Preparing for Success: Neural Frontal Theta and Posterior Alpha Dynamics during Action Preparation Predict Flexible Resolution of Cognitive Conflicts.

Cognitive conflicts typically arise in situations that call for sudden changes in our behavior. Resolving cognitive conflicts is challenging and prone to errors. Humans can improve their chances to successfully resolve conflicts by mentally preparing for potential behavioral adjustments. Previous studies indicated that neural theta oscillations (4-7 Hz), as well as alpha oscillations (8-14 Hz), are reflective of cognitive control processes during conflict resolution. However, the role or neural oscillations for conflict preparation is still unclear. Therefore, the aim of the current study was to determine which oscillatory changes during conflict preparation predict subsequent resolution success. Participants performed a cued change-signal task, in which an anticipatory cue indicated if the upcoming trial might contain a cognitive conflict or not. Oscillatory activity was assessed via EEG. Cues that indicated that a conflict might arise compared with cues that indicated no conflict led to increases, directly followed by decreases, in theta power, as well as to decreases in alpha power. These cue-induced changes in theta and alpha oscillations occurred widespread across the cortex. Importantly, successful compared with failed conflict trials were characterized by selective increases in frontal theta power, as well as decreases in posterior alpha power during preparation. In addition, higher frontal theta power and lower posterior alpha power during preparation predicted faster conflict resolution. Our study shows that increases in frontal theta power, as well as decreases in posterior alpha power, are markers of optimal preparation for situations that necessitate flexible changes in behavior.

The APOE E4 Allele Confers Increased Risk of Ischemic Stroke Among Greek Carriers.

BACKGROUND: Although several studies in various countries have indicated that the presence of the E4 allele of the apolipoprotein-E (APOE) gene is a risk factor for ischemic cerebrovascular disease, the strength of this association still remains a matter of debate. OBJECTIVES: The aim of the study was to determine the frequency of the APOE E4 allele and various other gene polymorphisms in in a well-characterized sample of Greek patients and to evaluate the potential associations with the risk of ischemic stroke (IS) and coronary heart disease (CHD). MATERIAL AND METHODS: A total of nine gene variants/polymorphisms - F5 (Leiden - R5 06Q, rs6025), F2 (20210G > A, rs1799963), F13A1 (V34L, rs5985), MTHFR (677C > T - A222V, rs1801133), MTHFR (1298A > C - E429A, rs1801131), FGB (-455G > A -c.-463G > A; rs1800790), SERPINE1 (PAI14G/5G - rs1799889), ACE (ACE I/D, rs1799752), ITGB3 (GPIIIa L33P, rs5918) and the APOE E2/E3/E4 alleles (rs7412, rs429358) - were genotyped in 200 newly diagnosed ischemic stroke (IS) patients, 165 patients with ischemic coronary heart disease (CHD) and 159 controls with no cerebroor cardiovascular disease (non-CVD). A statistical analysis was performed using univariate and multivariate logistic regression models. RESULTS: No significant association was found regarding most gene polymorphisms and the presence of IS or CHD in the patient cohort. However, the APOE E4 allele frequency was significantly higher (p = 0.02) among patients with ischemic stroke (IS) or IS + CHD (12.7%) when compared to the controls (5.1%). More accurately, E4 carriers had 2.66 and 2.71 times greater likelihood of IS or IS + CHD than non-carriers, respectively (OR = 2.66, 95% CI 1.39-5.07, OR = 2.71, 95% CI 0.98-7.48). CONCLUSIONS: In contrast to some previous studies, these results support the role of the APOE E4 allele as an independent risk factor for ischemic stroke and ischemic coronary heart disease among Greek patients.

Trigger factors in primary headaches subtypes: a cross-sectional study from a tertiary centre in Greece.

