Creatine Kinase and Myoglobin Levels as Indicators of Perioperative Muscle Damage during Open- and Mini-Invasive Stabilization of Thoracic and Lumbar Spine Fracture - a Prospective Randomized Study.

PURPOSE OF THE STUDY In this randomized prospective study, we monitored and compared perioperative changes in skeletal muscle enzymes blood levels in open and mini-invasive stabilization of thoracolumbar spine fractures. The established hypothesis was to confirm higher blood levels of muscle enzymes in open stabilization. MATERIAL AND METHODS This study included 38 patients with the mean age of 46.4 years. 19 injuries were managed in an open procedure and 19 procedures were mini-invasive. Venous blood was taken intermittently at short intervals to determine the levels of skeletal muscle enzymes. The catalytic concentration of creatine kinase was determined via an enzymatic UV-test, and the concentration of myoglobin via electro-chemiluminescent immunoassay. Enzyme levels were processed statistically. The Wilcoxon test was used. RESULTS The median increase in the values of both enzymes is higher in the mini-invasive method than in the open method in both the surgery phase for the injury and in the extraction phase. The median increase in the values of both enzymes is higher in both methods for the primary procedure phase compared to the extraction phase. All results are statistically significant at p of <0.05. All tests were calculated using the MATLAB Statistics Toolbox. DISCUSSION A very surprising finding, when testing the hypothesis of the levels increasing mainly in open stabilization, was confirming the opposite. Both enzymes were higher in the mini-invasive approach to stabilising the spine after the injury, but also after the extraction. This contradicts the available literature. However, this can be explained by the methodology of enzyme levels determination in the previously published studies. We believe that this phenomenon can be partially caused by an iatrogenic mini-compartment of muscles in the postoperative period, absence of wound drainage, but also by higher muscle contusion when inserting bolts through the tubes via small incisions, when the tubes penetrate to the entry points relatively violently and the muscles in this area are affected more than in the classical skeletization. CONCLUSIONS Analysis of biochemical changes in open and mini-invasive surgery did not confirm the hypothesis that levels of creatine kinase and myoglobin enzymes increase especially in open stabilization. On the contrary, they were statistically significantly higher in mini-invasive procedures. Key words: creatine kinase, myoglobin, muscle enzymes, spine fracture, spine surgery, miniinvasive surgery.

[Outcomes of Treatment of Calcaneal Fractures Using Locking Compression Plate with or without Augmentation]. / Výsledky lécení zlomeniny patní kosti LCP dlahou s augmentací a bez augmentace.

PURPOSE OF THE STUDY The retrospective study aims to compare the outcomes of augmentation of neutral triangle formed after the calcaneal fracture reduction with osteosynthesis using the locking compression plate with the outcomes of osteosynthesis without augmentation. MATERIAL AND METHODS In the period from 2005 to January 2011, 98 patients with 114 calcaneal fractures were treated by open reduction and internal fixation (ORIF) method with the use of calcaneal plate. The group included 15 women (15.3%) and 83 men (84.7%), with the mean age of 39.2 years (12-62 years). There were 16 cases of bilateral calcaneal fractures, of which 2 in women (12.5%) and 14 in men (87.5%). The fractures were classified based on the Sanders classification as Type I -IV. The patients with Type II and III fracture according to the Sanders classification were indicated for surgical treatment with ORIF using the calcaneal LCP. The defect in the region of neutral triangle of the calcaneus was filled with the injectable hydroxyapatite cement. The cohort of operated patients was evaluated based on the AOFAS (American Orthopaedic Foot and Ankle Society) Clinical Rating System. The bilateral fractures were not evaluated. This group shows a substantially higher occurrence of associated injuries, which causes strong distortion of results. RESULTS The cohort of 82 operated patients with Sanders Type II and III fractures were evaluated. In 20 fractures (24.4%) the defect in the calcaneus body was filled with hydroxyapatite cement. In osteosynthesis without defect augmentation an excellent result was achieved in 21 patients (33.9%). A good result was reported in 24 patients (38.7%), a satisfactory result in 12 patients (19.4%) and a poor result in 5 patients (8.0%). In patients with osteosynthesis of the calcaneus with augmentation, an excellent result was achieved in 6 cases (30%), a good result in 5 cases (25%), a satisfactory result in 7 cases (35%) and a poor result in 2 cases (10%). Early postoperative complications were observed in a total of 13 patients (15.8%). In osteosynthesis without defect augmentation, there were 2 cases of wound dehiscence (3.2%), 3 cases of marginal skin necrosis (4.8%), 4 cases of superficial wound infection (6.4%) and 1 case of deep wound infection (1.6%). In patients with performed augmentation, wound dehiscence was seen in 1 case (5%), superficial wound infection in 1 case (5%) and superficial marginal skin necrosis in 1 case (5%). Deep wound infection was not reported in this group. DISCUSSION A question frequently discussed is the filling of defect in the diaphysis of calcaneus. Brodt et al. state a statistically higher stability of the calcaneus in osteosynthesis with augmentation, but he does not use the locking plate. Longino in his study compares the results of calcaneal osteosynthesis with spongioplasty with a graft from pelvis and without it and does not observe any major differences in the final outcome in his cohort. Elsner evaluates the results in 18 patients, in whom calcium phosphate cement augmentation was used for osteosynthesis. Over the period of three years he did not observe a higher rate of complications. Schildhauer assesses the early load of the calcaneus with tricalcium phosphate cement augmentation. After three weeks of full loading no loss of reduction was found. Thordarson evaluates 11 operated patients with Sanders type II and III calcaneal fracture. The defect of the calcaneus was filled by calcium phosphate cement. In this small group 1 case of serious infection complication and 1 loss of reduction with full load at six weeks after the surgery were observed. In our group no differences were observed between the outcomes of patients with performed or not performed defect augmentation in the neutral triangle site. A higher percentage of complications in patients with filled defect of the calcaneus was not observed either. CONCLUSIONS The operative treatment of displaced intra-articular fractures consisting of open reduction from extended lateral approach and internal calcaneal LCP fixation brings good results. We concluded that there is no statistically significant difference in the results of osteosynthesis with a locking plate alone and combined with augmentation of diaphyseal defect of the calcaneus. Filling of the diaphyseal defect in the calcaneus is not necessary, it neither accelerates the healing, nor brings better treatment outcomes Key words: calcaneal fracture, cement augmentation of defect, locking plate, extended lateral approach.

