I. Teoman Benli

Magnetic resonance imaging abnormalities of neural axis in Lenke type 1 idiopathic scoliosis.

Study Design. Patients with Lenke type 1 single thoracic idiopathic scoliosis were included in this prospective study. All patients had preoperative magnetic resonance imaging (MRI). Objective. To examine the frequency of neural axis abnormalities and the need for preoperative MRI in this group of patients. Summary of Background Data. Because of the increasing use of MRI, neural axis abnormalities have been reported in association with certain clinical and radiologic findings in idiopathic scoliosis cases. Methods. A total of 104 patients (49 juvenile onset and 55 adolescent onset), older than 10 years, were included in the study. The association of neural axis abnormalities with pes cavus, abnormal deep tendon reflexes, age of onset, presence of pain, severity of the frontal plane deformity, and sagittal contours were investigated. Results. All 7 patients with a neural axis abnormality on MRI had an early onset disease, and 6 of them had back pain. Thus, age of onset and back pain seem to be predictive of these abnormalities. Frequency of MRI abnormalities was as high as 45% for patients with back pain in addition to a type IC curve. Conclusion. In patients with juvenile idiopathic scoliosis and back pain, preoperative MRI should be performed to eliminate the risk of postoperative neurologic deficits, even if the scoliosis is Lenke type 1. However, in patients with Lenke type 1 idiopathic scoliosis, preoperative MRI studies seem unnecessary if intraoperative neural monitoring is to be performed.

Evaluation of the two bundles of the anterior cruciate ligament with 1.5 tesla magnetic resonance imaging

OBJECTIVES Studies on the anatomy of the anterior cruciate ligament (ACL) have shown that the normal ACL consists of two functional bundles named as anteromedial (AM) and posterolateral (PL) bundles. In this study, we evaluated the AM and PL bundles of the ACL using 1.5 tesla magnetic resonance imaging (MRI), which is routinely used in clinical practice. METHODS The study included 150 patients (96 females, 54 males; mean age 33.4+/-11.6 years; range 18 to 59 years) who did not have any signs of ACL insufficiency and whose knees were examined by MRI for other reasons. Standard magnetic resonance images (77 right, 73 left) were evaluated independently by an orthopedist and a radiologist in terms of distinguishable ACL bundles. The angle between the ACL (and each bundle) and the tibial plateau was measured on sagittal and coronal sections. Arthroscopic surgery was performed in 64 patients (42.7%) for primary diagnoses and arthroscopic and MRI findings were compared. RESULTS Magnetic resonance imaging showed an intact ACL in all the patients. The ACL was assessed as a single bundle in the axial, coronal, and sagittal planes in 93 patients (62%). A double-bundle appearance was noted in 57 patients (38%), involving all three planes in 14 patients (9.3%), axial and coronal planes in 41 patients (27.3%), coronal and sagittal planes in one patient (0.7%), and only coronal plane in one patient (0.7%). On MRI sections showing a single bundle ACL, the mean angle between the ACL and the tibial plateau was found as 55.3 degrees in the sagittal plane, and 70.3 degrees in the coronal plane. On sections with a double-bundle appearance, the mean angles between the AM bundle and the tibial plateau were 70.1 degrees and 55.1 degrees in the coronal and sagittal planes, respectively. The corresponding angles for the PL bundle were 81 degrees and 53.5 degrees . The incidence of double bundle ACL appearance in coronal, sagittal, and axial MRI sections was not influenced by sex and side (p>0.05). The number of bundles identified in each plane did not show a significant difference between the two observers (p>0.05). During arthroscopic surgery, both bundles were identified with normal integrity and function of the ACL in all the patients. Of these, MRI could depict a double-bundle appearance in one or more planes in only 42.2% of the patients. CONCLUSION Even though standard 1.5 tesla MRI, routinely used in clinical practice, has a very high success rate in demonstrating the ACL, it can visualize the two-bundle structure only in about one-third of the patients.

Minimum 5-year follow-up surgical results of post-traumatic thoracic and lumbar kyphosis treated with anterior instrumentation: comparison of anterior plate and dual rod systems.