BACKGROUND: Previous studies have shown that common headache triggers contribute to the onset of headache attacks on predisposed individuals and are considered important in the prevention of headache. The aim of this study was to compare the different characteristics of triggers among the most common primary headache subtypes (migraine without aura, migraine with aura and tension type headache). METHODS: A total of 116 headache patients of the neurology outpatient department of a tertiary hospital in Athens were selected according to the criteria of the International Classification of Headaches-3nd Edition Beta. Patients were interviewed using a questionnaire that contained 35 potential trigger factors. RESULTS: The findings showed that migraine and tension-type headache patients report multiple triggers, on a frequent but variable basis. The most frequent triggers reported by all subjects were stressful life events followed by intense emotions. The same applies to both genders, as well as the three headache subgroups. Patients suffering from migraine with aura reported the highest mean number of trigger per person and the highest frequency in almost all the trigger categories. Furthermore, patients with migraine with aura were more likely to report the following triggers: oversleeping, premenstrual period, stressful life events, hot/cold weather, relaxation after stress, menstruation, wind, intense emotions, shining, hunger and bright sunlight. These associations were mostly independent of the sociodemographic characteristics and the presence of anxiety or depressive symptoms. CONCLUSION: The sensitivity to trigger factors should be considered by both clinicians and headache sufferers.

PMMA embolization to the left dorsal foot artery during percutaneous vertebroplasty for spinal metastases.

PURPOSE: Distal arterial embolization to the foot with PMMA during vertebral augmentation has not been previously reported. We report a rare case of distal PMMA embolization to the dorsal foot artery during ipsilateral percutaneous lumbar vertebral augmentation in a patient with spinal osteolytic metastases. METHODS: A 68-year-old woman was admitted because of severe disabling low back pain. Plain roentgenograms, MRI and CT-scan revealed osteolysis in the L4 and L5 vertebral bodies with prevertebral soft tissue involvement. Percutaneous vertebroplasty with PMMA was performed in L2 to L5 vertebrae under general anesthesia. Intraoperatively, leakage into the segmental vessels L3 and L5 was observed. RESULT: Four hours after the procedure the clinical diagnosis of acute ischemia and drop foot on the left was made. CT-angiography justified linear cement leakage in the course of the left third lumbar vein and fifth lumbar artery, and to the ipsilateral common iliac artery. The patient was treated with low molecular heparin and the ischemia resolved without further sequelae 1 week postoperatively. CONCLUSION: PMMA leakage is a complication associated with vertebroplasty and kyphoplasty. Although the outcome of the PMMA embolization to the vessels resolved without sequelae, in our case spine surgeons and interventional radiologists should be aware on this rare complication in patients with osteolytic vertebral metastases even when contemporary cement containment techniques are used.

Posterolateral versus circumferential instrumented fusion for monosegmental lumbar degenerative disc disease using an expandable cage.

BACKGROUND: Theoretically, 360° instrumented fusion has been considered to offer better radiological correction than PLF. Despite numerous publications, this correlation is still weak with several controversies in the relative literature. PURPOSE: This prospective randomized study was designed to compare the radiological segmental results, complications and outcome of 360° instrumented fusion with the use of a single diagonal expandable PLIF device versus posterolateral pedicle screw fixation in monosegmental lumbar DDD and to show that the use of an novel expandable cage is associated with low PLIF-related complication rate compared to conventional cages reported previously. STUDY DESIGN: Prospective randomized controlled clinical and radiological study. PATIENT SAMPLE: Adults who suffered from monosegmental DDD were eligible for enrolment in this trial. We randomly assigned 150 patients to receive either 360° instrumented fusion (group A) with expandable cage or PLF (group B). OUTCOME MEASURES: Differences between the two groups regarding clinical parameters and radiographic sagittal measurements after 36 months of follow-up. METHODS: The record included global [T12-S1 lordosis, sagittal global spinal balance (SB) (C7-mid-femoral axis)] and segmental [segmental disc wedging (SDW), anterior (ADHr) and posterior (PDHr) disc height ratio] radiological measurements at the instrumented segment. Additionally, clinical outcome was evaluated with VAS, SF-36 (Physical function and Bodily Pain) and ODI questionnaires. Fusion was evaluated with the use of Christiansen method. RESULTS: In 73 and 72 participants of group A and B, respectively, who completed follow-up to 36 months, there were no differences with respect to the rate of improvement in SF-36, ODI and VAS scores. However, in the spines of group A, there was a significant increase in anterior disc height ratio (P = 0.0057), posterior disc height (P = 0.016) and segmental disc wedging (P = 0.00021) without subsequent loss of correction. Fusion rate was radiologically shown in 94.5% and 87% spines of group A and B, respectively (P > 0.2). Four and 9 spines in group A and B, respectively, showed non-union at the final observation. CONCLUSIONS: Our findings suggest that 360° fusion offers better sagittal radiological restoration associated with circumferential fusion. However, this difference seemed not to have any medium-term clinical impact. The use of expandable cage was associated with low PLIF-related complications compared to conventional cages.

