Improvement of Life After PVCR in Complete Paraplegic Patients with Posttraumatic Severe Kyphosis.

AIM: To determine the effect of posterior vertebral column resection (PVCR) in patients with paraplegia by using the American Spinal Injury Association (ASIA) score and Scoliosis Research Society (SRS)-22 questionnaire. MATERIAL AND METHODS: Twelve patients with posttraumatic paraplegia and severe angular kyphosis ( > 60?) had undergone PVCR between 6-24 months after the trauma for severe pain, persistent vertebral instability and difficulty in adherence to rehabilitation. ASIA scores and SRS-22 questionnaire results obtained in the preoperative and postoperative periods, and the last control were statistically compared to assess the presence of any change. RESULTS: The average age of twelve patients included in this study was 35.6 ± 10.2 (21-51) years. Female/male ratio was 2/10 (20.0%). The mean follow-up duration was 50.3 ± 17.6 (24-86) months. None of the patients had additional changes in neuromonitoring records during surgery. The mean preoperative kyphotic angle of the patients was 66.58° ± 7.1? (60?-82?) which decreased to 7.0? ± 5.4? in the postoperative period (p < 0.05). The mean ASIA score, which was 43.3 ± 5.1 preoperatively, increased to 44.4 ± 4.4 in the postoperative period. The SRS-22 score, which was 2.4 ± 0.3 in the preoperative period, increased to 4.2 ± 0.4 in the early postoperative period. This increase was found to be statistically significant (p < 0.05). The SRS-22 score was 4.1 ± 0.4 at last follow-up and was not statistically different from the early postoperative value (p > 0.05). CONCLUSION: In the light of these data, it can be stated that PVCR is a safe and reliable procedure in paraplegic patients with rigid posttraumatic kyphosis and increases patient satisfaction.

Evaluation of the two bundles of the anterior cruciate ligament with 1.5 tesla magnetic resonance imaging.

OBJECTIVES: Studies on the anatomy of the anterior cruciate ligament (ACL) have shown that the normal ACL consists of two functional bundles named as anteromedial (AM) and posterolateral (PL) bundles. In this study, we evaluated the AM and PL bundles of the ACL using 1.5 tesla magnetic resonance imaging (MRI), which is routinely used in clinical practice. METHODS: The study included 150 patients (96 females, 54 males; mean age 33.4+/-11.6 years; range 18 to 59 years) who did not have any signs of ACL insufficiency and whose knees were examined by MRI for other reasons. Standard magnetic resonance images (77 right, 73 left) were evaluated independently by an orthopedist and a radiologist in terms of distinguishable ACL bundles. The angle between the ACL (and each bundle) and the tibial plateau was measured on sagittal and coronal sections. Arthroscopic surgery was performed in 64 patients (42.7%) for primary diagnoses and arthroscopic and MRI findings were compared. RESULTS: Magnetic resonance imaging showed an intact ACL in all the patients. The ACL was assessed as a single bundle in the axial, coronal, and sagittal planes in 93 patients (62%). A double-bundle appearance was noted in 57 patients (38%), involving all three planes in 14 patients (9.3%), axial and coronal planes in 41 patients (27.3%), coronal and sagittal planes in one patient (0.7%), and only coronal plane in one patient (0.7%). On MRI sections showing a single bundle ACL, the mean angle between the ACL and the tibial plateau was found as 55.3 degrees in the sagittal plane, and 70.3 degrees in the coronal plane. On sections with a double-bundle appearance, the mean angles between the AM bundle and the tibial plateau were 70.1 degrees and 55.1 degrees in the coronal and sagittal planes, respectively. The corresponding angles for the PL bundle were 81 degrees and 53.5 degrees . The incidence of double bundle ACL appearance in coronal, sagittal, and axial MRI sections was not influenced by sex and side (p>0.05). The number of bundles identified in each plane did not show a significant difference between the two observers (p>0.05). During arthroscopic surgery, both bundles were identified with normal integrity and function of the ACL in all the patients. Of these, MRI could depict a double-bundle appearance in one or more planes in only 42.2% of the patients. CONCLUSION: Even though standard 1.5 tesla MRI, routinely used in clinical practice, has a very high success rate in demonstrating the ACL, it can visualize the two-bundle structure only in about one-third of the patients.

