Panagiotis Korovessis

Adult idiopathic lumbar scoliosis : a formula for prediction of progression and review of the literature

Study Design A retrospective study was conducted of patients with untreated adult-type idiopathic lumbar scoliosis. Objectives To construct a mathematical formula that provides accurate progression of an idiopathic adult lumbar scoliosis using initial roentgenographic parameters. Summary of Background Data Osteoporosis, lateral spondylolisthesis of L2-L4, and degeneration of disc and joint may contribute to a poor prognosis for lumbar adult-type scoliosis. Methods Seven roentgenographic parameters taken from the standing roentgenograms of 91 patients with a scoliosis of more than 10oCobb angle and who were included in a follow-up for more than 2 years, were put into a multiple regression analysis to observe the relative weight of each in the progression of the scoliosis. Results and Conclusions Only lateral spondylolisthesis of the apical vertebra, Harrington factor, and disc index were related to progression of the scoliosis. Using the mathematical formula, the real progression of lumbar scoliosis can be predicted within an average of 0.85° ± 3.76°.

IgG and IgM concentration in the prolapsed human intervertebral disc and sciatica etiology.

Study Design A prospective study was conducted in patients who underwent surgeries for sciatica. The results were compared to those of control subjects. Objectives This study expanded knowledge about the pathogenesis of back pain and sciatica in disc herniation. Methods Nucleus pulposus, retrieved from 10 patients who underwent surgeries for sciatica caused by disc herniation and from 8 patients used as control subjects, was homogenized and together with serum and cerebrospinal fluid was examined for local production of IgG and IgM by rate nephelometry. Summary of the Background Data Experimental data have shown an inflammatory reaction in the nucleus pulposus of animal models. Results and Conclusions An increased ratio IgGNP/IgGs x 103 and IgMNP/IgMs x 103 was found in all patient samples, whereas only the IgMNP/IgMs x 103 ratio was significantly higher (P< 0.005) when compared with those of the control values. These findings may be secondary to an inflammatory reaction close to the nerve root and prolapsed nucleus pulposus. Therefore, they may contribute in some way to the inflammatory origin of sciatica.

COMPLETE FRACTURE-DISLOCATION OF THE THORACIC SPINE WITHOUT NEUROLOGIC DEFICIT: CASE REPORT

A case is presented of a motorcyclist who crashed and suffered a fracture-dislocation of the mid-thoracic spine without any neurologic deficit. The injury was discovered 6 weeks after the crash. The patient underwent surgical stabilization and correction of the kyphotic deformity with Luque rods and sublaminar wires and had an uneventful recovery.

Incidence of scoliosis in β−thalassemia and follow-up evaluation

STUDY DESIGN: One hundred fifteen of 120 patients with beta-thalassemia followed in the thalassemia unit were studied for the presence of scoliosis. Forty-nine of these patients were reevaluated 1 year later. OBJECTIVES: To determine the frequency and the course of scoliosis in beta-thalassemia and to compare the findings with those of patients with idiopathic scoliosis. SUMMARY AND BACKGROUND DATA: There is only one report indicating increased frequency of scoliosis in a limited number of patients with thalassemia. In this study, the authors assessed the frequency of scoliosis in a large sample of patients and followed the evolution of this spinal deformity. METHODS: Patients with beta-thalassemia aged 3-35 years were examined clinically and radiologically for scoliosis. Forty-nine of them were reexamined 1 year later for determination of the evolution of scoliosis. RESULTS: Lateral curves of at least 5 degrees Cobb were found in 77 patients (67%), with a male-to-female ratio of 0.9. Scoliosis of at least 10 degrees was found in 21.7% of the male and 20% of the female patients with thalassemia. The ratio was 1.18 for curves of at least 10 degrees and 0.77 for curves of a smaller magnitude. The most common curve pattern was the left lumbar (35.1%), followed by the double-curve pattern (16.9%). Forty-nine randomly selected patients (42.6%) of the 115 included in the study were reexamined 1 year later. Seven male and 7 female patients (total, 28.6%) showed a progression of at least 5 degrees. Six patients (12.2%) experienced spontaneous improvement of less than 6 degrees. The pattern and the evolution of scoliosis observed in patients with beta-thalassemia differ from those found in Greek children with idiopathic scoliosis. CONCLUSIONS: The findings of this study show that the incidence, evolution, and etiology of scoliosis in beta-thalassemia differ from those of idiopathic scoliosis, indicating that the spinal deformities in patients with beta-thalassemia represents a distinct type of scoliosis. Longer follow-up is needed to investigate the natural history of this type of scoliosis.

