Primary osteomyelitis due to an anaerobic microorganism.

Primary osteomyelitis in a teen-aged boy that mimicked Ewing's tumor radiologically showed small Gram-negative rods on the original smear. The organism isolated was an obligately anaerobic bacterium, finally identified as Clostridium sphenoides. This finding underlines the need for microbiologic analysis of orthopedic lesions.

Degenerative spondylolisthesis with an intact neural arch: a review of 60 cases with an analysis of clinical findings and the development of surgical management.

The treatment over the past 12 years of 60 patients with degenerative spondylolisthesis with an intact neural arch is reviewed. The patients averaged 65 years of age, with women outnumbering men by a ratio of 2:1. Symptoms in the lower extremities had been present for 3 months to 10 years, although varying back pain had existed for longer periods. Two-thirds showed signs of motor dysfunction. Sensory alterations and a positive Las ègue's sign could be demonstrated in only one-half of the patients studied. Four of 5 patients developed intermittent neurogenic claudication, with varying evidence of painful radiculopathy. The marked disability caused by claudication contrasted sharply with the lesser neurological changes, and these patients required early surgical decompression. Diagnostic studies included electromyography, plain x-ray films, tomography, computed tomographic scanning, and myelography. The latter outlined a relative stenosis caused by olisthesis as well as arthrotic and spondylotic changes that determined the extent of decompressive operation required. The L-4, L-5 interspace was involved in 56 patients, L-3, L-4 was involved in 2, and L-5, S-1 was involved in 2. The ideal operation with L-4, L-5 olisthesis included complete laminectomy of L-4 and L-5 with unroofing of the lateral recesses and foraminotomy. This more extensive procedure was justified because of the failures encountered in previous patients in whom inadequate decompression had been performed. Among failures, obesity, diabetes, hyperlordosis, and extensive long-standing dysfunction were prominent. The relief of symptoms of intermittent neurogenic claudication was the most gratifying response observed. There was no unusual morbidity.

Degenerative lumbar spondylolisthesis with an intact neural arch (pseudospondylolisthesis).

Twenty patients treated for degenerative spondylolisthesis with an intact neural arch principally at the L4-5 interspace had neural compression caused by dislocation of the vertebral bodies and intrusions of lamina and enlarged, arthrotic facets into a stenotic spinal canal. The resulting "pincer" effect caused complete or partial block demonstrable on myelography, with nerve root and cauda equina compression. Most of the patients were women aged 45-84 years. Seven had neurogenic claudication. The majority had unrestricted straight-leg raising, and no signs of acute neural entrapment were seen as in patients with a herniated disc. Absent ankle reflexes, and weakness and atrophy of the anterior tibial muscle group were common, while sensation was relatively undisturbed. Treatment consisted of liberal laminar decompression including foraminotomy and medial or total facetectomy. Good-to-excellent results were obtained, and no patient was made worse by the procedure.

Cervical myeloradiculopathy caused by arthrotic hypertrophy of the posterior facets and laminae.

Five patients with typical cervical myeloradiculopathy caused by focal cervical spinal stenosis are presented. Dorsal intrusions into the spinal canal by hypertrophied apophyseal joints and thickened laminae resulted in cord and nerve root compression. Minor spondylotic changes were present in the floor of the spinal canal. Laminar decompression with formainotomy and facetectomy relieved the patients of their symptoms. An anterior approach should not be considered in the management of this disorder. Our findings of severe apophyseal arthrosis with lesser degrees of associated spondylosis are similar to those described in anatomical studies by other authors. While uncommon, myelopathy caused by dorsal compression of the spinal cord and nerve roots deserves specific mention so that therapy can be directed to the proper quadrants of the spinal canal wherein the significant pathology is located.

Obliterative arachnoiditis complicating lumbar spinal stenosis.

The authors report five patients with spinal stenosis who had a total myelographic block at the level of the obliterated subarachnoid space. Arachnoiditis had not been considered as a primary diagnosis until laminectomy revealed a non-pulsating, thickened dural sac that conformed to the internal configuration of the involved spinal canal. Two patients had stenosis complicated by spondyloarthrosis over multiple lumbar levels, one had a previous spinal fusion, another had degenerative spondylolisthesis, and the fifth had a large midline extruded disc at L2-3 that completely blocked the spinal canal. The dura was opened in two patients, confirming the lesion. Despite obliteration of the subarachnoid space, significant relief for approximately 1 year followed decompressive laminectomy, foraminotomy, and discectomy, with disappearance of neurogenic claudication in three patients. Postoperative erect films showed no caudad passage of contrast. While further observations are required, an awareness of this complication of spinal stenosis is important in the diagnosis and management of such patients and in evaluating their ultimate prognosis.

Quadriceps myofibrosis. A complication of intramuscular injections.

Cases of fibrofatty replacement of the quadriceps muscles following repeated intramuscular injections into the thighs of infants and young children are being reported with increasing frequency. In such cases, the knee shows progressive painless limitation of flexion, habitual dislocation of the patella, or both. The recommended treatment is surgical release, done early before secondary adaptive changes occur in the soft tissues, cartilage, and bones comprising the joint. Full flexion should be obtained at the time of surgery. In children, the lag in extension that follows extensive release will usually disappear spontaneously.

Lumbar intervertebral disk herniation in teenage children: recognition and management of associated anomalies.

