Cagatay Ozturk

Degenerative lumbar spinal stenosis: correlation with Oswestry Disability Index and MR Imaging

Because neither the degree of constriction of the spinal canal considered to be symptomatic for lumbar spinal stenosis nor the relationship between the clinical appearance and the degree of a radiologically verified constriction is clear, a correlation of patient’s disability level and radiographic constriction of the lumbar spinal canal is of interest. The aim of this study was to establish a relationship between the degree of radiologically established anatomical stenosis and the severity of self-assessed Oswestry Disability Index in patients undergoing surgery for degenerative lumbar spinal stenosis. Sixty-three consecutive patients with degenerative lumbar spinal stenosis who were scheduled for elective surgery were enrolled in the study. All patients underwent preoperative magnetic resonance imaging and completed a self-assessment Oswestry Disability Index questionnaire. Quantitative image evaluation for lumbar spinal stenosis included the dural sac cross-sectional area, and qualitative evaluation of the lateral recess and foraminal stenosis were also performed. Every patient subsequently answered the national translation of the Oswestry Disability Index questionnaire and the percentage disability was calculated. Statistical analysis of the data was performed to seek a relationship between radiological stenosis and percentage disability recorded by the Oswestry Disability Index. Upon radiological assessment, 27 of the 63 patients evaluated had severe and 33 patients had moderate central dural sac stenosis; 11 had grade 3 and 27 had grade 2 nerve root compromise in the lateral recess; 22 had grade 3 and 37 had grade 2 foraminal stenosis. On the basis of the percentage disability score, of the 63 patients, 10 patients demonstrated mild disability, 13 patients moderate disability, 25 patients severe disability, 12 patients were crippled and three patients were bedridden. Radiologically, eight patients with severe central stenosis and nine patients with moderate lateral stenosis demonstrated only minimal disability on percentage Oswestry Disability Index scores. Statistical evaluation of central and lateral radiological stenosis versus Oswestry Disability Index percentage scores showed no significant correlation. In conclusion, lumbar spinal stenosis remains a clinico-radiological syndrome, and both the clinical picture and the magnetic resonance imaging findings are important when evaluating and discussing surgery with patients having this diagnosis. MR imaging has to be used to determine the levels to be decompressed.

The role of posterior instrumentation and fusion after anterior radical debridement and fusion in the surgical treatment of spinal tuberculosis: experience of 127 cases.

Long periods of immobilization, progressive kyphosis and graft failure are the major postoperative problems encountered after anterior radical surgical treatment for tuberculosis of the spine. Posterior fusion and instrumentation can be an effective solution for these problems. Effectiveness of posterior fusion and instrumentation was investigated in this study on the basis of the cases with anterior procedure only, and with combined anterior–posterior procedures. One hundred twenty-seven cases of tuberculosis of the spine were surgically treated between 1987 and 1995. All had either 1 or more of conditions such as spinal cord compression and neurological deficit, vertebral body collapse and kyphosis, or wide paravertebral abscess unresponsive to medical treatment. Of these, 57 had only anterior radical procedure between the years 1987 and 1993. Seventy cases had posterior instrumentation and fusion after the anterior procedure between the years 1991 and 1995. In about two third of the patients (81) autogenous iliac strut graft and in one third of them (40) autogenous fibular strut graft (cases with more than 2 level involvement) was used along with rib grafts after debridement. Twenty-one of the 57 patients who had only anterior procedure demonstrated a postoperative increase of kyphosis of more than 10 degrees. Increased kyphosis was due to graft slippage in 3, resorption in 2 and subsidence in 16 patients. No such increase or graft failure was noted in cases of combined anterior–posterior procedure. The difference in terms of kyphosis was found to be statistically significant (P=0.047). Anterior radical debridement and strut graft is the golden standard in the surgical treatment of spinal tuberculosis, but it should always be accompanied by posterior instrumentation and fusion to shorten the immobilization period and hospital stay, obtain good and long lasting correction of kyphosis, and prevent further collapse and graft failure.

