improved significantly only in Group B (P = 0.05) and (P = 0.06), respectively. Correction of AVBHr, PVBHr, and spinal canal clearance was similar in both groups. Spinal canal clearance did not differ between the two groups, but it was continuous until the last evaluation in Group B. The final Gardner angle loss of correction averaged 2° and 5° for Group A and Group B, respectively. The posttraumatic Gardner deformity did not significantly improve by SSTF at the final evaluation in the spines of Group B. Gardner angle correlated significantly with SCE in Group B and Group A in all three periods and in the last evaluation, respectively. Frankel grade did not correlate with loss of correction of AVBHr and PVBHr in Group A, while it significantly correlated with loss of PVBHr correction and SCE in the patients of Group B. There was no neurologic deterioration after surgery in any patient. VAS and SF-36 scores did not significantly correlate with the loss of kyphotic angle correction and AVBHr, PVBHr at the final observation in any patient of both groups. Conclusions. SSTF offered similar significant short-term correction of posttraumatic deformities associated with mid-lumbar A3-burst fractures, but better clinical results as compared to combined surgery. However, SSTF did not significantly maintain the after surgery achieved correction of local posttraumatic kyphosis at the final evaluation. Thus, SSTF is not recommended for operative stabilization of fractures with this severity.

Segmental roentgenographic analysis of vertebral inclination on sagittal plane in asymptomatic versus chronic low back pain patients.

Two homogenous groups of 120 volunteers and 120 low back pain (LBP) patients, age range 20-79 years, underwent a prospective roentgenographic segmental vertebral analysis of the thoracic and lumbar spine to compare several roentgenographic parameters useful for planning spine surgery. The following roentgenographic parameters were measured: thoracic kyphosis, lumbar lordosis, sacral inclination, distal lordosis (L4-S1), inclination of each vertebra from T4-S1, and relative vertebral inclination between adjacent vertebrae. Thoracic kyphosis increased (p < 0.0001) and sacral inclination decreased (p < 0.05) with age in the control group. Increased thoracic kyphosis correlated with decreased lumbar lordosis after the sixth decade in the control group (p < 0.01), less so in the LBP group (p < 0.05). Increased thoracic kyphosis was seen more in the LBP group than in the controls, but significantly solely in the sixth decade (p < 0.01). Lumbar lordosis was more increased in the controls than in the LBP group but significantly solely in the sixth decade (p < 0.001). The L5-S1 segmental lordosis was much more in the LBP patients than in the controls (p < 0.001). Lumbar lordosis was strongly correlated with sacral inclination in both groups (p < 0.0001) and it was significantly greater in the controls, particularly in the sixth decade (p < 0.001). Sacral inclination was significantly more in the female than in male volunteers (p < 0.05). Distal lordosis (L4-S1) represents 55% and 49% of total lumbar lordosis in controls and low back patients, respectively. Spine surgeons frequently deal with sagittal spinal deformities and the deviations of sagittal spinal curvatures and vertebral inclination in the sagittal plane, both in normal subjects and LBP patients should be clinically helpful.

Medium- and long-term results of open reduction and internal fixation for unstable pelvic ring fractures

Over a 10-year period, 74 patients with unstable pelvic injuries were treated with open reduction and internal fixation. Radiographic and clinical follow-up averaged 71 months (range: 38-141 months). Satisfactory (ie, good and very good) radiographic results were obtained in 90% of patients. Clinical results were superior in patients without associated injuries (P=.05-.001). Most of the complications in this series were due to associated injuries. Sepsis was mostly due to open pelvic injuries and malunion to either lack of patient cooperation or inadequate open reduction and internal fixation. Careful preoperative analysis of the nature of the pelvic injury and selection of the appropriate operative technique for open reduction and internal fixation result in a satisfactory outcome for the majority of operative patients.

Prediction of thoracic kyphosis using the Debrunner kyphometer.