Anterior instrumentation in tuberculous spondylitis: is it effective and safe?

Radical anterior débridement and strut grafting is the gold standard in the surgical treatment of tuberculosis spondylitis. For many years anterior instrumentation was avoided due to concerns about infection until recently. We investigated the effectiveness and safety of anterior instrumentation for different sites of involvement, number of involved levels, and different age groups in 100 consecutive patients (mean age, 44.3 +/- 12.4). We measured preoperative, postoperative, and final kyphotic deformities radiographically and looked for the presence of fusion. Patients had a minimum followup of 3 years (average, 4.5 years; range, 3-6 years). Addition of anterior instrumentation was effective in the correction of kyphotic deformity (19.8 degrees +/- 7.3 degrees) and facilitated solid fusion, with an average loss of 1.6 degrees +/- 1.8 degrees. Of the 44 patients with neurologic symptoms, 40 (90.9%) achieved full and four (9.1%) achieved partial recovery. There were no apparent pseudarthroses and implant failures. All patients demonstrated clinical healing of tuberculosis without recurrence and reactivation. All domains of the SRS-22 questionnaire showed improvements at the last followup. Anterior instrumentation represents a safe and effective method for the treatment of tuberculosis spondylitis, and it may be the ideal stabilization method thanks to less segment fusion, single approach, and obviating the need for external immobilization.

Minimum 5-year follow-up surgical results of post-traumatic thoracic and lumbar kyphosis treated with anterior instrumentation: comparison of anterior plate and dual rod systems.

STUDY DESIGN: A retrospective follow-up study of post-traumatic thoracic and lumbar kyphosis after anterior instrumentation with anterior plate and dual rod systems. OBJECTIVE: To investigate the outcome of anterior vertebrectomy, anterior strut grafting, and anterior instrumentation in patients with > 30 degrees sagittal contour deformity. SUMMARY OF BACKGROUND DATA: Post-traumatic kyphosis may lead to mechanical pain due to the impairment of physiologic sagittal contours as well as cosmetic complaints. METHODS: Forty patients with post-traumatic kyphosis were followed for a minimum of 5 years. Mean age was 44.7 +/- 12.4 years (range, 18-65 years); 18 were female and 22 were male. All patients underwent anterior vertebrectomy and decompression; anterior fusion was carried out with costal or iliac ala grafts. Patients were randomly assigned into 2 treatment groups: correction and internal fixation was performed by using either plate-screw (n = 20) or double rod-screw (n = 20). Patients were also evaluated clinically by using Pain and Functional Assessment Scale (PFA) and SRS-22 questionnaire. RESULTS: Before surgery, the mean value for local sagittal contours was 51.4 degrees +/- 13.8 degrees; after surgery, it was reduced to 7.0 degrees +/- 7.6 degrees, resulting in an 88.7% +/- 11.3% correction (P = 0.00). At the last follow-up visit, a mean correction loss of 1.4 degrees +/- 1.8 degrees was found. A statistically significant improvement in local kyphosis angles and PFA scores was found after surgery and at the last visit. In 92.5% of the patients (n = 36), pain completely resolved; and in the remaining 3 patients, it is markedly reduced. Neurologic improvement was achieved in all of the 24 patients with neural claudication and other neurologic findings. Solid fusion mass was obtained in all patients. The type of instrumentation system did not differ significantly in terms of kyphotic deformity correction rates, correction losses, PFA scores, and SRS-22 scores. Final PFA scores showed a statistically significant correlation with SRS-22 scores (r = -0.918, P < 0.01). Final pain, function, mental status, self image and satisfaction domain scores and total SRS-22 score were > or = 4. The time from trauma to operation and the severity of kyphotic deformity were inversely correlated with postoperative correction rates. On the other hand, these 2 parameters were positively correlated with both final PFA and final SRS-22 scores (P < 0.01). CONCLUSIONS: In light of the present study's findings, we suggest that the technique of anterior decompression, strut grafting, and anterior instrumentation is an effective method for the treatment of post-traumatic kyphotic deformity and that the success of the technique depends on the time from trauma to operation and the severity of baseline deformity, regardless of the type of instrumentation.