Conservative treatment of fractures of the thoracolumbar spine

We reviewed 48 patients with thoracolumbar fractures treated conservatively between 1988 and 1999. The average follow-up was 77.5 (31–137) months and average patient age (23 women, 25 men) was 46 (18–76) years. Twenty-nine patients suffered a fall from a height and 13 patients were injured in traffic accidents. Thirty-two patients had compression-type fractures and 16 burst-type fractures. There were no neurological deficits. Twenty-nine patients were treated by orthosis, 13 by body cast and six by bed rest. In addition to pain and functional scoring, we measured a number of radiographic parameters at the time of admission and at latest follow-up and compared the values. In patients with compression fractures there were significant changes in scoliosis angle and wedging index (p<0.05). The mean pain score was 1.66 and mean functional score 1.03. In patients with burst fractures, vertebral index, wedging index and height loss increased after treatment (p<0.05). The mean pain score was 1.26 and functional score 0.93. Compression fractures with kyphosis angle <30° are supposed to be stable and can be treated conservatively. If the kyphosis angle is more than 30°, magnetic resonance imaging (MRI) should be performed, and if the posterior ligamentous complex is damaged, surgery should be considered. In burst fractures, MRI should always be performed and conservative treatment should only be considered if there is no neurological deficit and the ligaments are intact.RésuméNous avons examiné 48 malades avec une fracture dorsolombaire traitée d’une manière conservatrice entre 1988 et 1999. Le suivi moyen était de 77,5 (31–137) mois et l’âge moyen des malades (23 femmes, 25 hommes) était de 46 (18–76) ans. Vingt-neuf malades avaient fait une chute de grande hauteur et 13 malades ont été blessés dans un accident de la circulation. Trente-deux malades avaient des fractures du type compression et 16 fractures du type explosion. Il n’y avait pas de déficit neurologique. Vingt-neuf malades ont été traités par orthèse, 13 par corset plâtré et six par repos au lit. En plus des scores douleur et des scores fonctionnels, nous avons comparé plusieurs paramètres radiographiques entre l’admission et le plus long recul. Chez les malades avec fracture-compression il y avait des changements significatifs dans l’angle de la scoliose et l’index angulaire (p<0.05). Le score moyen de la douleur était 1.66 et le score fonctionnel moyen 1.03. Chez les malades avec fracture-explosion, l’index vertébral, l’index angulaire, et la perte de hauteur ont augmenté après traitement (p<0.05). Le score moyen de la douleur était 1.26 et le score fonctionnel 0.93. Les fractures de type de compression avec angle de cyphose <30° sont supposés être stables et sont traités d’une manière conservatrice. Si l’angle de la cyphose est de plus de 30°, une IRM devrait être exécutée et si le complexe ligamentaire postérieur est endommagé, la chirurgie devrait être envisagée. Dans les fractures du type de explosion, une IMR devrait toujours être exécutée et le traitement conservateur devrait être retenu seulement s’il n’y a aucun déficit neurologique et si les ligaments sont intacts.

Enhancement of tendon-bone healing of anterior cruciate ligament grafts by blockage of matrix metalloproteinases

BACKGROUND The use of soft-tissue grafts for anterior cruciate ligament reconstruction delays the healing process. This delay may be due to biochemical and/or biomechanical insults. We hypothesized that the blocking effect of alpha2-macroglobulin on synovial matrix metalloproteinase activity may enhance the healing of tendon graft in a bone tunnel. METHODS The study was performed on twenty-eight healthy, skeletally mature New Zealand White rabbits. Each rabbit underwent bilateral anterior cruciate ligament reconstruction with use of the ipsilateral semitendinosus tendon. Alpha-2-macroglobulin (alpha2-macroglobulin) was injected into the knee joint in one limb, and the contralateral limb served as a control. The rabbits were killed two weeks (fourteen rabbits) or five weeks (fourteen rabbits) after the operative procedures. The presence of matrix metalloproteinases in synovial fluid, and the blocking effect of alpha2-macroglobulin on them, were determined with enzymatic assays. Healing between the tendon and the bone tunnel was assessed morphologically by determining the presence of fibrovascular tissue and collagen fibers. Healing also was assessed quantitatively by measuring the ultimate load to failure of the reconstructed complex. RESULTS There was an increase in matrix metalloproteinases in the control group; in contrast, there was a decrease in the study group (p < 0.05). In the control specimens, the fibrovascular tissue at the bone-tendon interface had developed into dense connective tissue with poor vascularization. In the treated specimens, the bone tunnel had more areas of denser connective-tissue ingrowth. The interface tissue was more mature and contained numerous perpendicular collagen bundles (Sharpey fibers). The ultimate load to failure was significantly greater in the alpha2-macroglobulin-treated specimens than in the untreated controls at both two and five weeks. CONCLUSIONS The present study demonstrated that alpha2-macroglobulin blockade of matrix metalloproteinases can enhance bone-tendon healing. This effect of alpha2-macroglobulin could occur through its effect solely on collagenase or on a subset of matrix metalloproteinases that are present at the healing interface.