Anterior decompression and fusion for Aspergillus osteomyelitis of the lumbar spine associated with paraparesis

Study Design A very rare case of Aspergillus fumigatus osteomyelitis of the spine is described. The differential diagnosis, medical and operative treatment, and follow-up evaluation are reported. Objectives To increase knowledge about the pathogenesis and treatment of vertebral osteomyelitis resulting from Aspergillus and to emphasize that such cases still exist. Summary of Background Data Vertebral osteomyelitis from Aspergillus species is an infrequently described disease in Europe and only few cases have been previously reported. Methods A 48-year-old woman with Aspergillus fumigatus spondylitis in the lumbar spine and tuberculosis-lung infection and concomitant debilitating systemic disease was afflicted with incomplete paraplegia and underwent successful combined operative and medical treatment. Results and Conclusions Early anterior decompression with spinal fusion, combined with Amphotericin B therapy, was crucial in bringing about complete neurologic recovery and maintaining the sagittal lumbar profile. Excellent clinical and radiologic results were shown in the 42-month follow-up period.

Spinal canal restoration by posterior distraction or anterior decompression in thoracolumbar spinal fractures and its influence on neurological outcome

SummaryThirty consecutive patients who had suffered unstable fractures and dislocations of the thoracolumbar spine mostly associated with neurologic impairment and bony encroachment on the spinal canal were treated either with Harrington distraction rods combined with sublaminar wires or with the Zielke-VDS device. These patients were subsequently assessed for neurologic outcome, spinal canal clearance, sagittal and coronal spinal deformity correction preoperatively and postoperatively with a minimum follow-up of 26 months. In the follow-up evaluation, the patients who underwent surgery with Harrington rods showed an overall improvement of their neurologic function of 90.9%, whereas all patients who underwent the Zielke operation improved. Preoperatively, positive correlations were found between the level of injury and Frankel grades; the cord lesion tended to demonstrate more severe neurologic deficit when compared with cauda equina ones (P < 0.001). Furthermore, dislocation accompanying the injury resulted in a more severe neurological deficit (P < 0.05). Harrington rods and Zielke device offer sufficient initial correction of the frontal spinal deformity but did not significantly either restore or maintain sagittal plane alignment. The Harrington series showed an overallimprovement of the segmental kyphosis of 26% (NS), with a subsequent loss of correction of 7.38% (NS) on the follow-up observation. The Zielke device produced an immediate, much better correction of the segmental posttraumatic kyphosis of 45% (NS), but a loss of correction of 22.9% (NS) was measured in the follow-up evaluation. Correction of the anterior and posterior vertebral height was shown to be better for the Zielke patient group. The coronal deformity was completely corrected equally well by the Harrington and Zielke devices. There was no statistically significant correlation between the degree of bony encroachment of the spinal canal and the initial Frankel grade. Additionally, no statistically significant correlation was found between correction of the sagittal deformity, restoration of anterior and posterior vertebral height, coronal deformity correction, and clearance of the vertebral canal. Concerning neurological status, no patient in either group was worse in the follow-up evaluation. A significant correlation was found between the age of the patient and the neurological improvement favoring young patients (P < 0.001).

Spinal bone mineral density changes following halo vest immobilization for cervical trauma

SummaryIn this prospective study we followed the bone mineral density (BMD) changes of the injured cervical spine immobilized with the halo vest. In order to define the natural history of cancellous vertebral bone loss and restoration, dual-energy densitometry was used on each of ten selected cervical spines in the lateral view (1) immediately after the application of the device, (2) at the end of the treatment and (3) 3 months after the removal of the halo vest. The halo vest produces local osteoporosis in the immobilized cervical spine with an overall reduction of BMD averaging 2.83% (P < 0.05). The response of the cervical spine to immobilization was only slightly different from patient to patient and between different vertebral bodies in each particular spine. The type and the level of injury of the cervical spine were not related to the changes of BMD, age or gender of the patient, whereas the local osteoporosis was mostly reversible in the follow-up evaluation of 5–6 months.