Effect of sagittal spinal balance, levels of posterior instrumentation, and length of follow-up on low back pain in patients undergoing posterior decompression and instrumented fusion for degenerative lumbar spine disease: a multifactorial analysis.

STUDY DESIGN: Prospective controlled clinical study on low back pain (LBP). OBJECTIVE: To investigate the possible effects of radiographic and other related parameters on LBP in patients underwent decompression and posterolateral instrumented fusion for degenerative lumbar spine disease. SUMMARY OF BACKGROUND DATA: Sagittal balance of the spine after spine surgery has gained increasing interest regarding its correlation with LBP and fusion rate. To our knowledge, no advanced statistical analysis on the effects of sagittal roentgenographic and other parameters on LBP after lumbar surgery has been published. METHODS: Forty-five patients with an average age of 63 years, who underwent pedicle-screw fixation in 2, 3, and 4 vertebrae for degenerative lumbar spine disease were selected to be included in this study. Radiographic and self-assessment (bodily pain, short form-36) data were evaluated using advanced statistics (multifactorial analysis) to investigate all possible correlations between a dependent parameter (LBP) and independent parameters (sex, extension of instrumentation, sagittal spinal balance, and angular motion at the adjacent free level above instrumentation). RESULTS: All patients were observed for an average of 5.5 years (range, 5-7 years). Male patients showed significantly more improvement of LBP than female counterparts (P = 0.024). LBP improved after surgery by the first year (P < 0.000) and thereafter decreased (P < 0.000) at the final evaluation, but remained at levels significantly higher than before surgery (P < 0.000). The deviation of the apical lumbar vertebra from C7-plumbline was correlated with LBP (P < 0.000). Patients, who received third- and fourth- level instrumentation had less LBP (P = 0.0245) than their counterparts, who received second-level instrumentation. CONCLUSION: Improvement of sagittal deviation of apical lumbar vertebra, instrumentation of third or fourth vertebrae, male gender, and fusion success were correlated with postoperative improvement of LBP after posterior decompression and pedicle screw fixation for symptomatic degenerative lumbar spine disease.This research suggests that the methods directed at the improvement in sagittal spinal balance of the lumbar spine, careful selection of fusion levels, and improvement of fusion rate might be beneficial for decreasing LBP after surgery in degenerative lumbar spine disease.

Beneficial influence of titanium mesh cage on infection healing and spinal reconstruction in hematogenous septic spondylitis: a retrospective analysis of surgical outcome of twenty-five consecutive cases and review of literature.

STUDY DESIGN: Single institution, single surgeon retrospective review. OBJECTIVE: To investigate if the use of titanium mesh cage on the site of infection could be beneficial for successful outcome of the operative treatment for pyogenic spondylitis. SUMMARY OF BACKGROUND DATA: There is a controversy concerning the optimal treatment for pyogenic spondylitis regarding approach, instrumentation and staging. This large series reports on single-stage instrumented open and minimally invasive surgery for septic spondylitis. METHODS: Twenty-four patients aged 57 +/- 16 years suffering from persistent or complicated septic spondylitis were treated by a total of 25 single stage combined surgeries (first: anterior debridement/partial vertebrectomy plus mesh cage filled with autologous bone graft; second: pedicle screw fixation with open and minimal invasive techniques). The indications for surgery included neurologic compromise, significant vertebral body destruction with kyphosis associated with segmental instability, failure of medical treatment, and/or epidural/ paravertebral abscess formation. Needle biopsy was performed in all patients before surgery. Patients were evaluated before and after surgery in terms of pain and neurologic level, sagittal segmental spinal balance, radiologic fusion and recovery. RESULTS: All but 1 tetraplegic patient with simultaneous cervical and lumbar spondylitis, who died because of massive clot lung embolism 2 months after surgery, were followed for 56 months (range, 31-116 months) The visual analogue scale score improved from 6.5 before surgery to 1.8 after surgery. The segmental kyphotic deformity was corrected at an average of 6 degrees, without cage settling. An insignificant loss of kyphosis correction of an average 0.6 degrees was measured in the thoracolumbar junction only. Blood loss, surgical time, and surgical complications were significant less in the patients who operated with minimal invasive technique. Patients with incomplete neurologic impairment improved after surgery. Physical function (SF-36) averaged 72 1 year after surgery. All operated patients had resolution of infection. There was neither migration of mesh cage nor posterior instrumentation failure at the last follow-up observation. CONCLUSION: The present study showed that radical debridement of spinal infection and anterior insertion of titanium cage, filled with autogenous bone graft, secured with pedicle screw instrumentation should have had a beneficial influence on the eradication of infection, segmental and global spinal reconstruction and fusion. Supplementary posterior minimal invasive pedicle screw fixation eliminates posterior soft tissue injury and preserves blood supply, and reduces surgical time, blood loss, and surgical complications.