Minimum 10 years follow-up surgical results of adolescent idiopathic scoliosis patients treated with TSRH instrumentation.

Last two decades witnessed great advances in the surgical treatment of idiopathic scoliosis. However, the number of studies evaluating the long-term results of these treatment methods is relatively low. During recent years, besides radiological and clinical studies, questionnaires like SRS-22 assessing subjective functional and mental status and life-quality of patients have gained importance for the evaluation of these results. In this study, surgical outcome and Turkish SRS-22 questionnaire results of 109 late-onset adolescent idiopathic scoliosis patients surgically treated with third-generation instrumentation [Texas Scottish Rite Hospital (TSRH) System] and followed for a minimum of 10 years were evaluated. The balance was analyzed clinically and radiologically by the measurement of the lateral trunk shift (LT), shift of head (SH), and shift of stable vertebra (SS). Mean age of the patients was 14.4+/-1.9 and mean follow-up period was 136.9+/-12.7 months. When all the patients were included, the preoperative mean Cobb angle of major curves in the frontal plane was 60.8 degrees +/-17.5 degrees . Major curves that were corrected by 38.7+/-22.1% in the bending radiograms, postoperatively achieved a correction of 64.0+/-15.8%. At the last follow-up visit, 10.3 degrees +/-10.8 degrees of correction loss was recorded in major curves in the frontal plane with 50.5+/-23.1% final correction rate. Also, the mean postoperative and final kyphosis angles and lumbar lordosis angles were 37.7 degrees +/-7.4 degrees , 37.0 degrees +/-8.4 degrees , 37.5 degrees +/-8.7 degrees , and 36.3 degrees +/-8.5 degrees , respectively. A statistically significant correction was obtained at the sagittal plane; mean postoperative changes compared to preoperative values were 7.9 degrees and 12.9 degrees for thoracic and lumbar regions, respectively. On the other hand, normal physiological thoracic and lumbar sagittal contours were achieved in 83.5% and 67.9% of the patients, respectively. Postoperatively, a statistically significant correction was obtained in LT, SH, and SS values (P<0.05). Although, none of the patients had completely balanced curves preoperatively, in 95.4% of the patients the curves were found to be completely balanced or clinically well balanced postoperatively. This rate was maintained at the last follow-up visit. Overall, four patients (3.7%) had implant failure. Early superficial infection was observed in three (2.8%) patients. Radiologically presence of significant consolidation, absence of implant failure, and correction loss, and clinical relief of pain were considered as the proof of a posterior solid fusion mass. About ten (9.2%) patients were considered to have pseudoarthrosis: four patients with implant failure and six patients with correction loss over 15 degrees at the frontal plane. About four (3.7%) patients among the first 20 patients had neurological deficit only wake-up test was used for neurological monitoring of these patients. No neurological deficit was observed in the 89 patients for whom intraoperative neurological monitoring with SSEP and TkMMEP was performed. Overall, average scores of SRS-22 questionnaire for general self-image, function, mental status, pain, and satisfaction from treatment were 3.8+/-0.7, 3.6+/-0.7, 4.0+/-0.8, 3.6+/-0.8, and 4.6+/-0.3, respectively at the last follow-up visit. Results of about 10 years of follow-up these patients treated with TSRH instrumentation suggest that the method is efficient for the correction of frontal and sagittal plane deformities and trunk balance. In addition, it results in a better life-quality.

Magnetic resonance imaging abnormalities of neural axis in Lenke type 1 idiopathic scoliosis.