[Lumbar total disc replacement. Short-term results]. / Mobilní náhrada bederních plotének - krátkodobé výsledky.

PURPOSE OF THE STUDY: Motion-preservation technologies for spinal disorders have evolved and come into use in the last decade. Three principal systems are currently available: total disc replacement, posterior neutralisation transpedicular system and interspinous implants. The aim of this retrospective study was to evaluate our group of lumbar total disc replacements at a follow-up of 2 years. MATERIAL AND METHODS: A total of 42 disc prostheses were implanted in 37 patients. Of these, 31 with 35 artificial discs were followed up for 2 years. There were 11 men and 20 women with an average age of 42.9 years (range, 21 to 61 years). The indication for surgery was lumbar disc pain without radicular syndrome and contraindications included advanced degenerative facet joint disease and obesity with a body mass index over 30. Surgery was carried out through the pararectal retroperitoneal approach. Early and late complications were recorded. The group evaluation was based on radiological outcomes, and VAS and ODI scores reported by the patients at 6 weeks, and 3, 6, 12 and 24 months after surgery. RESULTS: The average operative time was 68 minutes (range, 36 to 120 min) for single-level lumbar total disc replacement and 92 minutes (range, 72 to 130 min) for two-level procedures. The average hospital stay was 5.2 days (range, 3 to 12). Both keels of the prosthesis were in the exact center in 25 cases, they were shifted laterally in nine cases up to 2 mm and in one case more than 2 mm. Horizontal rotation of the prosthesis was seen in two patients, but not more than 5 degrees to the left. There was no disc loosening or subsidence, and no acceleration of adjacent segment degeneration. Two patients showed heterotopic ossification. Subjective evaluation was recorded as marked improvement in 15, partial improvement in 11 and no change in five patients. None of the patients reported deterioration. Low back pain assessed by the VAS score had an average value of 66.3 before surgery and 14.1 at 2 years after surgery. The average pre-operative ODI value was 48.9 and that at 2 years post-operatively was 24.5. DISCUSSION: Pain relief evaluated by the VAS score in our study is comparable with or slightly better than is reported by the other authors. Some recorded average values for lumbago were 74 before surgery and 35 at 2 years of follow-up, or 62.3 before and 25.4 at 2 years after surgery, while our patients had the average VAS score of 66.3 before surgery and that of 18.4 at 2 years after surgery. The ODI values in our group were similar to those of other authors. When we compare this group with the group of our patients who were treated by spinal fusion surgery, the outcomes at 1 year are better in the total disc replacement group, as shown by the VAS for lumbago of 17.8 and ODI of 24.5 in the former versus the respective values of 18.1 and 29.0 in the latter group. CONCLUSION: Based on the results it can be concluded that total disc replacement is an efficient method of treating degenerative intervertebral disc disease of the lumbar spine in young, active and motivated patients with no posterior spinal structure degeneration.