The Debrunner kyphometer is an accepted tool for detecting and evaluating thoracic kyphosis. This prospective study was conducted to create a mathematical formula that provides, with high approximation, the roentgenographic angle of thoracic kyphosis (T4-T12) using only the kyphometer. Several clinical (kyphometer value, age, and sex) and radiographic (Cobb angle [T4-T12]) parameters from 90 consecutively screened adolescents (44 male and 46 female) were correlated using simple and multiple linear regression analyses. The reliability of measurement using the Debrunner kyphometer was high. The kyphometer value was strongly correlated with the roentgenographically measured thoracic Cobb angle (simple linear regression analysis; probability range, 0.0026 to 0.0002). There was no correlation between age or sex and thoracic kyphosis. The predicted kyphosis angle using the kyphometer and the mathematic formula was 44.66 degrees +/- 2.68 degrees, (range 27 to 62 degrees), and the real roentgenographic kyphosis angle was 47.5 degrees +/- 3.53 degrees, (range, 24 to 70 degrees). The kyphometer and formula were more reliable and accurate when kyphosis less than 50 degrees was measured. In this study, the authors constructed a mathematical formula that accurately provides the roentgenographic T4-T12 kyphosis angle in adolescents using only the Debrunner kyphometer with a deviation of less than 3 degrees. The authors recommend that all physicians engaged in kyphosis screening programs use the kyphometer combined with the recently constructed simple mathematic formula. This method will reduce the cost of school screening programs, overdiagnoses, and unnecessary exposure of adolescents to irradiation.

Medium- and long-term results of high tibial osteotomy for varus gonarthrosis in an agricultural population.

High tibial valgus osteotomy for varus gonarthrosis was performed in 63 consecutive patients in a homogenous agricultural population using two different surgical techniques. Patients were divided into two groups. A two-level Mittelmeier osteotomy was performed in group A patients, and a lateral closed wedge high tibial osteotomy using the AO/ASIF L-plate was performed in group B patients. Operations were performed by two different groups of surgeons. Patients were evaluated postoperatively for correction of knee axis, functional result, subjective impression, and complications. In group A patients, 80% of the operated knees were corrected to the mechanical axis and in group B patients, 82% of the knees were corrected to 6 degrees-10 degrees valgus of the anatomical axis. Ninety percent, 70%, and 54% of group A and 91%, 73%, and 57% of group B patients were rated as satisfactory results at 5, 9, and 12 years postoperatively, respectively; these differences were not statistically significant. One year postoperatively, 91% of group A and 96% of group B patients reported their symptoms had improved. However, patient satisfaction decreased at 5, 7, and 12 years postoperatively, with 91%, 89%, and 66% of group A and 96%, 93%, and 68%, respectively, of group B patients reporting their symptoms had improved; these differences were not statistically significant. Postoperatively, most patients returned to full agricultural activity. Total knee arthroplasty, which was later required in 12% of the knees, was not significantly jeopardized by the previous osteotomy.

Factors affecting low back pain in adolescents.

Study Design Prospective multifactorial study on low back pain (LBP) in adolescents. Background Data Most studies on LBP have focused on adults although many investigations have shown that the roots of LBP lie in adolescence. Several mechanical, physical, and behavioral factors have been associated with nonspecific LBP in adolescents. Objective To investigate the effect of all previously reported parameters together with psychological and psychosocial factors using advanced statistics, on LBP in adolescents aged 15 to 19 years. Material and Methods Six hundred and eighty-eight students aged 16±1 years from 5 randomly selected high schools participated in this study and completed a questionnaire containing questions on daily activity, backpack carrying, psychological and psychosocial behavior. Anthropometric data as well as biplane spinal curvatures together with questionnaire results were included in the analysis using advanced statistics. Results LBP reported 41% of the participants. Generally, statistically significant correlations were found between LBP (0.002), physical activity (P<0.001), physician consultation (P=0.024), and depression (P<0.001). Sex-related differences were shown regarding LBP intensity (P=0.005) and frequency (P=0.013), stress (P<0.03), depression (P=0.005), and nervous mood (P=0.036) in favor of male students. Male adolescents had continuous energy (P=0.0258) and were calm (P=0.029) in contrast with female counterparts. Discussion LBP was sex-related and was less common in adolescents with frequent activity. Adolescent girls with stress, depressive mood, and low energy have more LBP than boys, which makes physician consultation for LBP more common in female adolescents. Conclusions Systematic physical activity and control of psychological profile should decrease LBP frequency and intensity.

