[An unusual case of non-structural scoliosis (case report)]. / Neobvyklý prípad nestrukturální skoliózy (kazuistika).

The case of a female patient with conversion scoliosis is described. At 24 years, the patient underwent surgery for herniated disks in the L4-L5 and L5-S1 regions and a short-time relief was achieved. At age 28, she was admitted to our department because of severe pain and antalgic posture. Because radiographs of her spine showed no findings corresponding to her symptoms, psychological examination was indicated. This revealed traumatic emotional experience in her family of origin and later also in her foster family, which unfavorably affected her married life. Psychotherapy, including cognitive behavioral treatment, hypnotherapy and audiovisual stimulation, markedly improved the patient's mental and somatic state during two periods of hospitalization. The effects of psychotherapy, physical therapy and adaptation of her physical activity regimen were still evident at 1 year after her therapy was commenced.

[Infections in surgery of idiopathic scoliosis]. / Infekce pri operaci idiopatické skoliózy.

PURPOSE OF THE STUDY: In this retrospective study, we evaluated infectious complications in the patients undergoing surgical treatment for idiopathic scolions in order to identify risk factors for postoperative infections. MATERIAL: A total of 786 patients with idiopathic scoliosis were operated on during 24 years. In 754 (96%) cases, we used the posterior approach, involving posterior fusion and internal fixation, and subsequent immobilization in a brace. During that period, we recorded 15 (1.9%) deep wound infections in the area of fusion. Early infections were treated by debridement and lavage, with targeted administration of antibiotics, while instrumentation was kept in place. In late und recurrent infections, instrumentation was always removed. METHODS: We investigated a relationship between the infectious agent and the device used, the length of period between surgery and the onset of infection, the effect of device removal on curve progression, the agent causing infection and the effect of allergy to metal or infectious lesions at other body sites on the outbreak of infection. RESULTS: Early infections (within 6 weeks) were observed in six, late in nine patients. Repeat operations were necessary on average after 487 days. Staphylococcus aureus, the most frequent infectious agent, was isolated from four patients; on four occasions, cultivation was negative. Allergy to nickel was found in four patients. Infection was most often associated with the most frequently used Harrington Instrumentation (six cases, 1.1%). However, in relation to the number of patients treated, infection frequency was highest in TSRH (5.0%) and Isola (4.8%) devices. When Miami Moss fixation or the anterior approach was used, no infection was recorded. In comparison with the non-infected cases, the patients with infectious complications showed the same average values for the curve before and after surgery. At a check up, however, the loss of correction increased to 6 degrees and, after instrumentation removal, to 10 degrees as against 3 degrees in the non-infected patients. Pseudoarthrosis developed in two cases. DISCUSSION: The incidence of deep wound infections in patients who had surgery for idiopathic scoliosis was comparable with the data in the relevant literature. A higher number of infections, particularly late ones, in patients treated with the use of modern instrumentation is probably related to a higher volume of these implants. Early infections are a rare feature and their cause is known (allergy, sepsis). Treatment involves surgical intervention; in early infections, instrumentation is retained but is removed in late infections. CONCLUSIONS: Even though our group included a low number of patients with infections, we can conclude that risk factors for the development of infectious complications associated with surgical treatment of idiopathic scoliosis are as follows: allergy, higher age, large volume of metal used for stabilization and the presence of another infectious lesion.

Conservative treatment versus surgery in spondylotic cervical myelopathy: a prospective randomised study.

A prospective randomised 2-year study was performed to compare the conservative and operative treatment of mild and moderate forms of spondylotic cervical myelopathy (SCM). Forty-eight patients presenting with the clinical syndrome of SCM, with a modified Japanese Orthopaedic Association (mJOA) score of 12 points or more, were randomised into two groups. Group A, treated conservatively, consisted of 27 patients, mean age 55.6 +/- 8.6 years, while group B was treated surgically (21 patients, mean age 52.7 +/- 8.1 years). The clinical outcome was measured by the mJOA score, recovery rate (RR), timed 10 m walk, score of daily activities (recorded by video and evaluated by two observers blinded to the therapy), and by the subjective assessment of the patients at 6, 12, and 24 months of the follow-up. There was, on average, no significant deterioration in mJOA score, recovery ratio, or timed 10 m walk within either group during the 2 years of follow-up. In the surgery group there was a slight decline in the scores for daily activities and subjective evaluation. A comparison of the two groups showed no significant differences in changes over time in mJOA score or quantified gait, but there were significant differences in the score of daily activities recorded by video at 24 months, which was a little lower in the surgical group, and also in RR and subjective evaluation, which were both worse in the surgical group at months 12 and 24. However, at month 6, this last parameter was significantly better in the surgical than in conservative group. Surgical treatment of mild and moderate forms of SCM in the present study design, comprising the patients with no or very slow, insidious progression and a relatively long duration of symptoms, did not show better results than conservative treatment over the 2-year follow-up.