STUDY DESIGN: Patients with Lenke type 1 single thoracic idiopathic scoliosis were included in this prospective study. All patients had preoperative magnetic resonance imaging (MRI). OBJECTIVE: To examine the frequency of neural axis abnormalities and the need for preoperative MRI in this group of patients. SUMMARY OF BACKGROUND DATA: Because of the increasing use of MRI, neural axis abnormalities have been reported in association with certain clinical and radiologic findings in idiopathic scoliosis cases. METHODS: A total of 104 patients (49 juvenile onset and 55 adolescent onset), older than 10 years, were included in the study. The association of neural axis abnormalities with pes cavus, abnormal deep tendon reflexes, age of onset, presence of pain, severity of the frontal plane deformity, and sagittal contours were investigated. RESULTS: All 7 patients with a neural axis abnormality on MRI had an early onset disease, and 6 of them had back pain. Thus, age of onset and back pain seem to be predictive of these abnormalities. Frequency of MRI abnormalities was as high as 45% for patients with back pain in addition to a type IC curve. CONCLUSION: In patients with juvenile idiopathic scoliosis and back pain, preoperative MRI should be performed to eliminate the risk of postoperative neurologic deficits, even if the scoliosis is Lenke type 1. However, in patients with Lenke type 1 idiopathic scoliosis, preoperative MRI studies seem unnecessary if intraoperative neural monitoring is to be performed.

Results of complete hemivertebra excision followed by circumferential fusion and anterior or posterior instrumentation in patients with type-IA formation defect.

To evaluate the results of surgical treatment in patients with unlocked full-segmented hemivertebra treated by excision. Twenty-six patients with a mean age of 12.4+/-1.7 years were included in the study. The mean duration of follow-up was 47.8+/-21.9 months. Diagnosis of type-IA hemivertebra was established by clinical, radiological, CT, and MRI evaluation. Preoperatively, patients were randomly allocated into two groups. In the first group, patients underwent anterior hemivertebrectomy initially; this was followed by posterior excision of the hemivertebra, posterior instrumentation, and fusion. In the second group, posterior components of the hemivertebra were excised at first, then the hemivertebra body was excised anteriorly, and this was followed by anterior instrumentation and fusion. For both groups, compression was applied to the convex side while distraction was applied to the concave side. Frontal and sagittal plane analysis of radiograms obtained preoperatively, postoperatively, and after a minimum period of 2 years was performed. The balance was analyzed clinically and radiologically by the measurement of the lateral trunk shift (LT) and shift of head (SH). The mean preoperative and postoperative Cobb angles were 45.5 degrees -/+11.4 degrees and 16.8 degrees -/+7.9 degrees, respectively, and postoperatively, a mean correction rate of 64.4+/-13.9% was obtained (P=0.00). The mean correction rate was 61.2+/-13.3% (19.2 degrees -/+7.6 degrees) for the last follow-up visit. Sagittal plane analysis demonstrated either conservation of physiological sagittal contours or a normalizing effect following excision of hemivertebra combined with anterior or posterior instrumentation. When postoperative balance values were compared, a statistically significant correction was found in terms of LT and SH values. Although none of the patients had complete balance (SH: 0 mm) or balanced curves (0 mm

Comparison of sagittal plane realignment and reduction with posterior instrumentation in developmental low or high dysplastic spondylolisthesis.

BACKGROUND CONTEXT: In situ fusion is the gold standard method of treatment of spondylolisthesis. There is no study in the literature evaluating the effect of sagittal contour realignment on clinical outcomes in comparison with the addition of anterior slippage reduction. PURPOSE: The correction of sagittal plane vs. reduction with instrumentation in the patients with low or high dysplastic spondylolisthesis. STUDY DESIGN/SETTING: A prospective randomized study in patients treated with the same surgical team at the same center. PATIENT SAMPLE: 40 patients, 20 with low and 20 with high dysplastic spondylolisthesis (mean age: 33.1+/-10.6; average follow-up: 37.9+/-11.9 Mo.). OUTCOME MEASURES: The extent of displacement, lumbosacral angle values, lumbar sagittal contours, correction rates, JOA scores, SRS-22 questionnaire were evaluated preoperatively, postoperatively, and at the final visit. Fusion rates, complications and quality of fusion were recorded. METHODS: 4 groups of patients were generated. Only posterolateral fusion, neural decompression, and sagittal plane correction with posterior instrumentation using 3rd generation instrumentation system transpedicular screws was accomplished in 20 patients (low dysplastic: 10 patients, high dysplastic: 10 patients). Additional reduction of anterior slippage was done in the remaining 20 patients (low dysplastic: 10 patients, high dysplastic: 10 patients). RESULTS: No statistically significant difference was found between low vs. high dysplastic patients and between patients with sagittal contour realignment vs. patients with additional anterior slippage reduction (p>0.05). The correction rates for displacement were statistically similar at the final visit. Postoperative and final JOA and SRS scores were similar between in situ fusion and reduction groups (p>0.05). A solid fusion mass of 77.5 % was achieved in both groups. CONCLUSIONS: A high percentage of fusion was achieved with posterolateral in situ fusion with or without reduction; and an additional reduction procedure did not have a statistically detectable impact on clinical outcomes. Successful fusion and neural decompression were the most important parameters that have an impact on clinical outcomes in patients with developmental spondylolisthesis, irrespective of the extent of preoperative displacement and the type of listhesis.