Ultrasonography in differentiation between chronic viral hepatitis and compensated early stage cirrhosis.

AIM: To assess the value of gray scale (GS) and colour Doppler ultrasonography (CDU) in differentiating the progression of chronic viral hepatitis (CVH) and compensated liver cirrhosis (CIR). METHODS: Seventy-two patients and 32 normal individuals who were used as controls were studied. Forty-four patients suffered from CVH and 28 from CIR. All patients were underwent to liver biopsy. Multiple qualitative and quantitative variables were studied in liver, portal vein (PV), hepatic artery (HA) and spleen with GS and CDU. On the basis of the obtained CDU data, several known indexes were calculated. In addition, alternative indices [PV diameter (D)/time average mean velocity (VTAM), HA/PV VTAM ratio] were calculated and studied. RESULTS: ROC analysis showed that PV congestion index, PV D/VTAM and HA/PV VTAM indices had the best sensitivity and specificity in discriminating CVH from CIR. Stepwise discriminant analysis showed that 88.9% of the originally grouped cases could be correctly classified by the three qualitative and four quantitative variables selected as statistically significant predictors. Among the CVH patients who underwent to biopsy, statistically significant changes were found in those at fibrosis stage 5 compared to fibrosis stages 1-4. CONCLUSION: Simple GS and CDU parameters discriminate CVH from CIR. The alternative Doppler indexes can accurately differentiate chronic virus hepatitis from cirrhosis. These indexes can be used in monitoring chronic virus hepatitis and avoiding unnecessary biopsies.

Direct reduction of thoracolumbar burst fractures by means of balloon kyphoplasty with calcium phosphate and stabilization with pedicle-screw instrumentation and fusion.