[Instrumentation of idiopathic scolioses by isola and miami-moss systems.]. / Instrumentace idiopatických skolióz systémy Isola a Miami-Moss.

In our University department 135 patients were operated and followed up for minimally 2 years postoperatively. Isola system was used in 92 patients, Miami-Moss in 43 patients. The average curve magnitude was preoperatively in Isola group 61,0 degrees , in Miami-Moss 54,8 degrees . Isola was used exclusively posteriorly, Miami Moss also anteriorly (16 cases). In more severe curves the rib osteotomy of concavity was added (22 patients), most severe curves were released by anterior discectomy with interbody fusion (24 patients). The average postoperative correction was in Isola 55,6 %, in Miami Moss 64,1 %, loss of correction in Isola 2,8 degrees, in Miami Moss 4,3 degrees. No complications were observed in Miami group. A double severe complications in one patient were recorded in Isola group, one transient monoparesis and 5 wound infections.The achieved correction and its loss of both systems were practically not different. Key words: idiopathic scoliosis, surgery, Miami Moss, Isola.

The value of somatosensory- and motor-evoked potentials in predicting and monitoring the effect of therapy in spondylotic cervical myelopathy. Prospective randomized study.

STUDY DESIGN: A 2-year follow-up prospective randomized electrophysiologic and clinical study of patients with spondylotic cervical myelopathy. OBJECTIVE: To assess the value of somatosensory- and motor-evoked potentials in the evaluation and prediction of the effect of therapy. SUMMARY OF BACKGROUND DATA: Previous studies have yielded conflicting data concerning the correlation between the changes in evoked potential parameters and the clinical postsurgical outcome in spondylotic cervical myelopathy. METHODS: Sixty-one patients with magnetic resonance images suggesting spondylotic cervical cord compression and clinical signs of cervical myelopathy were divided into two groups according to the degree of clinical cervical cord involvement. The 49 patients with mild and moderate spondylotic cervical myelopathy were randomized into groups that underwent either surgical or conservative therapy. Patients were evaluated clinically and by the means of somatosensory- and motor-evoked potentials. RESULTS: The clinical and evoked potential changes showed good correlation on the group level, but poor correlation intraindividually. There were no significant evoked potential and clinical group changes after 6 months and 2 years in the mild myelopathy group treated either surgically and conservatively, whereas patients with severe myelopathy displayed significant improvement in clinical and evoked potential parameters after surgery. In a subgroup of patients, the isolated segmental medullar N13 abnormality could potentially predict favorable postsurgical clinical outcome. CONCLUSIONS: Longitudinal evoked potentials showed limited use for evaluating the results of therapy in an individual patient. They could be useful in the group assessment of therapy results and in labeling a subgroup of patients with potentially favorable postsurgical outcome.

[Osteoid Osteoma and Lumbar Non-structural Scoliosis.]. / Osteoid osteom a bederní nestrukturální skolióza.

A benign bone lesion osteoid is characterized by sclerotic bone interface with a central nidus and pain at night which can be influenced by salicylates. When located on vertebrae or ribs it may cause non-structural scoliosis. Authors describe a case of 11-year old girl suffering from pain in lumbar spine at night, with left-side non-structural scoliosis which was unsuccessfully treated by physical therapy. Subsequently she was handled by radical resection of the L5 pedicle on the right side where osteoid osteoma was revealed by means of CT and later verified by histology. Unfortunately, minor non-structural scoliosis of lumbar spine persist also after the surgery. Key words: osteoid osteoma of spine, non-structural scoliosis, surgical treatment.