Augmentation of third generation instrumentation with sublaminar titanium wiring in late onset idiopathic scoliosis: the surgical results and analysis of trunk balance.

In recent years, third generation instrumentation systems which achieve correction by maneuvers like derotation and translation, have been widely used in the treatment of idiopathic scoliosis. To increase correction, additional procedures that increase stability, such as screw application for every segment, have been used. In this study, as a new technique, the effects of combined translation and derotation maneuver with augmentation by using titanium double crimp Songer cable applied on apical region, on trunk balance, sagittal and frontal planes have been examined. 45 idiopathic scoliosis patients operated between 1996 and 2002 have been included in the study. Mean age was 14.5+/-1.7 years and female/male ratio was 30/15. Mean follow up time was 51.9+/-22.7 months. According to King Classification, 15 patients had Type II, 18 patients Type III and 12 patients had Type IV curves. One of the apical cables has been tensioned and translation has been performed. At the second step, derotation has been applied to the vertebra, which is firmly attached to the rod. Sagittal and frontal Cobb angles have been measured in preoperative, postoperative and recent radiographic examinations. Trunk balance has been examined both clinically and radiographically. Also, secondary curves have been measured in every examination for decompensation findings. In overall frontal plane measurements, postoperative correction was 79.9+/-13.5 %, loss of correction 2.9 degrees +/-3.2 degrees and final correction 74.3 % +/-14.3 %. In postoperative measurements, normal physiological contours have been achieved in 97.8 % of the patients for the thoracic region (30 degrees -50 degrees ) and 80.7 % of the patients for the lumbar region (40 degrees -60 degrees ). In secondary curves, 75.2+/-34.4 % postoperative correction has been observed. No decompensation findings have been observed in the last examination. In postoperative and last follow up examinations, balanced and totally balanced vertebral column has been achieved in every patient of the study group. Solid fusion mass has been observed in every patient. No early or late, local or systemic postoperative complications have been observed. Given these findings, we conclude that derotation-translation combined maneuver performed with 3rd generation instrumentation reinforced sublaminar wires is a good choice in the treatment of the late-onset idiopathic scoliosis.

Comparison of anterior instrumentation systems and the results of minimum 5 years follow-up in the treatment of tuberculosis spondylitis.