STUDY DESIGN: Prospective consecutive series. OBJECTIVE: To evaluate the outcomes of the treatment of acute thoracolumbar burst fractures by transpedicular balloon kyphoplasty with calcium phosphate cement and posterior instrumented fusion. SUMMARY OF BACKGROUND DATA: In the surgical treatment of thoracolumbar fractures, the major problem after posterior correction and transpedicular instrumentation is failure to support the anterior spinal column, leading to the loss of correction and instrumentation failure. METHODS: Twenty-three consecutive patients with an average age of 48 years, who sustained thoracolumbar A3-type burst fracture with or without neurologic deficit were included in this prospective study. Twenty-one of 23 patients had single fractures and 2 had each one additional A1 compression contiguous fracture. On admission 5 (26%) of 23 patients had neurologic lesion (5 incomplete, 1 complete). Bilateral transpedicular balloon kyphoplasty was performed with quick hardening calcium phosphate cement to reduce segmental kyphosis and restore vertebral body height and supplementary pedicle-screw instrumentation [long including 4 vertebrae for T9-L1 fractures and short (3 vertebrae) for L2-L4 fractures]. Gardner kyphosis angle, anterior and posterior vertebral body height ratio, and spinal canal encroachment were calculated before to after surgery. RESULTS: All 23 patients were operated within 2 days after admission and were followed for at least 24 months after index surgery. Operating time and blood loss averaged 70 minutes and 250 cc, respectively. The 5 patients with incomplete neurologic lesions improved by at least 1 American Spine Injury Association grade, whereas no neurologic deterioration was observed in any case. Overall sagittal alignment was improved from an average preoperative 16 degrees to 1 degrees kyphosis at final follow-up observation. The anterior vertebral body height ratio improved from 0.6 before surgery to 0.9 (P < 0.001) after surgery, whereas posterior vertebral body height was improved from 0.95 to 1 (P < 0.01). Spinal canal encroachment was reduced from an average 32% before surgery to 20% after surgery. No differences in preoperative values and postoperative changes in radiographic parameters between short and long group were shown. Cement leakage was observed in 4 cases: 3 anterior to vertebral body and 1 into the disc without sequela. In the last computed tomography evaluation, there was shown a continuity between calcium phosphate and cancellous vertebral body bone. Posterolateral radiological fusion was achieved within 6 to 8 months after index operation. There was no instrumentation failure or measurable loss of sagittal curve and vertebral height correction in any group of patients. CONCLUSION: Balloon kyphoplasty with calcium phosphate cement secured with posterior long and short fixation in the thoracolumbar and lumbar spine, respectively, provided excellent immediate reduction of post-traumatic segmental kyphosis and significant spinal canal clearance and restored vertebral body height in the fracture level in an equal amount both in the short and the long instrumentation.

Gray and color Doppler ultrasonography in differentiation between chronic viral hepatitis and compensated early stage cirrhosis.

AIM: To assess the value of Gray scale (GS) and Colour Doppler Ultrasonography (CDU) in differentiating the progression of chronic viral hepatitis (CVH) and compensated liver cirrhosis (CIR). PATIENTS AND METHODS: Seventy-two patients and 32 normal individuals used as controls were studied. Forty-four patients suffered from CVH and 28 from CIR. All patients underwent liver biopsy. Multiple qualitative and quantitative variables were studied with GS and CDU in the Liver, Portal Vein (PV), Hepatic Artery (HA) and spleen. On the basis of the obtained Doppler data several known indexes were calculated. Alternative indexes [PV diameter (D)/time average maximum velocity (Vmax), PV diameter/time average mean velocity (VTAM), HA/PV VTAM ratio] derived from them were calculated. RESULTS: ROC analysis showed that PV Congestion Index, PV D/VTAM and HA/PV VTAM indexes had the best sensitivity and specificity in discriminating CVH from CIR. Stepwise discriminant analysis selected as significant predictors 3 qualitative and 4 quantitative variables that correctly classify 88.9% of the original grouped cases. In CVH patients that underwent biopsy we found statistically significant changes in those at fibrotic stage 5 compared to fibrotic stages 1-4. CONCLUSION: We found significant differences in haemodynamic parameters and indexes for CVH patients at fibrosis stage 5 compared to all other stages. Simple GS and CDU parameters may discriminate CVH from CIR. The alternative Doppler indexes suggested that accurate differentiation between CVH and CIR is possible. These indexes could be useful for monitoring CVH and avoiding unnecessary biopsies.

Evolution of anterior chest wall blood supply in female adolescents with progressive right-convex thoracic idiopathic scoliosis.

Breast asymmetry was believed to be related to the asymmetry of anterior chest wall blood supply and subsequently to etiology of idiopathic thoracic scoliosis in female adolescents. Recent investigations on the anterior chest wall blood supply with colour Doppler ultrasonography in such individuals did not show anatomic and hemodynamic abnormalities. The present study investigated the evolution of anterior chest wall blood supply in these individuals over a 2-year period. Twenty female adolescents with progressive right-convex idiopathic thoracic scoliosis (scoliotics), who were during the study in therapy with thoracolumbosacral orthosis and 20 age-matched girls, without spine deformity (controls) were studied with colour Doppler ultrasonography [internal mammary artery (IMA)] twice within the 2-year period. IMA-anatomic parameters [lumen diameter (D) and cross sectional area (AR)] and also hemodynamic flow parameters [time average mean flow velocity (TAM) and flow volume per minute (FV)] were measured. In the 2-year period of observation, thoracolumbosacral orthosis prevented scoliosis progression (P=0.004), whereas IMA-AR decreased bilaterally in the individuals of both groups (P<0.03). In the last evaluation: in scoliotics right IMA FV decreased (P<0.04), whereas in controls IMA FV decreased bilaterally (P<0.03); left IMA FV was significantly higher (P<0.05) in scoliotics than in controls. The significant, within the 2-year period, decrease of IMA-diameter, cross-sectional area, and flow volume seems to be a physiologic ageing process because it was observed in all individuals (scoliotics and controls) and thus these anatomic and hemodynamic changes seem not to have been affected by bracing. The maintenance of left flow volume of IMA in the prebrace levels in scoliotics was the most significant finding of this investigation. In conclusion, this study provided evidences for abnormalities in the evolution of anterior chest wall blood supply in female adolescents with progressive right-convex female thoracic scoliosis. Further studies are needed to investigate if this asymmetric blood evolution contributes to the development of this pattern of scoliosis in girls.