[Zásady operacního osetrení metastáz pátere.]. / Principles of the Treatment of Spinal Metastases.

The authors describe the principles of the treatment of spinal metastases. In the case of rapid progression of neural symptoms the surgery should be performed in the first 24 hours after the symptoms onset. In the case of slow progression or normal neurology the surgery follows the detailed assessment. According to the tumor extent is decided posterior, anterior or combined surgery. The decompression with or without stabilization is indicated in 12 months life expectancy. In longer survival an extensive surgery is indicated. The goal of this treatment is the spine realignment and its stabilization. Surgery improves the life quality and enables the patient his return to family in most cases. Key words: spinal metastasis, principles of surgical treatment.

[Principles of treatment of spinal injuries.]. / Zásady osetrení úrazu pátere.

This paper is meant for those colleagues who are faced with spinal injuries only sporadically or not at all, to make them familiar with contemporary principles of treatment of these injuries. The treatment of spinal injuries has the objective to restore the anatomical set-up of the spine, stabilize it against surrounding forces which act on it and to preserve its function. Thus the same principles are involved as in the treatment of other fractures. Treatment involves reposition, releasing of nerve structures and stabilization which can be achieved by a conservative procedure or surgery. An indication for surgery are dislocations which cannot be treated conservatively and dislocated fractures, instable injuries, major anterior defects, unrest of the patient, onset or deterioration of the neurological affection after injury, nervous affection with stenosis of the spinal canal, and last not least, also economic reasons. Surgical stabilization must be so reliable as to make postoperative immobilization unncessary, the fusion must be as short as possible, it must make early mobilization possible and must not enhance the risk of secondary damage. The implant must make reposition possible and ensure the required stability and make thus early mobilization possible. Key words: spinal injury, objective of treatment, reduction and stabilization indication for surgery.

[Principles in sequelae of spinal injuries.]. / Principy osetrení následku úrazu pátere.

Persisting or newly developed sequelae of spinal injuries can be encountered after conservative as well as surgical treatment. On the spine it is a deformity, most frequently a pathological kyphosis, instability or possibly stenosis of the spinal canal. All these factors can evoke pain and lead secondarily to progression of an already present nervous affection or to its late development. In the first place it is necessary to deal in these conditions with the deformity which along with the instability leads to permanent pain. The usual indication for surgery is a pathological kyphosis of the thoracolumbal transition above 15 degrees, but its tolerance is frequently individual. Late nervous lesions are usually the result of the intra- and extradural development of scars, spinal cord atrophy and posttraumatic syringomyelia. Failure of the original treatment is due to incorrect assessment of the type of injury, inadequate conservative or surgical treatment, incorrect surgical technique and errors as regards the selection of the surgical procedure. Correct assessment of the posttraumatic condition calls for detailed radiodiagnostic assessment. Many posttraumatic deformities call for a combined anterior and posterior operation. However, if there is no posterior obstacle for correction it is possible to implement only an anterior operation. Contemporary surgical techniques and implantation systems make short fusion with a minimal functional loss possible. Key words: posttraumatic deformity, neural deficit, surgical tactics.

[Surgical treatment of cervical spondylotic myelopathy in the Czech and Slovak Republic in 1994]. / Stave operacní terapie spondylogenní cervikální myelopatie v Ceské a Slovenské republice v roce 1994.

The authors investigated the state of surgery on account of cervical spondylosis and in particular spondylogenic cervical myelopathy in the Czech and Slovak Republic in 1994. They assessed the number of operated patients, surgical methods, indication criteria and the diagnostic strategy of different departments. The total number of patients operated on account of cervical spondylosis in 1994 was 347, incl. 113 on account of cervical spondylogenic myelopathy. As to surgical techniques in the majority the anterior approach was selected (Smith-Robinson's method). Laminectomy was performed in 14 and laminoplasty in 22 cases. The number of operated patients is, as compared with the frequency of similar operations in the United States, six times lower. As all departments where enquiries were made operate every cervical compression regardless of the degree of functional deficiency, this may reflect inadequate diagnosis of the disease.

[Contemporary view on the treatment of deformities of the spine.]. / Soucasný pohled na lécení deformit pátere.

