Ufuk Talu

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.

Assessment of curve flexibility in adolescent idiopathic scoliosis.

Study Design. A prospective comparative evaluation of the commonly accepted or described radiologic techniques to determine curve flexibility in adolescent idiopathic scoliosis (AIS), comparison of the results to those obtained by supine traction radiographs taken with the patient under general anesthesia (UGA) just before surgery and correlation of all findings to surgical correction. Objective. To determine if supine traction radiographs taken with the patient UGA help provide better assessment of curve flexibility and better predicting surgical correction. Summary of Background Data. Supine lateral bending radiographs are the standard methods of evaluating curve flexibility before surgery in idiopathic scoliosis. Supine traction radiographs have also been used at the authors’ institution in addition to the supine lateral bending radiographs before surgery, believing that it is usually more helpful to analyze the response of the main and compensatory curves to corrective forces. Methods. A total of 34 consecutive patients with AIS who had surgical treatment were studied. Preoperative radiologic evaluation consisted of standing anteroposterior and lateral, supine lateral bending and traction, fulcrum bending radiographs, and also supine traction radiographs taken with the patient UGA just before surgery. All structural curves were measured, and the flexibility ratio was determined on each radiograph. The amount of correction obtained by all radiographic methods was compared with the amount of surgical correction by evaluating the differences from surgery as absolute values. Mean absolute differences from surgery were used to determine the confidence intervals. Statistical differences were calculated with the comparison of the exact 95% confidence intervals for the mean. Results. Curves were accepted to be moderate if between 40° and 65° (29 patients) and severe if >65° (5 patients). In these 29 patients, average frontal Cobb angle of the thoracic and lumbar curves were 49.7° (range 40°−60°) and 39.4° (range 22°−58°), respectively. For the moderate thoracic curves, fulcrum radiographs providedthe best amount of flexibility, with no significant difference from traction with the patient UGA but with significant difference from bending radiographs. For the moderate lumbar curves, flexibility obtained by fulcrum and bending radiographs were significantly better than traction radiographs with the patient UGA. For the lumbar and thoracic curves more than 65°, traction radiographs with the patient UGA provided clearly better flexibility compared to bending and fulcrum radiographs, however, the number of patients is not enough to determine whether the differences are statistically significant. Better flexibility in traction radiographs with the patient UGA helped us eliminate the need for anterior release in all 5 patients who had severe and rigid curves more than 65°, which did not bend to less than 40° and were planned to have anterior release. Conclusion. Fulcrum higher than bending higher than traction with the patient UGA is the order of radiographs for better predicting flexibility and correction in curves between 40° and 65°. Flexibility obtained at traction radiographs with the patient UGA is clearly better in numerical values, and closer to the amount of surgical correction than the amount of flexibility at fulcrum and side-bending radiographs for curves larger than 65°, although not statistically significant as a result of the small number of patients in this group. However, pedicle screw instrumentation provides even more correction than the traction radiographs with the patient UGA. Thus, traction radiographs with the patient UGA may show much better flexibility, especially in more than 65° and rigid curves.

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.

Superior cluneal nerve entrapment

Background and Objectives Pain due to superior cluneal nerve entrapment is an infrequent cause of unilateral low back pain. Here we present a case of acute unilateral low back pain treated by superior cluneal nerve (SCN) block. Case Report A 55-year-old woman presented to the outpatient clinic suffering from unilateral low back pain localized to right iliac crest and radiating to the right buttock. Her history was taken, physical examination was performed, and a thorough radiologic evaluation was performed to minimize radiculopathy and facet syndromes as causative. After transient pain relief with a diagnostic trigger point injection, entrapment of SCN was diagnosed and therapeutic nerve block with local anesthetic and steroid combination was performed. Conclusion SCN is prone to entrapment where it passes through the fascia near the posterior iliac crest. Unilateral low back pain and deep tenderness radiating to the ipsilateral buttock are the clinical findings accompanying SCN entrapment. The case presented emphasizes the relief of possible SCN after limiting other etiologic causes of low back pain.

Surgical correction of kyphosis: posterior total wedge resection osteotomy in 32 patients.

Background Many surgical procedures have been developed for the treatment of kyphoscoliosis. We present our experience of one technique for posterior total wedge resection osteotomy, with clinical and radiographic results. This is a one-stage solution which results in a shortened posterior column and reduced tension on the spinal cord in rigid angular kyphosis. Patients and methods Between 1990 and 2000, we treated 32 patients with rigid local kyphosis by posterior wedge osteotomy and instrumentation. The etiology was congenital malformation in 17 cases, infection in 11 and previous laminectomy in 4 cases. The osteotomy is performed at the apex of the kyphotic deformity and covers two vertebrae. The upper and lower borders of the osteotomy are right inferior to the transverse processes of the upper and lower vertebrae respectively. The apex of the posteriorly based triangular osteotomy is either at the anterior vertebral body or anterior longitudinal ligament. Results The mean preoperative angle of local kyphosis was 72 (25–112) degrees mainly at the thoracolumbar region, and it improved to a mean of 23 (0–48) degrees after an average follow-up of 57 (24–108) months. The mean preoperative sagittal plumbline imbalance of 5.5 (2–12) cm was improved to 1.2 (−2–3.5) cm postoperatively. The mean loss of correction since operation was 3.4 (0–11) degrees. Radiographically, solid anterior and posterior fusion was achieved in all patients by 6 months. 1 patient had irreversible paraplegia and 2 others had transient nerve root injury postoperatively. Interpretation Posterior total wedge resection osteotomy eliminates the need for anterior procedure and does not cause tractional force on the spinal cord, since the posterior column is shortened. This is an effective one-stage procedure, especially for the treatment of sharp and rigid kyphosis.

