The role of melatonin in the pathogenesis of adolescent idiopathic scoliosis (AIS).

The cause of adolescent idiopathic scoliosis (AIS) in humans remains obscure and probably multifactorial. At present, there is no proven method or test available to identify children or adolescent at risk of developing AIS or identify which of the affected individuals are at risk of progression. Reported associations are linked in pathogenesis rather than etiologic factors. Melatonin may play a role in the pathogenesis of scoliosis (neuroendocrine hypothesis), but at present, the data available cannot clearly show the role of melatonin in producing scoliosis in humans. The data regarding human melatonin levels are mixed at best, and the melatonin deficiency as a causative factor in the etiology of scoliosis cannot be supported. It will be an important issue of future research to investigate the role of melatonin in human biology, the clinical efficacy, and safety of melatonin under different pathological situations. Research is needed to better define the role of all factors in AIS development.

Uninstrumented posterolateral spinal arthrodesis: is it the gold standard technique for I degrees and II degrees grade spondylolisthesis in adolescence?

We retrospectively reviewed the outcome of uninstrumented posterolateral spinal arthrodesis in 49 patients with lumbar isthmic spondylolisthesis grades I degrees and II degrees in adolescent patients in the time of surgery, who participate at follow-up, between 1980 and 1995. The goal of our study is to analyse the clinical and radiographic imaging at long follow-up in uninstrumented posterolateral arthrodesis and to evaluate the efficiency and the validity of surgical technique in young patients (<18 years). All patients had failed previous conservative treatment. The average age at follow-up was 33.5 years (range 25-42 years) and the average follow-up time was 19.7 years (range 12-27 years). The clinical outcome measures were the Oswestry Disability Index, the SF-36, and the visual analogic score. All measures assessed the endpoint outcomes at 20 years after surgery. The outcome of spinal fusion was good with 43 (87.7%) patients attaining solid fusion, pseudoarthrosis in 6 patients (12.3%). None of our patients complained of excessive postoperative wound pain. Additionally, no complications, such as wound infection, were encountered. Satisfactory results were obtained in 94% of patients and this was closely associated with the rate of successful fusion. The results suggest that clinical outcome is closely related to the attainment of solid fusion.

Evaluation of conservative treatment of non specific spondylodiscitis.

The objective of this study was to analyse the presentation, aetiology, conservative management, and outcome of non-tuberculous pyogenic spinal infection in adults. We performed a retrospective review of 56 patients (35 women and 21 men) of pyogenic spinal infection presenting over a 7-year period (1999-2006) to the Department of Spinal Surgery of Hesperia Hospital. The medical records, radiologic imaging, bacteriology results, treatment, and complications of all patients were reviewed. The mean age at presentation was 47.8 years (age range 35-72 years), the mean follow-up duration was 12.5 months. The most common site of infection was lumbar spine (n: 48), followed by the thoracic spine (n: 8). Most patients were symptomatic for between 4 and 10 weeks before presenting to hospital. The frequently isolated pathogen was Staphylococcus aureus in 31 of 56 cases (57.6%). Percutaneous biopsies were diagnostic in 57% of patients; the open biopsy was indicated if closed biopsy failed and when the infection was not accessible by percutaneous technique. The patients were managed by conservative measures alone, including antibiotic therapy and spinal bracing. The mean period of antibiotic therapy was 8.5 weeks (range 6-9 weeks), followed by oral antibiotics for 6 weeks. All patients had a supportive spinal brace for mean 8 weeks (range 6-10 weeks). The duration of the administration of oral antibiotics was dependent on clinical and laboratory evidence (white cell count, erythrocyte sedimentation rate, C-reactive protein) that the infection was resolved. The follow-up MR gadolinium scans were essential to monitor the response to medical treatment. The diagnosis of pyogenic spinal infection should be considered in any patient presenting with severe localised unremitting back and neck pain, especially when accompanied with systemic features, such as fever and weight loss and in the presence of elevated inflammatory markers. The conservative management of infection with antibiotic therapy and spinal bracing was very successful.