[Vertebral body augmentation using a vertebral body stent]. / Augmentace obratlového tela vertebrálním stentem.

PURPOSE OF THE STUDY: Osteoporotic vertebral fractures can be treated by minimally invasive percutaneous vertebral augmentation with bone cement using vertebroplasty or balloon kyphoplasty. Transcutaneous reduction and vertebral body stenting has been the most recent principle. In contrast to balloon placement in kyphoplasty, the stent remains in the vertebral body and supports both the vertebral body and cement filling. In this retrospective study we present the essential information on the method and our first results. MATERIAL AND METHODS: The method of vertebral body stent placement was used in 22 patients treated at 29 levels. Of these, 19 patients with 26 segments followed up for 3 months were evaluated. The group included 12 women and seven men with an average age of 68.3 years (12 to 83). The patients assessed their subjective complaints on the visual analogue scale (VAS) before surgery, and then at 1, 6 and 12 weeks post-operatively. The value of vertebral body reduction was obtained by measurement of anterior, middle and posterior vertebral body heights (AVBH, MVBH and PVBH, respectively) and a change in the vertebral body kyphotic angle (VBKA). RESULTS: Twenty-four vertebrae were treated for osteoporotic fracture and two as preventive stenting in metastatic breast cancer. In 24 fractures, the stents extended fully in 20 vertebrae, i.e., 40 stents. These fractures evidently were not older than 3 months. In four segments, a total of eight stents did not extend at all or did only slightly. The 20 stabilised vertebral bodies had an average AVBH value of 19.41 mm pre-operatively and that of 22.775 mm post-operatively, which is an average increase by 3.365 mm in absolute numbers and by 17.34 %. The average pre- and post-operative MVBH values were 16.625 mm and 23.065 mm, which was improvement by 6.41 mm or by 38.56 %. The average PVBH values pre- and post-operatively were 26.835 mm and 28.31 mm, which meant improvement by 1.475 mm or by 5.5 %. The average correction of the kyphotic angle was 4.58°, i.e., 35.2 %, from a VBKA of 11.71° pre-operatively to 7.13° post-operatively. There were five cases (22.7 %) of cement leakage, i.e., two of ventral leakage, one of lateral leakage, one of dorsal leakage through a canal left in the pedicle by cannula insertion, and a dorsal leakage in metastatic disease. No neurological findings were recorded. The average VAS scores were as follows: 81.4 before surgery, 30.6 at 1 week, 16.3 at 6 weeks and 15.4 at 12 weeks after surgery. DISCUSSION: Two experimental and one clinical study on vertebral body stenting only have been available in the recent relevant literature. In comparison with their results as well as with those of previous reports on vertebroplasty and kyphoplasty, our results showed high quality fracture reduction in all vertebrae. The rapid decrease in pain intensity in our group is comparable with all available groups treated by any method of vertebral body augmentation by cement injection; and cement leakage was recorded in even fewer cases. CONCLUSIONS: The novel method of vertebral body stenting with cement augmentation provides a rapid pain relief, gives stability to fracture reduction and has a low rate of cement leakage. However, care must be taken not to indicate cases with a damaged posterior corticalis of the vertebral body.

[Seat-belt and chance fractures of the thoracolumbar spine]. / Sitzgurt- (Seat-belt) und Chance-Frakturen der thorakolumbalen Wirbelsäule.

INTRODUCTION: The authors have attempted to elucidate the differences between Chance, seat-belt, and flexion distraction fractures. Chance and seat-belt fractures have more common features, while flexion distraction fractures differ, in particular, due to the mechanism of injury. A difficult diagnosis is sometimes a common characteristic, while therapy is always the same. PATIENTS AND METHODS: During the period from 1997 to 2005, the authors treated 23 seat-belt fractures, and only three "genuine" Chance fractures. All patients had normal neurological findings. The mechanisms of injury were a car crash in 20 cases, and a fall associated with flexion in 6 cases, such as a rolling fall while skiing. According to the localisation, Chance fractures were found at the L 1 level twice and at the L 2 level once. Seat-belt injury was found once each in the areas of T 7, L 4, L 5, -twice at L 2 and L 3, and 16 times at the T / L spine transition, respectively. All patients were operated on using instrumented posterolateral spondylodesis. RESULTS: All fractures healed by spondylodesis as confirmed by X-ray images. All patients returned to their original job or school. 14 patients were evaluated 6 months after removal of the metallic implants. The mean subsequent kyphotisation was 1.4 degrees with the largest deviation of 4 degrees in a patient with a pure ligamentous variant of a seat-belt fracture. CONCLUSION: The objective of this work is to illustrate the various types of spinal distraction injuries of a seat-belt character and Chance fracture, when the vertebral body is not compressed. X-rays and often also CT scans show a "benign" character. Interpretation of the findings is very important for the development of further chronic instability of the spine and all consequences. If the diagnosis of a distraction injury is made the operative stabilisation is essential. That is why all our patients were tretaed by operation.