Posterior compact Cotrel-Dubousset instrumentation for occipitocervical, cervical and cervicothoracic fusion

The authors report on 32 consecutive patients with instability at the craniocervical, cervical and cervicothoracic regions suffering from various pathologies, who were treated with posterior instrumentation and fusion using the posterior hooks-rods-plate cervical compact Cotrel-Dubousset (CCD) instrumentation alone or, in three patients, in combination with anterior operation. The patients were observed postoperatively for an average of 31 months (range 25–44 months) and evaluated both clinically and radiographically using the following parameters: spine anatomy and reconstruction, sagittal profile, neurologic status, functional level, complications and status of arthrodesis. All patients but one (who died) achieved a solid arthrodesis based on plain and flexion/extension roentgenograms. Cervical lordosis (skull–C7) and cervicothoracic kyphosis (C7–T2) was improved by instrumentation towards a physiological lateral curve by an average of 33% (P<0.05) and 28% (P<0.05) respectively. Anterior vertebral olisthesis was reduced in the craniocervical and cervicothoracic region, by 73% and 90% respectively. At final follow-up there was an improvement of the neurologic Frankel status by an average of 1.2 grades and of myelopathy in 75% of the operated patients. Good to excellent functional results were seen in 77% of the operated patients, while acute and chronic pain was reduced by an average of 2.4 grades, on a scale of 0–3, in operated patients. No neurovascular or pulmonary complications arose from surgery. There was no significant change in lateral spine profile and olisthesis at the latest follow-up evaluation. There were no instrument-related failures. One patient requested hardware removal in the hope of reducing postoperative pain in the cervicothoracic region. The poor and fair results were related to the lack of improvement of neurologic impairment and myelopathy. The results of this study demonstrate that cervical CCD instrumentation applied in the region of the skull to the upper thoracic region for various disorders is a simple and safe instrumentation that restores lateral spine alignment, improves the potential for a solid fusion and offers sufficient functional results in the vast majority of the operated patients. However, the use of hooks in spinal stenosis is contraindicated.

Transthoracic disc excision with interbody fusion. 12 patients with symptomatic disc herniation followed for 2-8 years.

Thoracic disc herniation is a rare and slowly progressing disease, commonest at the lower thoracic spine. We performed transthoracic discectomy and interbody fusion in 12 patients with an average age of 46 years suffering from symptomatic herniated thoracic disc. Pain and neurologic impairment were the commonest symptoms at admission. The outcome at a mean follow-up of 4 (2-8) years concerning pain were excellent or good in 10 patients, fair in 1 and unchanged in 1 patient. There were no approach-related complications. All 7 patients with incomplete neurologic impairment preoperatively improved postoperatively at least 1 Frankel grade. Posterior complementary fusion at the thoracolumbar junction was necessary in 2 patients because of increasing symptomatic local kyphosis. Although the number of patients is small, due to the rarity of the disease, it seems that the transthoracic approach for anterior discectomy and fusion is an appropriate treatment for symptomatic thoracic disc herniation. Proper patient selection, preoperative planning and surgical technique resulted in good pain relief, neurologic recovery in cases associated with incomplete neurologic impairment and restoration of the sagittal profile of the thoracolumbar spine.

Relapsing pancreatitis after combined anterior and posterior instrumentation for neuropathic scoliosis.

We report a case of pancreatitis in a 28-year-old woman who underwent a combined anterior Zielke procedure followed by Luque-TSRH (Texas Scottish Rite Hospital) operation in the same session for severe polioscoliosis. To our knowledge, only one case of a child with acute pancreatitis after posterior instrumentation for spondylolisthesis has been reported. In the early postoperative period, the patient developed acute pancreatitis that was diagnosed by a marked increase in plasma amylase and was confirmed by ultrasonography. The symptoms of pancreatitis in this patient temporarily resolved a few weeks after conservative treatment (diet, infusions, antibiotics). Six, 16, and 32 months after the combined operation, there were repeated relapsing episodes of pancreatitis with elevated amylase levels and concomitant symptoms. In the last follow-up evaluation in December 1995, the patient was well and the amylase levels were within normal limits. Although the etiology of pancreatitis in this case is obscure, we believe that the correction of the severe biplane spinal deformity, achieved by the two major operations on the spine in the same session, may have contributed to the pathogenesis of the disease. This observation suggests that pancreatitis after major scoliosis surgery should be suspected when abdominal symptoms persist associated with elevated serum amylase levels. Some cases of acute pancreatitis, such as this case, can persist in chronic-relapsing form for long periods postoperatively.