Late post-operative paraparesis after rib penetration of the spinal canal in a patient with neurofibromatous scoliosis.

Rib displacement into the spinal canal is a rare cause of paraplegia or paraparesis in patients affected by neurofibromatous scoliosis. We describe a case of paraparesis in a 14-year-old child affected by neurofibromatous dystrophic kyphoscoliosis, treated with combined posterior and anterior spinal arthrodesis. Seventeen days after the surgical treatment the patient developed clinical signs and symptoms of paraparesis. A CT scan showed the head of the fifth rib protruding into the spinal canal with cord compression. Rib resection and posterior cord decompression were carried out following complete neurological recovery.

[Hemoperitoneum due to rupture of an omental arterial aneurysm]. / Hémopéritoine par rupture spontanée d'un anévrisme de l'arcade vasculaire omentale.

We report a case of spontaneous hemoperitoneum due to rupture of an omental arterial aneurysm. This source of bleeding is unusual (2 cases published); the diagnosis was made preoperatively by doppler ultrasound and CT scan with IV contrast. Omental resection was performed and histological analysis confirmed the diagnosis. A literature review of the rare cases of hemoperitoneum due to rupture of a digestive arterial aneurysm is done.

Surgical treatment of spinal deformities in Duchenne muscular dystrophy: a long term follow-up study.

BACKGROUND: Surgical treatment of spinal deformities in Duchenne muscular dystrophy (DMD) is influenced by a number of factors which have proven to be a difficult challenge. Each case should be carefully evaluated, considering not only the natural history of the spinal deformity, but also the patient's general condition. These should be thoroughly assessed through clinical and radiographic investigations together with other medical specialists. Life expectancy should be determined according to the cardio-respiratory function, and both preoperative and postoperative quality of life should be taken into consideration, trying to imagine the functional status of each patient after surgery. METHODS: From February 1985 to February 2000, 58 patients with spinal deformity in DMD were surgically treated. Of 25 patients that were operated on between 1985 and 1995, only 20 were followed-up after 5 years because 5 of them had died during this time. Therefore, the present study focuses on the results obtained in 20 cases. The 20 cases reviewed presented with a mean angular value of scoliosis equal to 48 degrees (range 10-92 degrees). Spinal fusion with our modified Luque technique [6] was performed in 19 cases, whereas CD instrumentation was applied in only one case. RESULTS: At the 5 year follow-up (range 5.6-10 years), the age ranged from 18 to 24 years and averaged 20.4 years. The postoperative angular value of scoliosis averaged 22 degrees (58%, range 0-43 degrees), the mean correction at follow-up was 28 degrees (range 0-60 degrees), and the mean loss of correction was equal to 6 degrees (range, 0-11 degrees). Vital capacity showed a slow progression, slightly inferior to its natural evolution in untreated patients. The severest complication was the death that occurred in one of the patients. CONCLUSIONS: According to the present study, an early surgery (angular value lower than 35-40 degrees) dramatically reduces the rate of risk factors associated with spinal deformities in DMD, and its advantages far exceed the disadvantages, above all in terms of quality of life.

Surgical treatment of scoliosis associated with myelomeningocele.

Twenty-nine patients (mean age 12 years) with severe thoracolumbar and lumbar scoliosis due to myelomeningocele were treated by spinal fusion (7 by posterior arthrodesis with instrumentation, 3 by anterior arthrodesis with instrumentation, 19 by combined anterior and posterior fusion with instrumentation). Fusion was extended to the sacrum in 15 patients. Mean period of follow-up was 6.2 years. The average Cobb angle changes were as follows: thoracic and thoracolumbar curves preoperatively 86 degrees to 45 degrees at follow-up (the final average curve correction was 47%); lumbar curves preoperatively 97 degrees to 48 degrees at follow-up (the final average curve correction was 50%). Average pelvis obliquity changed from 26 degrees to 13 degrees at follow-up with an average correction of 49%. The combined anterior and posterior instrumentation and fusion gave the best correction of deformity (the final average thoracic and thoracolumbar curve correction was 55%; the final average lumbar curve correction was 61%). Independent of the method of stabilization, post-operative wound infection was a serious problem (24%). The combined fusion-instrumentation method reduced the rate of pseudoarthrosis to 14%.