[Mid-term results of 360-degree lumbar spondylodesis with the use of a tantalum implant for disc replacement]. / Strednedobé výsledky 360 degrees lumbální spondylodézy s pouzitím tantalové náhrady ploténky.

PURPOSE OF THE STUDY: The study presents the mid-term results in patients treated with circumferential, i.e., 360-degreee, fusion of the lumbar spine carried out by posterolateral instrumented spondylodesis and anterior intersomatic fusion using a tantalum implant for replacement of an intervertebral disc. The aim of the study was to verify tantalum implant quality, to evaluate segment fusion and to assess the outcome of this method by patients' subjective findings. MATERIAL AND METHODS: The prospective non-randomised study included the implantation of 47 tantalum cages in 40 patients by the technique of anterior lumbar interbody fusion (ALIF) and posterolateral spondylodesis. Only patients followed up longer than for one year were included in this evaluation. The patient group comprised 16 men and 24 women, with an average age of 47.9 years. The patients indicated for this procedure had mono- or bisegmental lumbar disc degeneration with advanced chan- ges of articular facets. The procedure involved posterior transpedicular screw fixation with decompression, if spinal stenosis existed, and reposition of the segment, if spondylolisthesis was present, and posterior spondylodesis by the open book method. No autogenous bone grafts were used because of the risk of donor-site pain and because one of the aims of the study was to test tantalum cage properties. Subsequently, ALIF and disc replacement with a tantalum cage were carried out after cage insertion, the anterior borders of the upper and lower adjacent vertebral bodies were adjusted so that the lamellar bone should overlap the cage and thus provide continual bridging for the segment, with an emphasis being on joining the lamellae with preserving their blood supply from the respective vertebral bodies. RESULTS Implant subsidence in a rotation/flexion fashion, i.e. ventrally into the upper endplate of the distal vertebra and dorsally into the lower endplate of the proximal vertebra, was observed in two cases; subsidence in a vertical fashion, i.e., symmetrically into the lower endplate of the upper vertebra was found in one patient. Neither vertical mode of subsidence into the upper endplate of the lower vertebra only, nor rotation/extension type of subsidence was recorded.No frontal/rotational mode of subsidence was found either. No osteolytic lesion between the implant and adjacent bone was diagnosed. No migration of an implant sideways or in a ventral/dorsal direction was detected. Anterior bridging fusion was observed in 32 cages. No fusion dorsal to or lateral to the cage was seen. Evaluation of bone ingrowth into the cage was not possible due to a high X-ray contrast effect of the material. High-quality bridging posterolateral spondylodesis was diagnosed in 33 cases. Subjective evaluation by the patients was based on a visual analogue scale (VAS) and an Oswestry Disability Index (ODI) questionnaire. For the whole group, the average VAS value for back pain dropped from 58.3 points before surgery to 18.1 points at one year post-operatively; there were no differences between the genders. The VAS value for leg pain decreased from 54.1 pre-operatively to 9.4 at one year after surgery. Also, the results of ODI assessment were similar in both genders, with the average value for the whole group having decreased from 53.5 % pre-operatively to 29.0 % at one year post-operatively. DISCUSSION: By using the mechanical properties of a tantalum implant, i.e., its high strength and flexibility, the structure almost identical to cancellous bone and its high stability following implantation, we avoided the necessity of harvesting autogenous bone grafts from the iliac crest. Instead, we introduced the method of bridging a stable and strong implant with lamellar bone, while preserving its blood supply from the adjacent vertebral bodies. Our results showed that this approach resulted in implant subsidence in 1.8 % of cases only.We achieved good-quality fusion by bridging the whole segment in 68 %, and diagnosed good posterolateral fusion in 71 % of the cases. All patients showed good spondylodesis, which was either ante- rior, posterior or bilateral. CONCLUSIONS: Avery stable fixation of the lumbar spinal segment can be achieved by using posterolateral fusion and ALIF.With this approach, ALIF is augmented with a porous tantalum cage, and the use of autogenous bone grafts, derived from the adjacent anterior vertebral borders and placed before the cage, results in high-quality anterior bridging spondylodesis in a lar- ge proportion of cases. The subjective evaluation by the patients is in agreement with the stability and fusion achieved.