Osteotomies/spinal column resections in adult deformity

Osteotomies may be life saving procedures for patients with rigid severe spinal deformity. Several different types of osteotomies have been defined by several authors. To correct and provide a balanced spine with reasonable amount of correction is the ultimate goal in deformity correction by osteotomies. Selection of osteotomy is decided by careful preoperative assessment of the patient and deformity and the amount of correction needed to have a balanced spine. Patient’s general medical status and surgeon’s experience levels are the other factors for determining the ideal osteotomy type. There are different osteotomy options for correcting deformities, including the Smith-Petersen osteotomy (SPO), pedicle subtraction osteotomy (PSO), bone-disc-bone osteotomy (BDBO) and vertebral column resection (VCR) providing correction of the sagittal and multiplanar deformity. SPO refers to a posterior column osteotomy in which the posterior ligaments and facet joints are removed and a mobile anterior disc is required for correction. PSO is performed by removing the posterior elements and both pedicles, decancellating vertebral body, and closure of the osteotomy by hinging on the anterior cortex. BDBO is an osteotomy that aims to resect the disc with its adjacent endplate(s) in deformities with the disc space as the apex or center of rotational axis (CORA). VCR provides the greatest amount of correction among other osteotomy types with complete resection of one or more vertebral segments with posterior elements and entire vertebral body including adjacent discs. It is also important to understand sagittal imbalance and the surgeon must consider global spino-pelvic alignment for satisfactory long-term results. Vertebral osteotomies are technically challenging but effective procedures for the correction of severe adult deformity and should be performed by experienced surgeons to prevent catastrophic complications.

Posterior Only Pedicle Screw Instrumentation With Intraoperative Halo-femoral Traction in the Surgical Treatment of Severe Scoliosis (>100°)

Study Design. Retrospective clinical study. Objective. To report the results of surgical correction achieved by intraoperative halo-femoral traction and posterior only pedicle screw instrumentation in severe scoliosis (scoliosis greater than 100°). Summary of Background Data. Although previous reports show the effectiveness of preoperative halo traction in the treatment of severe spinal deformity, the intraoperative use of halo-femoral traction in conjunction with posterior pedicle screw instrumentation has never been reported in patients with severe spinal deformity. Methods. A total of 15 consecutive patients with severe (>100°) thoracic idiopathic scoliosis and/or kyphoscoliosis operated by using intraoperative halo-femoral traction and posterior only pedicle screw instrumentation were included in the study. Subjects were analyzed by age at date of examination, gender, major coronal curve magnitude, major compensatory coronal curve magnitude, major sagittal curve magnitude, shoulder imbalance, and preoperative vital capacity of the lungs. Halo-traction related complications and short- and long-term complications were noted in each case. Results. The average age at the time of surgery was 17.8 years (range, 16–19). There were 4 males and 11 females. The average improvement was 51% in the major thoracic curve, 33% in the compensatory lumbar curve, and 53% in the major sagittal curve. The average follow-up was 56 (range, 24–96) months. Loss of correction averaged 4° for major thoracic curves and 2° for thoracic kyphosis based on measurements at the final follow-up date. Conclusion. The use of intraoperative halo-femoral traction together with the wide facet resection and posterior release gradually provide a good correction and balance maintained by pedicle screw instrumentation. Intraoperative halo-femoral traction not only elongates spinal column but also elongates the thoracic cavity improving the compromised pulmonary function.

Simultaneous Surgical Treatment in Congenital Scoliosis and/or Kyphosis Associated With Intraspinal Abnormalities

Study Design. Retrospective clinical study. Objective. To show retrospective analysis of 21 consecutive patients who underwent simultaneous surgical treatment for progressive spinal deformity and coexisting intraspinal pathologies (tethered cord and/or diastematomyelia). Summary of Background Data. The classic advocated approach in patients with congenital spine deformity associated with intraspinal anomalies is first to perform surgery for the intraspinal pathologies and then surgery for correction and stabilization of the deformity 3 to 6 months later. To our knowledge, there is no study on simultaneous surgical treatment for these 2 associated conditions. Methods. In the surgery; after the exposure of the determined levels, placement of all pedicle screws was performed as the initial part of surgical procedure. Then surgical treatment for intraspinal pathology was performed by the neurosurgical team and then followed by completion of instrumentation and correction of the deformity. Additional anterior surgery was done later to prevent pseudarthrosis and crankshaft phenomenon. Results. The mean age of the patients at presentation ranged from 3 to 19 years (mean, 13 years). There were 17 female patients and 4 male patients. Four patients had neurologic deficits at the time of presentation, and all 4 had associated kyphosis. The mean operation time was 9.3 hours (range, 7–12 hours) and the mean blood loss was 1980 mL (range, 1500–3000 mL). The average follow-up was 6.8 years (2–12 years). None of the patients experienced deterioration in their neurologic status after surgery. None of the patients had infection, pseudarthrosis, or loss of correction during the follow-up visits. Conclusion. The simultaneous surgical treatment for congenital deformity and intraspinal abnormality does not involve significant complications and seems to be an alternative and safe treatment option.

The pedicle screw fixation with vertebroplasty augmentation in the surgical treatment of the severe osteoporotic spines.