Magnetic resonance imaging of tuberculous spondylitis.

The clinical and imaging findings of patients with a confirmed diagnosis of tuberculous spondylitis were retrospectively analyzed to assess the diagnostic value of magnetic resonance imaging (MRI) and determine the different patterns of spine involvement. Fifty-three patients with plain radiographs and MRI of the entire spinal column were included in the study. Sagittal T1- and T2-weighted MRIs of the entire spine and axial T1- and T2-weighted MRIs at the levels of interest were retrospectively evaluated. Plain radiographic correlation was obtained in all patients. The lower thoracic and thoracolumbar spine was the most commonly involved region. Magnetic resonance imaging is effective in the early diagnosis of tuberculous spondylitis. It also detects lesions, which may not be apparent on plain radiographs.

Bone healing regulated by nitric oxide: an experimental study in rats.

Nitric oxide has many functions in wound healing and metabolism of bone. In the current study the role of nitric oxide on bone healing was investigated. Thirty-six young adult male Sprague-Dawley rats were divided into three groups: control, nitroso-bovine serum albumin, and aminoguanidine. Five millimeter segmental defects were created in the middle of the right femora. A polyethylene plate and screw posts were used for rigid fixation. Demineralized bone matrix served as the graft material in all groups. Nitroso-bovine serum albumin (an active nitric oxide congener) carried by demineralized bone matrix was applied locally at the defect in the nitroso-bovine serum albumin group. Aminoguanidine (an inducible nitric oxide synthase inhibitor) group received oral aminoguanidine treatment. Formation and healing of bone were determined by radiographic and histologic analyses. In comparison to the control group the healing rate was faster in both experimental groups as indicated by radiographic and histologic data. If accompanied by bone graft with a suitable delivery system, nitric oxide may be useful as a therapeutic adjuvant in clinical situations when local formation of bone is needed. Moreover, when combined appropriately, treatment with orthotopic nitric oxide supplementation and systemic inducible nitric oxide synthase inhibition may enhance bone healing.

Long-term result of treatment for paraspinal and extradural hydatid cyst: a case report

Hydatid cyst is a zoonosis affecting any part of the body and presenting difficulty in diagnosis and treatment. Primary bone involvement seen in about 2% of the cases is accompanied by spinal involvement in 50%. A 41-year-old female presented with low back pain radiating to the left leg. After physical examination, radiologic and laboratory investigations, a diagnosis of spinal hydatid cyst was made with intraspinal extradural, vertebral, and paravertebral involvement. The patient was treated with two-staged posterior and anterior surgical resections with addition of pre- and postoperative antihelminthic therapy. No recurrences developed within a follow-up of 5.5 years. Recurrences can be reduced by initiation of antihelminthic therapy preoperatively, perioperative injection of scolicidal agents into the cyst, and careful excision of the cyst without spread to neighboring tissues.

Vertebral osteomyelitis after cardiac surgery

BACKGROUND Mediastinitis after open-heart surgery is a serious complication that has a decreasing incidence but still a significantly high mortality rate. Back pain may develop during the course of treatment for mediastinitis, and this should suggest vertebral osteomyelitis in the differential diagnosis. Diagnosis of vertebral osteomyelitis may be difficult because of the insidious onset and delayed diagnosis, and treatment may result in serious neurologic compromise and even death of the patient. METHODS This retrospective study involves 5 patients who had open-heart surgery and mediastinitis that was further complicated by vertebral osteomyelitis. Average delay in diagnosis was 18 days after the onset of symptoms. Magnetic resonance imaging was the most helpful tool for diagnosis. Methicilline-resistant Staphylococcus aureus was identified as the responsible microorganism in all patients. Neurologic compromise occured (one paraplegia and one paraparesia) in 2 patients during medical treatment. RESULTS Along with the medical treatment, all patients were surgically treated due to either one or more of the following reasons: unresolving symptoms, sudden neurologic compromise, or impaired spinal column stability despite appropriate conservative treatment. One patient died 10 days postoperatively. The mean follow-up period for the remaining 4 patients was 47 (12 to 95) months. Complete recovery was achieved, and they were able to return to their routine daily activities. CONCLUSIONS Vertebral osteomyelitis should be borne in mind when a patient develops back pain during the course of mediastinitis. Suspicion, early diagnosis with appropriate imaging, and proper treatment are crucial to prevent catastrophic complications.

Total knee and hip arthroplasty in a patient with dwarfism: a report of a patient with a spondylo-epiphyseal dysplasia

In patients with spondylo-epiphyseal dysplasia, coxa vara and genu valgum deformities cause malalignment, which lead to early degenerative changes in hip and knee. It is mandatory to give them a functional replacement for their deformed, painful knees and hips to lead a normal life. We report a patient with inherited dwarfism on whom a replacement of knee and hip was performed.RésuméChez les patients présentant une dysplasie spondylo-épiphysaire, la coxa vara et les genu valga sont responsables de malalignements, qui mènent aux changements dégénératifs précoces de la hanche et du genou. Il est obligatoire de leur offrir une arthroplastie pour que, malgré leurs genoux et hanches déformés et douloureux, ils puissent mener une vie normale. Nous rapportons le cas d’un patient atteint de nanisme héréditaire chez lequel un remplacement de genou et de hanche a été réalisé.