[Unilateral lumbosacral dislocation]. / Unilaterale lumbosakrale Dislokation.

The authors present a very uncommon case of unilateral lumbosacral dislocation. Twenty two similar cases have been published in the literature so far. Most of them occurred due to the flexion mechanism of injury, in our case the injury was caused by a combination of hyperextension and subsequent flexion with rotation. This rare injury can create diagnostic dilemma and in relation to complexity of soft tissue lesion we propose early circumferential instrumented fusion of lumbosacral region.

[Vertebral body replacement with a Synex implant]. / Náhrada obratlového tela implantátem Synex.

AIM: The authors assessed options for vertebral body replacements with the Synex telescopic expansion cage. Autologic or homologic bone grafts, a titanium "Harm's" cage or a polymethylmetacrylate filling reinforced by Kirschner wires, may be used for vertebral body replacements. The cement filling is indicated in oncological patients, the Harm's cage requires filling with a quantity of bone grafts and, with massive bone grafts, the collection place or the graft availability may be a problem. The telescopic expansion implant is fairly easy to implant, is stable and requires to be filled with a minimum of spongious grafts. MATERIAL: From May 2001 to November 2005, 20 telescopic Synex cages were implanted in 18 patients. Vertebral body replacements were performed 14x for acute fractures, 4x for posttraumatic kyphosis and 2x for metastatic skeletal disorder in breast and prostate tumors. METHODS: Vertebral body replacement was completed with posterior transpedicular stabilization in 14 subjects, in 5 subjects, additional anterior Ventrofix stabilization was performed. Vertebral body replacements down to the L1 level were conducted through thoracotomy or video-assissted minithoracotomy, L2-L4 replacements from lumbotomy or anterior retroperitoneal approach. RESULTS: The most requently affected and operated vertebrae included the L1 (4 patients), Th12 (4 patients), Th6 (3 patients). The minimal interval between the procedure and a follow- up was 12 months. No fatal outcome has been recorded. In one patient with a vertebral body metastasis, the disorder has generalized and in a second one, no further metastatic spread has been reported. In one subject, the left-sided L4 root injury was recorded postoperatively, a cauda equina syndrome, diagnosed after the injury, persits in one subject. No signs of deep infection have been recorded. There are no records of the Synex release or displacement. Correction loss (kyphotisation) of up to 2 degrees was recorded in patients with transpedicular stabilization, in Ventrofix patients the loss was up to 5 degrees, except one case, where the loss reached 10 degrees. DISCUSSION: One of the commonest indications for the anterior approach surgical stabilization of the spine, is the vertebral body destruction in burst fractures or posstraumatic kyphotizations of the spinal column. Unhealed or poorly healed type A and B (AO classification) pincer vertebral body fractures are other common indications for partial corpectomy and vertebral body replacements. Such fractures can be managed using posterior transpedicular stabilization. However, provided the procedure results in insufficient fracture repositioning, the anterior procedure and the anterior column reconstruction must be performed. A vertebral body can be replaced by a bone graft, a cement filling with Kirschner wiring, a traditional Harm's cage or an expansion implant. The bone graft may be autologic, which involves a disadvantage of the "donor site pain", or homologic, although a potential for reconstruction is not fully evidenced here. Implant migration into the vertebral body has been recorded in the classical titanium Harm's cage with a sharp edge without an additional endplate. Furthermore, it is a rather complicated implantation, requiring an exact implant size, which is considered another disadvantage. The expansion implant may be expanded telescopically in the very place, which is considered its biggest advantage. Furthermore, it need not be filled with bone grafts, but is applied only ventrally or laterally to the cage. CONCLUSION: The Synex titanium expansion implant has been designed for vertebral body implantations in any indication. It requires additional stabilization, either by an anterior fixator or a cast, or a posterior transpedicular fixation. It is primarily indicated in traumatic vertebral body destructions or in reconstructions of maltreated fractures. Considering its higher price and the expected shorter patient survival period in oncological patients, its use in oncological indications is controversial.