Combined VDS and Harrington instrumentation for treatment of idiopathic double major curves

The authors reviewed the results of the combined ventral derotation system (VDS) and Harrington operation in 34 selected patients with idiopathic scoliosis and kyphoscoliosis of double major curve pattern. The use of both VDS and Harrington instrumentation gives better correction and stabilization of the particular curves. It is thought that a greater degree of correction can be obtained in the lumbar curve, thus putting the spine into balance and correcting the kyphosis. The L4 could be centralized and made horizontal, in most operated cases, above the midsacrum. Another useful advantage of the combined procedure is “saving” lower lumbar functional segments.

Effects of the combined VDS-Zielke and Harrington operation on the frontal rib cage deformity of double major curves in idiopathic scoliosis

Study Design. This study analyzed the changes in the frontal plane of the deformed lower rib cage and the scoliosis-related alterations on the spine in patients with double major curve-pattern idiopathic scoliosis. Objectives. The results obtained preoperatively, after the Zielke operation, postoperatively after the Harrington instrumentation, and at the follow-up evaluation were compared to investigate which changes of the elements of the rib cage deformity are caused by each of the two instrumentations. Summary of Background Data. Previously, Wojcik reported on the effects of a Zielke operation on the lower rib in mild S-shaped idiopathic scoliosis. No previous data exist regarding the lower rib cage deformities in severe idiopathic double major-pattern scoliosis and their changes after combined VDS-Zielke and Harrington instrumentation. Methods. Fifteen patients who underwent the staged Zielke operation followed by Harrington rod instrumentation were followed-up for an average period of 31.1 months. The methods used in our study included Cobb angle and a segmental analysis (T7-T12) of each of convex and concave rib-vertebra angles, rib-vertebra angle differences, vertebral rotation, and vertebral tilt. Results. In this series, the apical convex ribs showed an increased droop preoperatively compared with the concave apical ribs. The VDS-Zielke operation corrected the lumbar scoliosis in an average of 63% of patients, whereas the thoracic scoliosis showed an immediate spontaneous correction of 30%. The VDS-Zielke operation also produced a significant correction of the scoliosis-related vertebral tilt (T10-T12), derotated the lumbar vertebrae and the T12 vertebra significantly, elevated the “mobile” concave ribs, and increased the droop of the lower (T11, T12) “mobile” convex ribs. The Harrington instrumentation did not change the vertebral rotation, the vertebral tilt, the convex rib-vertebra angle, or the L4 obliquity, but significantly changed the apical concave rib-vertebra angle. The combined Zielke-Harrington instrumentation reduced the thoracic kyphosis and the thoracolumbar junction-kyphosis significantly, whereas the lumbar lordosis remained practically unchanged. Conclusions. Only the anterior VDS-Zielke instrumentation significantly corrects severe spinal deformities, elevates the three lower ribs on the concavity, and increases the droop of the two lower ribs on the convexity in the severe idiopathic double major curve-pattern scoliosis combined operated (Zielke-Harrington). Therefore, the Harrington instrumentation should have only limited use in cosmetic scoliosis surgery and should be replaced with posterior multi-hook instrumentation with a derotation effect.

Primary osteosarcoma of the L2 lamina presenting as “silent” paraplegia: case report and review of the literature

SummaryPrimary osteosarcomas of the vertebral column are not common, and to our knowledge a total of 78 cases, mostly located in the vertebral body, have been previously reported. We report a primary osteosarcoma of the spine with an extremely rare location — the lamina of the second lumbar vertebra. The patient, a 38-year-old woman, was admitted with paraplegia of a short duration without pain. Preoperatively, the patient underwent CT scanning for staging (Enneking IIB) followed by a needle biopsy and local preoperative arterial embolization. An emergency decompressive laminectomy was performed, and stabilization was carried out using methylacrylate. The patient showed a complete neurologic recovery. Combined chemotherapy and local irradiation did not prevent tumor recurrences, which occurred 12 and 19 months after the initial intervention and were associated with recurrent neurologic impairment. The patient died 19 months after the initial presentation, while in paraplegia, from lung metastases. Based on our unique observation, it seems that in primary osteosarcomas located in the posterior elements of the spine, the symptoms are not specific, and the disease may only become manifest when the tumor is no longer resectable. When the tumor is associated with neurologic impairment, spinal canal decompression should be performed even though it does not radically resect the tumor because it significantly improves the quality of the patients life.