Asymmetric evolution of anterior chest wall blood supply in female adolescents with progressive right-convex thoracic idiopathic scoliosis.

Breast asymmetry was believed to be related to asymmetry of anterior chest wall blood supply and subsequently to aetiology of idiopathic thoracic scoliosis in female adolescents. Recent investigations on the anterior chest wall blood supply with Colour Doppler Ultrasonography (CDU) in such individuals did not show anatomical and hemodynamic abnormalities. The present study investigated the evolution of anterior chest wall blood supply in these individuals over a 2-year period. Twenty female adolescents with progressive right-convex idiopathic thoracic scoliosis (scoliotics), who were during the study in therapy with horacolumbosacral orthosis (TLSO) and 20 age-matched girls, without spine deformity (controls) were studied with CDU [internal mammary artery (IMA)] twice within the 2-year period. IMA-anatomical parameters [lumen diameter (D) and cross sectional area (AR)] as well as hemodynamic flow parameters [time average mean flow velocity and flow volume per minute (FV)] were measured. In the 2-year-period of observation, TLSO prevented scoliosis progression (P = 0.004), while IMA-AR decreased bilaterally in the individuals of both groups (P < 0.03). In the last evaluation: in scoliotics right IMA FV decreased (P < 0.04), while in controls IMA FV decreased bilaterally (P < 0.03); left IMA FV was significantly higher (P < 0.05) in scoliotics than in controls. The significant, within the 2-year period, decrease of IMA-diameter, cross-sectional area, and flow volume seems to be a physiological ageing process because it was observed in all individuals (scoliotics and controls), and thus these anatomic and hemodynamic changes seem not to have been affected by bracing. The maintenance of left flow volume of IMA in the pre-brace levels in scoliotics was the most significant finding of this investigation. In conclusion, this study provided evidence for abnormalities in the evolution of anterior chest wall blood supply in female adolescents with progressive right-convex female thoracic scoliosis. Further studies are needed to investigate if this asymmetric blood evolution contributes to the development of this pattern of scoliosis in girls.

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 degrees and 5 degrees 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.

Anterior surgery with insertion of titanium mesh cage and posterior instrumented fusion performed sequentially on the same day under one anesthesia for septic spondylitis of thoracolumbar spine: is the use of titanium mesh cages safe?