Study Design. A retrospective follow-up study of post-traumatic thoracic and lumbar kyphosis after anterior instrumentation with anterior plate and dual rod systems. Objective. To investigate the outcome of anterior vertebrectomy, anterior strut grafting, and anterior instrumentation in patients with >30° sagittal contour deformity. Summary of Background Data. Post-traumatic kyphosis may lead to mechanical pain due to the impairment of physiologic sagittal contours as well as cosmetic complaints. Methods. Forty patients with post-traumatic kyphosis were followed for a minimum of 5 years. Mean age was 44.7 ± 12.4 years (range, 18–65 years); 18 were female and 22 were male. All patients underwent anterior vertebrectomy and decompression; anterior fusion was carried out with costal or iliac ala grafts. Patients were randomly assigned into 2 treatment groups: correction and internal fixation was performed by using either plate-screw (n = 20) or double rod-screw (n = 20). Patients were also evaluated clinically by using Pain and Functional Assessment Scale (PFA) and SRS-22 questionnaire. Results. Before surgery, the mean value for local sagittal contours was 51.4° ± 13.8°; after surgery, it was reduced to 7.0° ± 7.6°, resulting in an 88.7% ± 11.3% correction (P = 0.00). At the last follow-up visit, a mean correction loss of 1.4° ± 1.8° was found. A statistically significant improvement in local kyphosis angles and PFA scores was found after surgery and at the last visit. In 92.5% of the patients (n = 36), pain completely resolved; and in the remaining 3 patients, it is markedly reduced. Neurologic improvement was achieved in all of the 24 patients with neural claudication and other neurologic findings. Solid fusion mass was obtained in all patients. The type of instrumentation system did not differ significantly in terms of kyphotic deformity correction rates, correction losses, PFA scores, and SRS-22 scores. Final PFA scores showed a statistically significant correlation with SRS-22 scores (r = −0.918, P < 0.01). Final pain, function, mental status, self image and satisfaction domain scores and total SRS-22 score were ≥4. The time from trauma to operation and the severity of kyphotic deformity were inversely correlated with postoperative correction rates. On the other hand, these 2 parameters were positively correlated with both final PFA and final SRS-22 scores (P < 0.01). Conclusions. In light of the present studys findings, we suggest that the technique of anterior decompression, strut grafting, and anterior instrumentation is an effective method for the treatment of post-traumatic kyphotic deformity and that the success of the technique depends on the time from trauma to operation and the severity of baseline deformity, regardless of the type of instrumentation.

The results of anterior fusion and Cotrel-Dubousset-Hopf instrumentation in idiopathic scoliosis