Study Design Retrospective clinical study. Objective To present the early clinical results of pedicle screw fixation augmented by vertebroplasty using polymethylmethacrylate in severely osteoporotic patients requiring spine surgery due to the neurologic deficit. Summary of Background Data It is postulated that combining a formal vertebroplasty—that is, maximum filling of the trabecular space with polymethylmethacrylate—with pedicle screw placement in osteoporotic vertebrae could result in resistance to pullout forces significantly. Methods Between the years 2003 and 2006, pedicle screw placement with vertebroplasty augmentation was performed in 49 patients who had severe osteoporosis and who required spine surgery due to neurologic deficit. Eleven patients with less than 2 years of follow-up and 2 patients who died from unrelated illness were excluded from the study. Thirty-six of 49 patients having minimum 2 years of follow-up were included. Cement augmentation was also performed in segments proximal and distal to instrumentation to prevent junctional segment fractures. Early and late postoperative complications were recorded during follow-up. Results The mean postoperative follow-up was 37 (24 to 48) months. The average age of the patients was 66 (59 to 78) years. The instrumentation was performed meanly at 5 segments and vertebroplasty was performed averagely at 7 segments. All patients had the T-score value of less than −2.5 from the anteroposterior and lateral lumbar spine and hip views, so regarded as severe osteoporosis. In our study group, there were no extravasation and subsequent thermal neural injury. Four superficial wound infections have been observed and they responded well to local debridement and antibiotics. There were no proximal and distal junctional segment fractures during the follow-up course. Postoperatively, all patients with neurologic symptoms had complete relief of their nerve compression symptoms. Conclusions In patients requiring spine surgery due to neurologic deficit and having no sufficient time for the medical treatment of severe osteoporosis, pedicle screw fixation with vertebroplasty augmentation and vertebroplasty in segments proximal and distal to the instrumented segments can be good alternative methods to provide well fixation and fusion while preventing proximal and distal junctional fractures. One should be careful about pulmonary cement embolism after such kind of procedures.

The pathophysiology of Osgood-Schlatter disease: a magnetic resonance investigation.

Osgood–Schlatter disease (OSD) is a well-described clinical condition, although its origin remains controversial. Mechanical, growth or traumatic factors are suggested as causes of this lesion. Thirty-five patients were included in this study. Twenty of them had OSD (study group) and the remaining 15 adolescents constituted the control group. Magnetic resonance imaging of the knees was performed in all patients. The distance between the distal pole of the patella and the proximal margin of patellar tendon attachment to the tibial apophysis (A), the distance between the distal pole of the patella and the tibial tubercle epiphysis (B), the distance between the proximal margin of the patellar tendon attachment to the tibia and the tibial tubercle epiphysis (C) and the distance between the knee joint level and the tibial tubercle epiphysis (D) were measured. The ratio of the distance between the distal pole of the patella and the proximal margin of the patellar tendon attachment to the tibia to the distance between the distal pole of the patella and the tibial tubercle epiphysis (A : B) was lower in the study group. The ratio of the distance between the proximal margin of the patellar tendon attachment point to the tibia and the tibial tubercle epiphysis to the distance between the knee joint level and the tibial tubercle epiphysis (C : D) was higher in the control group. We conclude that if the patellar tendon attaches more proximally and in a broader area to the tibia, this might probably cause OSD.

Dural tears in lumbar burst fractures with greenstick lamina fractures.

Study Design. This study investigated the incidence, predictions, and treatment principles of greenstick lamina fractures in lumbar burst fractures. Objective. To determine the incidence of dural tears in lumbar burst fracture with greenstick lamina fracture and to find out if any specific clinical and radiographic factors or intraoperative pathologic findings are predictive of dural tears and nerve root entrapment. Summary of Background Data. A retrospective review was conducted on 45 patients with 47 lumbar burst fractures treated operatively. Ages ranged from 15 to 70 years (average, 33 years). The duration of follow-up ranged from 32 months to 8 years (average, 52 months). Methods. All clinical charts and radiologic data of these patients were reviewed. Age, sex, etiology, and all the radiologic parameters were analyzed for their association with greenstick lamina fracture and dural tear. Student’s t test and multiple logistic regression analysis were used for statistical analysis. Results. Greenstick lamina fracture occurred in 20 (42.5%) of 47 burst fractures. Dural tear was detected in 9 (19%) of 47 burst fractures and was predominantly higher in L3 (6 of 9 burst fractures). According to multiple logistic regression analysis of the data, a 20% increase in the interpedicular distance gives a 79% probability of greenstick lamina fracture. The distance between the edges of greenstick lamina fractures was obviously higher in fractures with dural tear. Neurologic status was completely normal before surgery in three of the patients with dural tear and nerve root entrapment. Conclusions. It is not possible to detect dural tear and nerve root entrapment in greenstick lamina fracture before surgery. Therefore, if there is any suspicion of such an occurrence, it should be the rule to begin with posterior approach and use the open book technique to expose the dura safely before any reduction maneuver.