STUDY DESIGN: Retrospective study. OBJECTIVE: To evaluate the outcome on patients with pyogenic spondylitis of the thoracolumbar spine following combined anterior and posterior surgery. SUMMARY AND BACKGROUND DATA: Several methods of surgical treatment of pyogenic spondylitis have been reported. These include anterior approach, staged and simultaneous anterior decompression, and posterior stabilization. The use of anterior implants in the presence of an infection presents a challenge for spine surgeons. This study analyzes the clinical and radiologic outcome of surgical intervention on patients with pyogenic spondylitis of the thoracolumbar spine who were treated surgically for intractable pain, instability, and neurologic impairment. METHODS: Fourteen patients (6 women, 8 men) with thoracolumbar spondylitis were treated with anterior surgery with insertion of titanium mesh cage and posterior instrumented fusion performed sequentially on the same day under one anesthesia. The age (average, SD) of the patients at the time of surgery was 55 +/- 16 years (range, 29-83 years). Most patients had also systemic diseases as lung tuberculosis, hepatic cirrhosis, diabetes mellitus, or chronic renal failure. Patients were evaluated before and after surgery in terms of pain, neurologic level, sagittal spinal balance, and radiologic fusion. RESULTS: The average duration of the combined surgery was 4.5 hours. All patients were observed up for an average of 45 months (range, 37-116 months). The Visual Analog Scale score (average, range) improved from 7 (range, 4-10) before surgery to 2 (range, 0-5) after surgery. Correction (average, range) of segmental kyphotic deformity was 6 degrees (range, 0 degrees-11 degrees) without loss of correction at the final observation. Neither a postoperative change of the position of mesh cage nor any posterior instrumentation failure was recorded. Patients with incomplete neurologic impairment showed improvement after surgery at an average 1.4 Frankel's grade. There was one complication, an anterior wound abscess culminating in an abdominal hernia. CONCLUSIONS: This clinical study showed that patients with thoracolumbar osteomyelitis can successfully undergo anterior surgery with insertion of titanium mesh cage and posterior instrumented fusion performed sequentially on the same day under one anesthesia. The presence of the mesh cage anteriorly at the site of spondylitis had no negative influence on the course of infection healing, and additionally it stabilized the affected segment maintaining sufficient sagittal profile.

One-stage combined surgery with mesh cages for treatment of septic spondylitis.

UNLABELLED: There is a controversy regarding most effective operative method for treatment of pyogenic spondylitis and whether to use metallic implants on the site of infection. This retrospective study reports on the outcome of 17 patients with persistent cervical and lumbar pyogenic spondylitis who had one-stage combined surgery and fusion with use of a titanium mesh cage for intractable pain, kyphosis, and neurologic impairment. All patients tolerated the combined operation and were followed up on for 45 months. Incomplete neurologic lesions improved postoperatively an average 1.4 Frankel grades. Visual analog pain score (mean) improved from 7 preoperatively to 2 postoperatively. Average correction of local kyphotic deformity was 6 degrees without loss of correction at final observation. There was no expulsion or migration of any titanium mesh cage or loosening of the posterior instrumentation. There was an approach-related abdominal hernia after wound infection. At the final followup, the combined operation in combination with the use of the mesh cage improved sagittal alignment and resulted in eradication of the infection and attainment of solid fusion. The presence of the titanium mesh cage anteriorly at the site of infection had no adverse effect on the course of infection. Patients with cervical and lumbar osteomyelitis can successfully have instrumented-combined, one-stage surgery. LEVEL OF EVIDENCE: Prognostic study, Level II (retrospective study). Please see the Guidelines for Authors for a complete description of levels of evidence.

Colour Doppler ultrasonography for evaluation of anterior chest blood supply: the possible role of arterial blood supply to the costosternal junction in the aetiology of idiopathic scoliosis in female adolescents.