The author draws attention to errors which are still encountered in the treatment of deformities of the spine, and to recent findings. In conservative as well as surgical treatment of scolioses little attention is paid to curvatures in the sagittal plane. Thoracic hypokyphosis is relatively frequent, it has a significant impact on pulmonary functions, it reduces the effectiveness of orthosis and plays also a significant role in the indication for surgery. Conservative treatment involves the wearing of an orthosis, physical exercise and other rehabilitation procedures do not affect the curvature. Correct indication, effective orthosis and a correct therapeutic regimen are essential. If, however, the curvature does not respond to orthosis it is necessary to operate regardless of age. In some deformities it is useless to attempt treatment by orthosis, surgery is necessary immediately. Frequently the essential continuation of conservative and surgical treatment is lacking due to the decision of a department which tries to use only orthosis, although there is progression of the curvature. Frequently the progression of the curvature is due to low-standard orthesis. The result of the conservative procedure is considered satisfactory where after completed growth the value of the curvature is equal to that at the onset of treatment. In recent years some authors hold the view that treatment by orthesis is useful only when started during the prepubertal period; with the onset of menstruation it is no longer meaningful because during that period its effectiveness declines briskly. According to contemporary knowledge in idiopathic scolioses surgery should be considered when the values are about 40 degrees , moreover, we take into account the degree of rotation and possible presence of thoracic hypokyphosis. Contemporary surgical techniques of segmental instrumentation permit correction of idiopathic curvatures above 50 degrees . Stiffer and more severe curvatures, however, call for longer preoperative preparation, relaxing operations such as thoracic discectomy or procedures in the thoracolumbar and lumbar spine, a combination of Zielke's anterior operation with some posterior segmental instrumentation. Decision on the most suitable surgical system and extent of instrumentation is governed by an effort to preserve as many mobile segments in the lumbar spine as possible. The classification according to King et al. and a suitable surgical system frequently make it possible to meet this demand.

[Fractures of the humerus in multiple injuries (comparison with the same injury in a group of single injuries/associated injuries).]. / Zlomeniny humeru u polytraumatizovaných pacientu (Srovnání s výsledky lécby téhoz poranení ve skupine monotraumat/sdruzených poranení).

The authors compare retrospectively, based on material of the Research Institute of Traumatology and Special Surgery in Brno (1985-1990), a group of 13 patients who suffered fractures of the diaphysis of the humerus as part of a multiple injury with a group of 29 patients who suffered the same injury as a monotrauma or associated injury. Both groups are characterized, the therapeutic approach is described as well as the complications which developed. The patients were checked on average after 45 months following the injury (12-96 months) and the results are reviewed. The authors consider the groups comparable and the results achieved in the two groups equivalent. Based on the submitted work they are convinced that casualties with fractures of the diaphysis of the humerus as part of a multiple injury are no worse looked after in their department than casualties with a single injury. Key words: fractures of the diaphysis of the humerus, polytrauma vs. monotrauma/associated injuries, comparison of results.

[Impossibility of artificial ventilation in a prone position in a patient with deformity of the spine (case-history).]. / Znemoznení umelé plicní ventilace pronacní polohou u nemocné s deformitou pátere.

The authors present the case of a 15-year-old female patient (Jehova's Witness) who was operated at the age of two on account of a Wilms' tumour of the kidney and irradiated with subsequent postirra-diation scoliosis. In 1990-1993 she was six times subjected to anaesthesia for distraction with a Harrington rod and repeated redistractions. All anaesthesias were of the general type, with artificial pulmonary ventilation in the prone position and without complications. Anaesthesiological methods and procedures were used which made it possible to avoid administration of blood or blood derivatives. In March 1993 the patient was prepared with erythropoietin for the final treatment of the deformed spine. During general anaesthesia suddenly artificial pulmonary ventilation in a prone position became impossible due to complete collapse of the trachea closely behind the end of the armed tracheal tube. After postponing the procedure, bronchoscopic and CT examination in a supine position during spontaneous respiration confirmed stenosis of the distal portion of the trachea to one third of the lumen. The authors assume that the cause are altered anatomical relations of the mediastinum caused by distraction and repeated redistractions in a field affected by irradiation. Key words: deformity of the spine, stenosis of the trachea, Jehova's Witnesses.