Herniated disks in children and adolescents can be extremely disabling and difficult to diagnose because of the paucity of neurologic abnormalities and the consequent suspicions of hysteria. The Laségue sign is often the only consistent positive finding, and when persisting without remission, justifies early diagnostic studies such as CT scanning, and electromyography. Myelography may be avoided if these studies are definitively diagnostic. The almost uniformly good results that follow diskectomy do not justify prolonged conservative care. Management is facilitated by awareness of often unrecognized structural abnormalities found in these patients. These include spinal stenosis, lateral recess narrowing, and transitional vertebra. Spinal fusion, while rarely indicated, should be considered where motion segment instability contributes to persistent backache. The management of 25 patients is recorded. Twenty-one of these presented with an anomaly worthy of record requiring modifications in surgical technique to provide proper decompression and lasting relief of symptoms.

Treatment of congenital pseudarthrosis of the tibia with direct current.

Bone possesses a bioelectric property that is important in maintaining its structural and architectural integrity. In vivo experiments demonstrate that bone formation can be accelerated by the application of direct current. We hypothesize that bone formation occurs through an electrochemical rather than an electromechanical effect. Two cases of congenital pseudarthrosis of the tibia treated by direct current stimulation are presented. A bone graft may be added to enhance bony union in conjunction with direct current. The implications of this work are that there is need for further fundamental studies including ultrastructural observations.

On electrical condution in living bone.

Despite the effectiveness of electrical currents in enhancing bone repair, there is little information in the literature on electrical parameters per se. Very little is known about the nature of the conduction mechanism or the current path between the electrodes. Without a better understanding it is difficult to establish meaningful hypotheses at the cellular level and to design relevant experimental protocols. In the present work, a first attempt is made at an in vivo delineation of the current-voltage relationship in the medullary area between two platinum electrodes embedded in the femur, by one of the techniques generally known to stimulate bone growth. At potential differences of less than 1 volt, a rather good ohmic dependence is observed, with an approximate specific resistance of 2 to 5 times 10-5 ohms/cm. At potentials higher than 1 volt, electrolytic processes appear to predominate and there is increasing non-linearity. Experimental techniques involving the adjustment of current through bone tissue assuming an ohmic dependence with little or no associated polarization effects are valid and certainly warrant further investigation.

A comparative study of the treatment of cervical spondylotic myeloradiculopathy. Experience with 50 cases treated by means of extensive laminectomy, foraminotomy, and excision of osteophytes during the past 10 years.

This paper reviews management by means of the posterior approach of 50 patients with cervical myeloradiculopathy caused by spondylosis and stenosis of the spinal canal seen in the past 10 years. Careful selection of patients is an absolute necessity since a primary cause of failure occurred in individuals who subsequently proved to have motor neurone disease. Older individuals with long-standing neurological deficits, especially long tract signs indicative of fixed lesions, were benefited primarily by a lack of further progression of their disorder and occasional improvement in hand function and gait. Diagnostic evaluation should include electromyography, nerve conduction studies, and sensory evoked cortical potentials. With the introduction of the fourth generation CAT scanning equipment, additional diagnostic information is available regarding the internal configuration of the spinal canal, its contents, and the amount of available space at various levels. Supplementary myelography remains of basic importance. Laminectomy includes two levels above and below the areas of significant canal encroachment. Foraminal decompression with removal of only the innermost third of the foramen permits mobilization of the nerve roots, removal of osteophytes and untethering of the dural sac. A great deal of importance is attached to the preservation of the cervical lordotic curve since, with an adequate decompression and an intact dura, the cord moves dorsally into an expanded canal, rising above the ventrally situated osteophytes. In those patients with reversal of the cervical curve and swan neck deformities, posterior decompression has not been of value. Recent more radical procedures in such cases, such as vertebrectomy, remain to be evaluated. Any procedure which will permit further kyphotic deformity, such as laminectomy, is contraindicated. Eighty-five percent of the patients operated upon by the recommended surgical approach improved.

Transverse bayonet dislocation of the proximal interphalangeal joint.

Complete dislocation of the proximal interphalangeal joint with complete rupture of both the collateral ligaments and volar plate was seen in 8 patients. We call this, "transverse bayonet dislocation of the proximal interphalangeal joint." When treated early, closed manipulation resulted in stable reduction. After a brief period of immobilization of 3 to 5 days with a dorsal aluminum splint, sustained active range of motion exercises were begun by strapping the injured finger to the adjacent finger obtaining good end results in all cases. An untreated dislocation of 5 weeks duration needed operative reduction. This was achieved with good result by release of all the retaining ligaments around the proximal interphalangeal joint including both the collateral ligaments, the volar plate, the transverse retinacular ligaments, and extensor tenolysis.

Functional outcome of pathologic fracture secondary to malignant disease in a rehabilitation hospital.

Fifty-eight patients with 62 pathologic fractures secondary to metastatic disease were admitted to a rehabilitation hospital during a 5-year period. Thirty-four patients were discharged home, 7 were transferred to other facilities, and 17 died. The average hospital stay for the patients who went home (37 days) was only 3 days longer than for patients with nonpathologic fractures. No patient could transfer independently or ambulate at the time of admission, but 26 and 23, respectively, could do so by the time of discharge; 27 patients showed significant improvement in their ability to perform activities of daily living as measured by Kenny scores. All 11 patients who had hypercalcemia died. Eleven of 13 patients requiring parenteral narcotics died. Patients with pathologic fractures secondary to metastatic disease are excellent candidates for intensive rehabilitation programs, but hypercalcemia and administration of parenteral narcotics suggest a poor rehabilitation outcome.