Neurological complications in segmental spinal instrumentation: analysis of 750 patients.

The authors report on neurological damage caused by the use of sublaminar segmental fixation in the correction of vertebral deformities. Three groups were reviewed: 600 patients instrumented with Harrington rods and segmental wiring, 50 patients treated with the Hartshill system and 100 patients instrumented with Luque bars. All of the patients were operated on using sublaminar wiring fixation. We report two transitory neurological complications among the 600 patients with Harrington rod instrumentation and segmental wiring, two permanent neurological deficits among the 50 cases treated with the Hartshill system and none among the 100 patients instrumented using Luque bars. The purpose of this study is to analyse the causes of these neurological complications, which occurred late in all four of the cases described.

Evaluation of several immunological parameters in patients with aseptic loosening of hip arthroplasty.

The authors evaluated several immunological parameters in patients with loosened hip arthroplasty in order to determine the state of sensitization with regard to the metallic constituents of the prosthesis. The results obtained by in vivo epicutaneous testing did not reveal a correlation between loosening and sensitization, as the patch test was positive in only 1 out of 16 cases examined. An evaluation of the lymphocyte subpopulation on peripheral blood demonstrated that patients with prostheses in Cr, Co, Mo, Ni alloy present significant lymphopenia, with a reduction in subpopulations CD4 and CD8 and a decrease in in vitro cytotoxic activity. The meaning of these modifications could be interpreted to be either a toxic effect products released from the implant, or as the recruitment of lymphocytes in the site of loosening, due to lymphocyte sequestration phenomena consequent to a cell-mediated hypersensitivity reaction.

[Percutaneous computed tomography-guided biopsy in spinal diseases]. / La biopsia percutanea guidata con tomografia computerizzata nelle malattie spinali.

The use of percutaneous spinal biopsy (PSB) is on the increase in the field of interventional radiology. From July 1990 to December 1992 in the Department of Radiology in the Istituto Ortopedico Rizzoli, 74 patients (50 men and 24 women, mean age: 47 years old) underwent CT-guided spinal biopsy. This study was aimed at evaluating the diagnostic capabilities and accuracy of CT-guided percutaneous biopsy, which is considered as a simple, reliable and definitive method for histopathologic diagnosis. In our case histories, the total average accuracy rate, which varies according to the involved segment and to the kind of lesion to be examined, was 86%; in 14% of cases the excised tissue proved insufficient for histologic diagnosis. By allowing the histopathologic diagnosis to be made, CT-guided PSB proves a valuable technique to plan the treatment of primary/secondary neoplastic lesions or of inflammatory and dysmetabolic processes.

Modern diagnostic imaging of lumbar spondylosis.

The authors retrospectively analyzed 205 patients affected with low back pain and submitted to conventional radiology, CT scan, MR. The purpose of the study was that of gaining a better understanding of the mechanisms caused by the occurrence of spondylosis and its evolution. In light of the most recent literature, the authors conclude: 1) the degenerative process nearly always initiates with laceration of the anulus; 2) dysfunction of the disc then has repercussions on the posterior structures at varying times and with different modalities; 3) symptoms do not always coincide with radiological findings. Thus, the authors believe that for a more complete understanding of the etiopathogenesis and the evolution of spondylosis, further studies involving long-term follow-up of a young population, in relation to clinical and MR findings are needed. MR is the method of choice in determining disc degeneration.

The anchor nail in osteosynthesis of fractures of the humerus.

Osteosynthesis with a humeral anchor nail may be listed along with other methods of intramedullary fixation for the treatment of diaphyseal fractures. The authors report their experience with 33 cases of humeral fractures treated between July 1987 and July 1991. Results were excellent in 61% of the cases, good in 24%, and fair in 15%; no particular complications were reported. The authors believe that the anchor nail constitutes a system of osteosynthesis involving only a small amount of trauma, and allowing for positive elastic stability for the consolidation of the fracture, as well as being a sufficiently safe system so that immobilization in plaster may be avoided. When compared with other systems of intramedullary fixation, the anchor nail is more effective than the Rush nail from a mechanical point of view, and the Kuntscher nail from a biological one.