[Initial experience with peroperative autotransfusion in spinal surgery]. / První zkusenosti s peroperacní autotransfúzí ve spondylochirurgii.

The authors describe combinations of anaesthesiological methods which enabled them during extensive spondylosurgical operations in 66 patients to reduce the consumption of homologous blood during operation to 90 ml, on the first day after operation to 300 ml and on the second day after operation to 120 ml. In six patients they used preoperative collection of the patient's own blood, in 45 patients acute normovolaemic haemodilution, in all patients controlled hypotension with sodium nitroprusside to a mean arterial pressure of 8-9 kPa and peroperative collection of blood by means of an autotransfusion apparatus Dideco Stat with a standard programme and yield higher than 50%. During and after peroperative collection they did not record any complications. Lower haemoglobin and haematocrit values and a reduced number of erythrocytes, lower than the lower normal range, during and after operation did not threaten the postoperative course in these patients. The authors draw, however, attention to the rise of the number of leucocytes immediately after operation to 19.7 x 10(9). 1(-1) which is due to their shift into the final product. Solution of this phenomenon which can produce ARDS is according to the authors the use of a programme different from the standard one.

[Results of treatment of acute injuries of the thoracolumbar spine by ridged plates.]. / Výsledky osetrení cerstvých úrazu torakolumbální pátere rýhovanými dlahami.

The authors evaluate the results of surgery of fresh injuries of the thoracolumbar spine achieved by transpedicular fixation, using ridged plates. At the orthopaedic clinic in Brno-Bohunice this technique was systematically introduced in 1989; in 1991 they started to use a better principle of stabilization by an internal fixation device. The authors used plates fixed in a transpedicular way in 58 injured subjects. Most frequently fractures of L1, T12 and L2 were involved, usually of a burst type. In more than half the patients they recorded a nervous deficit of varying degree. They stabilized usually typically four mobile segments and fused two internal ones. In 44 patients manual realignment before operation and during its course were used. After reduction of the vertebral body by reposition of the adjacent surfaces they added spongioplasty. In 3/4 they decompressed nervous structures. In more than 1/3 they supplemented the operation by intersomatic fusion. Stabilization was enhanced by translaminar fusion of intervertebral joints. The results of treatment were evaluated in 54 patients; 38 patients were checked for more than two years after operation. A positive neurological finding after operation did not change in 15 patients, in 13 it improved and in one it deteriorated. In 1/4 the screws cracked, usually caudal ones, in two operated patients a pseudoarthrosis was repaired. In 38 patients checked for a minimum period of 2 years after operation two are confined to a wheelchair, two walk with two French crutches, three with one, 31 without support. Impaired voiding is reported by 18 patients, impaired sexual function by four. Sixteen patients resumed their original occupation, 22 operated patients have invalid pensions. Transpedicular fixation by means of plates contributed significantly to the improvement of comprehensive care of deformities, injuries and spinal injuries. It proved useful not only in the treatment of fresh injuries but also in the treatment of their sequelae and the necessity to 1 LQ / ACTA CHIRURGIAE ORTHOPAEDICAE I DO / ET TRAUMATOLOGIAE CECHOSL., 59. 1992, CS PUVODNI PRACE achieve stabilization in other diseases, e. g. tumours or olisthesis. However, with regard to the mentioned disadvantages the authors abondoned this technique in 1991 and started to use the principles of stabilization of the spine by internal fixation devices. Key words: injuries of the thoracolumbar spine, transpedicular stabilization, surgical technique.

[Sequelae of injuries of the thoracolumbar spine and indications for surgery]. / Následky úrazu torakolumbální pátere a jejich indikace k operacnímu resení.