Abstract Anterior instrumentation for the correction of scoliotic curves has recently been gaining in popularity. The problems of high mortality and morbidity that were associated with the employment of anterior instrumentation in the first years it was used have now been overcome. Efforts are now being concentrated on increasing the correction rates in the frontal plane and decreasing the kyphotic effect in the sagittal plane. The anterior Cotrel-Dubousset-Hopf (CDH) system is a recently developed instrumentation that has been claimed to decrease the kyphotic effect through the use of double rods. This study aimed to investigate the impact of the anterior CDH system on idiopathic scoliotic curves in frontal and sagittal planes. To this end, 26 idiopathic scoliosis patients treated with the CDH system were followed for a mean period of 32.8 ± 5.3 months. In the frontal plane, Cobb angles of major and secondary curves were measured, and postoperative and final correction rates determined. In the sagittal plane, sagittal contours of both the instrumented region and the thoracic and lumbar regions were measured, and their preoperative, postoperative and final control values were determined. In addition to clinical examination, lateral trunk shift (LT), shift of head (SH) and shift of stable vertebra (SS) were measured in vertebral units (VU), on the preoperative and postoperative radiographs in order to evaluate the effect of the system on trunk balance. It was established that in patients with single flexible thoracolumbar and lumbar curves and those with rigid thoracic curves, the correction rates obtained in the frontal plane were respectively 79.4 ± 14.8%, 68.0 ± 9.4% and 61.5 ± 8.0%, with statistical significance. Their final corrections at the last control were 76.3 ± 17.4%, 56.9 ± 9.1% and 52.3 ± 8.3%, respectively. Although the corrections in the lumbar rigid curves were relatively low, they were still statistically significant. Taking all the patients together, the mean preoperative Cobb angle of the major curves of 67.2°± 20.2° improved to a mean of 28.6°± 21.0°, which was a statistically significant difference (P < 0.05), giving a mean correction rate of 61.2 ± 20.3%. The mean correction loss of major curves in the frontal plane in all patients was 6.0°± 3.8° and the mean final correction rate was 52.6 ± 23.2%. In the sagittal plane, there was a favorable kyphotic effect on the thoracic region of patients with hypokyphosis and lordosis pattern, whilst in patients with kyphotic pattern, this effect was minimal. In patients with a single flexible lumbar curve, kyphotic effect was not observed except in two patients. In these two patients, it was thought that excessive compression force may have been used. As to the patients with a rigid lumbar curve, there was a slight decrease in lumbar lordosis. No postoperative complaints were made about imbalance, and the mean overall correction in LT values was 60.1 ± 21.7%. While preoperatively, the SH and SS values of all patients were over 0.5 VU, postoperatively, 12 patients (46.2%) were completely balanced (SH = 0 VU, SS = 0 VU) and 8 patients (30.8%) were balanced (0 VU < SH and SS < 0.5 VU). The remaining six patients, whose balance values were corrected with statistical significance but were still over 0.5 VU, were found to be the ones with rigid lumbar curves. Implant failure and systemic complications were not noted in the follow-up period. In view of these findings, it was determined that CDH instrumentation achieves significant correction rates in the frontal and sagittal planes, particularly in single flexible lumbar, thoracolumbar and thoracic rigid curves. It was found that the kyphotic effect was minimized with a double rod system. Significant clinical and radiological corrections were achieved in balance values, without any imbalance and decompensation problems.

Isola spinal instrumentation system for idiopathic scoliosis

Abstract Since the definition of three-dimensional components of the scoliotic deformity, there have been important improvements in the surgical treatment of the problem. A derotation maneuver was proposed as a treatment option with CD instrumentation, but the reports of imbalance and decompensation with this system repopularized sublaminar wiring and translation as a corrective maneuver. Isola spinal instrumentation is one of the modern systems that utilizes vertebral translation instead of rod rotation. This study analyzes the results of 24 patients with idiopathic scoliosis who had been followed up for at least 2 years, and were surgically treated with titanium Isola Spinal Instrumentation in the Department of Orthopaedics and Traumatology, Ankara Social Security Hospital. Patients were grouped according to the King-Moe classification. Patients with type III, IV or V curves received only posterior instrumentation while this procedure followed anterior release and discectomy in the same session in patients with type I or II curves. A translation maneuver was utilized in the correction of scoliotic curves using the cantilever technique, either alone or supplemented by sublaminar wiring with Songer multifilament titanium cables. This study aimed to elucidate the effects of this technique in the frontal and sagittal plane curves and the trunk balance. The balance was analyzed clinically and radiologically by measurement of the lateral trunk shift (LT), shift of stable vertebra (SS), and shift of head (SH) in vertebral units (VU). The postoperative correction was significant in the frontal plane for all types of curves (p < 0.05). The postoperative correction was 80.9% ± 9.5% in type III curves. Overall, the mean Cobb angle of the major curve value in the frontal plane was 66.9°± 18.8°, and it was corrected by 62.8% ± 20.1%. The correction loss of Cobb angles in the frontal plane was 5.4°± 5.5° at the last follow-up visit. A normal physiologic thoracic contour (30°–50°) was achieved in 83.3% of the patients and normal lumbar contour (40°–60°) in 66.7% of the patients in the sagittal plane. The correction was found to be significant in all balance values (p < 0.05). The postoperative correction in LT values correlated with the correction of the Cobb angle values in the frontal plane. All patients had complete balance (SH: 0 VU and SS: 0 VU) or balanced curves (0 VU < SH, SS < 0.5 VU).Finally, the study concluded that the translation maneuver, especially when used with the cantilever technique, resulted in high correction rates in the frontal plane. Additionally, the technique was also successful in obtaining normal sagittal contours and correcting balance values.