This prospective comparative study was carried out to investigate the blood supply to the anterior chest wall by measurement of several anatomical and haemodynamic flow parameters of the internal mammary artery, with the use of colour Doppler ultrasonography, in female scoliotics with idiopathic right convex scoliosis in adolescence. Previous investigations have postulated that asymmetry of the breasts in female adolescents may be linked with the development of right convex thoracic scoliosis. This breast asymmetry is supposed to be linked with anatomical and functional asymmetry of the internal mammary artery that is the main supplier to the mammary gland. However, no measurements of anatomical and haemodynamic parameters of the internal mammary artery have been made to justify or reject the hypothesis of asymmetric blood flow volume to the breasts and costosternal junction in female adolescent scoliotics. Twenty female adolescents with right convex thoracic scoliosis and 16 comparable female individuals without spine deformity were examined with roentgenograms (scoliotics only) to measure scoliosis curve, vertebral rotation and concave and convex rib-vertebra angle at three vertebrae (the apical, one level above and one below the apical vertebra). Doppler ultrasonography was used to measure, at the origin of the internal mammary artery, its lumen diameter, cross-sectional area, time average mean flow and flow volume per minute in scoliotics and controls, which were compared with each other. The roentgenographic parameters were compared with the ultrasonographic parameters in the scoliotics to disclose any relationship. The reliability of colour Doppler ultrasonography was high and the intra-observer variability low (ANOVA, P=0.92-0.94). There was no statistically significant difference in the ultrasonographic parameters of the internal mammary artery between right and left side in each individual as well as between scoliotics and controls. In scoliotics the right mammary artery time average mean velocity increases with the convex ( P<0.05) and concave ( P<0.01) rib-vertebra angle one level above the apical vertebrae and with the apical convex rib-vertebra angle ( P<0.05). The right internal mammary artery flow volume per minute increases with convex ( P<0.01) and concave ( P<0.01) rib-vertebra angle one level above the apical vertebrae and with the apical convex rib-vertebra angle ( P<0.05). Left internal mammary artery cross-sectional area increases with convex apical rib-vertebra angle ( P<0.01) and concave rib-vertebra angle one level above the apical vertebra ( P<0.01). Conclusively, this investigation showed that haemodynamic flow parameters of the right internal mammary artery and anatomical parameters of the left internal mammary artery are significantly correlated with the magnitude of rib-vertebra angles close to the apex of right thoracic scoliosis in female adolescents. This study did not find any evidence for side-difference in vascularity of the anterior thorax wall and, thus, it could not clearly justify previous theories for development of right thoracic scoliosis in female adolescents.

Color Doppler ultrasonography for evaluation of internal mammary artery application in adolescent female patients with right-convex thoracic idiopathic scoliosis.

STUDY DESIGN: Prospective comparative study. OBJECTIVE: To establish the use of Color Doppler Ultrasonography to investigate internal mammary artery. SUMMARY OF BACKGROUND DATA: Breast asymmetry in female adolescents with right convex idiopathic scoliosis was supposed to be linked with anatomic and functional asymmetry of the internal mammary artery that is the main supplier to the mammary gland. However, no measurements of anatomic and hemodynamic parameters of internal mammary artery have been made to justify or to reject the hypothesis of asymmetric blood flow volume to the breasts and costosternal junction in female adolescent scoliotics. Color Doppler Ultrasonography is a well established noninvasive method to assess vessel anatomy and hemodynamics. METHODS: Twenty female adolescents with right thoracic scoliosis and 16 comparable female individuals without spine deformity were examined with Color Doppler Ultrasonography to measure at the origin of internal mammary artery lumen diameter, cross sectional area, time average mean flow and flow volume per minute and were compared each other. RESULTS: The reliability of Color Doppler Ultrasonography was high and the intraobserver variability low (ANOVA, P = 0.92-0.94). There was no statistically significant difference in the ultrasonographic parameters of the internal mammary artery between right and left side in each individual as well as between scoliotics and controls. CONCLUSIONS: Color Doppler Ultrasonography applied to assess anatomic or hemodynamic blood flow parameters at the origin of internal mammary artery was proven a highly reliable method. Color Doppler Ultrasonography disclosed no side-differences, while there were no differences between scoliotics and controls. Thus, it seems that this study cannot justify previous theories for development of right thoracic scoliosis in female adolescents.

Short-term results with the Zweymueller-SL metal-on-metal total hip arthroplasty.

In a prospective study we followed 266 consecutive patients who received 350 Zweymueller-SL uncemented total hip replacements with metal-on-metal articulation for osteoarthritis. Mean follow-up was 52 (range 37-92) months. Patient age at the time of surgery was 55±9 (25-70) years. Pre-operative Harris score of 45±19 was increased post-operatively to 96±4. Pre-operative invalidity was significantly improved post-operatively (P<0.001), and 97% of the patients were either satisfied or very satisfied with the results. There was no aseptic loosening of either component. Revision was made in six hips (1.8%) because of either septic loosening (five, 1.5%) or technical error (one, 0.3%). At revision, surgical microscopic evidence for metalosis (Mirra grades 1 and 2) was shown in all revised hips. The reasons for early loosening were unrelated to the metal-on-metal bearing but rather were the result of either low-grade deep infection or inadequate surgical technique. Survival rate for Zweymueller screw socket and stem 7.6 years after implantation was 99.4% and 96.8% respectively. There was no evidence that metal-on-metal articulation gives rise to new problems or complications.