Inadequate treatment of a fresh injury of the thoracolumbar spine of failure or surgical treatment may lead to substantial restriction of the physical activity of the patient. This is due to posttraumatic kyphosis, possibly its progression, instability, painfulness and a persisting or progressing neurological finding. Forty-eight patients with unstable fracture of the thoracolumbar spine were, except one operated patient, treated originally by conservative methods, 15 of them were moreover subjected to isolated laminectomy. In 30 patients a partial nervous lesion was involved. The majority of patients in the group subjected to laminectomy had a more severe kyphotic deformity which more frequently was progressive. The authors indicated surgery in 18 patients (37%) on account of pain, in 14 (29%) on account of instability, in 12 (25%) on account of progressing kyphosis and in 4 (8%) on account of an increasing nervous deficit. They included 26 patients with persisting partial nervous affections in the group with instability and progressing kyphosis, as anterior compression of the dural sac was revealed and they indicated release of nervous structures as part of the surgical operation. In the remaining partial neurological lesions with a patient spinal canal decompression was not indicated.

Enthesopathy in the vertebral disc region.

In view of the increased numbers of vertebrogenic complaints in society today, the authors investigated the clinical and morphological relations involved in these conditions. Histological techniques and the scanning electron microscope were used to examine the different structures of the spine under conditions of tensile overload. Chief attention was paid to the structures most exposed to mechanical stress, such as the interface between the vertebral body and the intervertebral disc. The authors found that the insertion of collagen fibres in cartilage or bone in the regions overloaded by tensile forces is identical to that found in epicondylitis in other locations. Such enthesopathies in the spinal region may form a major component of back pain states, and special therapy should be employed for them.

[The effect of controlled hypotension on kidney function in spinal surgery]. / Vliv rizené hypotenze pri operacich pátere na funkci ledvin.

The authors investigated the influence of controlled hypotension on renal function in patients operated on account of idiopathic scoliosis of the spine. The deformity was corrected by posterior fusion with Harrington instrumentation under general anaesthesia during controlled hypotension induced by sodium nitroprusside (n = 20). The control group was formed by 20 patients with the same deformity and the same surgical procedure without hypotension. The renal function was assessed before operation, during operation and continuously for 102 hours after operation. In the group of patients with controlled hypotension (median arterial pressure 8.0 kPa) during operation a significant decline of the creatinine clearance occurred (0.7 ml/s), as compared with the control group (1.3 ml/s), as well as compared with the value before operation (1.7 ml/s). After terminated hypotension the mean value of creatinine clearance rose to 2.0-2.2 ml/s for a period of 42 hours. In the control group the creatinine clearance persisted at a slightly reduced level, recorded during operation, for another 30 hours. Sodium retention as a manifestation of hyperaldosteronism was less marked in patients with controlled hypotension. During the investigation period no biochemical signs of retention of nitrogenous substances were recorded.

[Spondylothoracic dysplasia]. / Spondylotorakální dysplazie.

The authors describe 4 cases of spondylothoracal dysplasia. In two of them the severity of scoliotic deformity necessitated surgical treatment, the other two cases are under observation, as numerous malformations are at present compensating each other. All of them fall into the type II with a good life prognosis. The analysis of patients and survey of findings from the available literature facilitates a better familiarization with this syndrome.

[The effect of controlled hypotension during spinal surgery on kidney function]. / Der Einfluss der kontrollierten Hypotension bei Wirbelsäulenoperationen auf die Nierenfunktion.

The effect of controlled hypotension on renal function in patients operated on for idiopathic scoliosis of the spine was examined (n = 20). The deformity was corrected under general anesthesia by posterior fusion using Harrington's instrumentation during controlled hypotension induced by sodium nitroprusside. The control group included 20 patients suffering the same deformity and operated on in the same way but without hypotension. Renal function tests were performed before and during the operation and continuously for 102 h after surgery. In the group with controlled hypotension (medium arterial pressure 8.0 kPa) there was a significant decrease in creatinine clearance during the operation (0.70 ml/s) compared with that in the control group (1.30 ml/s) and with the value before surgery (1.70 ml/s). At the end of hypotension, the average clearance value of creatinine increased up to 2.0-2.2 ml/s within 42 h. In the group of control patients (medium arterial pressure 11.5 kPa) the creatinine clearance persisted at a mildly decreased level (1.3 ml/s) during surgery and for a further 30 h after. The sodium retention characteristic of hyperaldosteronism was less marked in the patients with controlled hypotension. We did not observe any biochemical findings indicating retention of nitro substances. Controlled hypotension induced by sodium nitroprusside at surgical treatment of the vertebral column does not cause any impairment of the renal function either during surgery or as a late sequela.