Fractures of the occipital condyles: report of four cases and review of the literature.

Fractures of the occipital condyle are rare; 32 cases have been reported in the literature. Here, the authors describe four additional cases of occipital condylar fracture. Anderson's classification is used: type I fracture: comminution of the condyle without significant displacement; type II: basilar fracture extending into the condyle; type III: condylar avulsion. The possible mechanisms are identified. Computed tomography proved essential in diagnosing these fractures; coronal reconstructions together with axial scans are particularly helpful. Three-dimensional reconstruction did not prove essential in diagnosing these fractures.

Intraoperative ultrasonography imaging in spinal surgery (technique and indications).

Intraoperative ultrasonography was conducted in 20 patients; the technique of intraoperative ultrasonography for use in spinal surgery is described. The authors emphasize that this non-invasive method obtains real time images of considerable diagnostic importance, allowing for a significantly minor use of image intensifier, with a consequent reduction in doses for both the patient and the staff.

Radiology of the stenotic lumbar canal.

The main objective of imaging diagnostics in the study of the stenotic lumbar canal is that of revealing the presence of any contents/container conflict, of determining its site, extent, extension and, when possible, its etiopathogenesis. At present, CT and MRI constitute the most sensitive and specific methods, available necessarily preceded by a conventional radiological examination. Clinical assessment influences the choice of the method to use, whether alone or in association with others, as well as the method used to carry out the investigation; if we add all of this to correct technical execution, the radiological examination will provide a considerable amount of data.

The letournel lateral approach for treatment of acetabular fractures.

The authors report 9 cases of acetabular fracture, 6 recent complex and 3 inveterate, treated surgically through the lateral incision of Letournel. This approach provides excellent exposure of the acetabulum, the iliac wing, the posterior column, and the anterior column up to the iliopectineal eminence. Nevertheless, the high incidence of often serious complications makes the combined anterior-posterior approach preferable for severe inveterate fractures of the acetabulum.

Powdered alumina implants in the experimental animal: a histological study conducted in the rat.

The authors present a histological study conducted in the rat after powdered alumina implantation in the subcutis, the muscle and the peritoneum. After two weeks the same intense acute inflammatory reaction was observed in all of the implantation sites. After eight weeks the inflammatory reaction had regressed: there was a thin layer of connective tissue around the implant, completely isolating it from the surrounding tissues.

An evaluation of some leukocytary phenotypes in subjects with evolutive primary coxarthrosis and in subjects with hip prostheses.

The authors examined 52 patients (36 females and 16 males) of whom 15 affected with evolutive primary coxarthrosis, 27 with hip prostheses for 4 to 13 years, and 10 with a prosthetic implant which was not tolerated. A method of indirect immunofluorescence with monoclonal antibodies against specific antigens of the cellular surface was used to typify the T-lymphocytic subpopulations (T-helper/inducer and T-suppressor/cytotoxic), the activated mononucleate cells (DR+), and the B-lymphocytes and monocytes. A good correlation between the imbalances in the T-lymphocytic subpopulations, an increase in the activated mononucleate cells (principally due to T-lymphocytes) and the tolerance of the implant were observed. Based on the results obtained, the authors hypothesize the possibility of using the typing of T-lymphocytes and activated mononucleate cells, together with other biohumoral parameters, as indicators of periprosthetic tissue phologosis.

Fracture of the posterior arch of the atlas.

The authors analyzed the results obtained in 10 fractures of the posterior arch of the atlas treated nonsurgically. There was consolidation in all of the cases at the end of treatment. According to the authors the element which most characterizes this fracture is constituted by its radiological diagnosis which principally makes use of lateral projection. In particular cases, when patients are characterized by multiple trauma, the fracture may go unrecognized.