Anterior debridement, strut grafting and instrumentation have an increasing popularity in the treatment of tuberculosis of spine. Anterior fixation can be done either by a plate or a rod system. This study reports on the surgical results of 59 patients with Pott's disease that had anterior radical debridement and anterior fusion and anterior instrumentation with 5 years follow-up. Average age at the time of operation was 46.3+/-13.5 years. Average follow-up was 84.6+/-11.3 months. Local kyphosis was measured as the angle between the upper and lower end plates of the collapsed vertebrae preoperatively, postoperatively and at the last follow-up visit. Vertebral collapse, destruction, cold abscess, and canal compromise were assessed in MR images. The indication for surgery was either one of the deformity, instability or neurological compromise. Surgical treatment included anterior radical debridement followed by grafting with tricortical auto graft and anterior instrumentation at levels just above and below the diseased segment(s) with either plate (Sofamor-Danek, Z plate, Group A) or rod (Sofamor-Danek, CDH, Group B) systems. There were 23 patients in group A and 36 patients in group B. All patients had similar anti tuberculosis chemotherapy. Patients had similar rehabilitation program after the surgery. The deformity in the sagittal and the coronal plane was measured and presence of significant consolidation, along with the absence of implant failure or correction loss was considered as signs of fusion. The two groups were similar according to age (46.9+/-14.2 vs. 45.8+/-13.1), gender, average number of involved levels (1.8+/-0.5 vs. 1.6+/-0.5), location of involved levels, severity of deformity (21.5 degrees+/-9.9 masculine vs. 24.8 degrees+/-11.9 masculine) and type of autografts (p>0.05 for all parameters). 39.1 % of patients in group A and 41.6 % of patients in group B had neurological compromise with improvement in majority at the end of follow-up. Deformities were corrected to 5.2 degrees+/-5.7 masculine in group A and 6.1 degrees+/-6.8 masculine in group B with no significant difference. At the time of latest follow-up there were 1.7 degrees+/-2.0 masculine correction loss in group A and 1.4 degrees+/-1.9 masculine in group B with no significant difference in between two groups (p>0.05). Overall, it was observed that, the addition of anterior instrumentation increased the rate of correction of the kyphotic deformity (78.5+/-20.5%), and was effective in maintaining it with an average loss of 1.5 degrees+/-1.9 degrees. Of the 24 (44.1%) patients with neurological symptoms, 20 (83.3%) had full and 4 (16.7%) partial recoveries. There was no apparent pseudoarthrosis and implant failure in both groups and all patients demonstrated clinical improvement in tuberculosis infection without recurrences and reactivation. Four major complications occurred in the group A (major vessel complication: 3.4%, secondary non-specific infection: 3.4%). Disease reactivation was not seen with the employment of an aggressive chemotherapy regimen. It was concluded that anterior instrumentation is a safe and effective method in the treatment of tuberculosis spondylitis. There were no significant differences between the two instrumentation systems in terms of sagittal alignment reconstruction and fusion rate. In rod-screw systems, the disadvantages of scoliotic deformity correction through frontal plan in plate performing did not occur and it is though to have the advantage of long instrumentation in multiple level deformities.

[An evaluation of the types and the results of surgical treatment for congenital scoliosis]. / Dogustan skolyozda cerrahi tedavi seçeneklerinin degerlendirilmesi.

OBJECTIVES: We evaluated the types and the results of surgical treatment performed for congenital scoliosis. METHODS: Forty-one patients (26 females, 15 males; mean age 12.8 years) with congenital scoliosis were included. The patients were classified according to the Winter's system. Transpedicular hemiepiphysiodesis, "egg shell" procedure, and anterior hemiarthrodesis and posterior convex fusion were performed in infantile (n=1) and juvenile (n=8) patients. In the adolescent (n=32) group, posterior in situ fusion was performed for rigid curves (n=15), posterior fusion after correction with posterior instrumentation for moderate curves (n=8), and posterior fusion and correction with posterior instrumentation after an anterior osteotomy for segmentation failures (n=6). Five patients with unincarcerated fully segmented hemivertebrae had anterior or posterior instrumentation following anterior-posterior hemivertebrectomy. The mean follow-up was 51.8 months (range 26 to 132 months). RESULTS: Fourteen patients (34.2%) had formation failures, 19 patients (46.2%) had segmentation failures, and eight patients (19.6%) had mixed types of deformities. Klippel-Feil syndrome was detected in two patients, and heart valve abnormality was found in two patients. Although the infantile patient who underwent transpedicular hemiepiphysiodesis showed no improvement after surgery, a spontaneous correction rate of 60% was found during her final controls. Patients who underwent anterior hemiarthrodesis obtained a final correction rate of 54.3% following a 42% of correction at surgery. The correction rates for posterior instrumentation were 26.2% with translation and 49.3% after an anterior osteotomy. Patients who had anterior or posterior instrumentation after anterior-posterior hemivertebrectomy had final correction rates of 73.3% and 59.2%, respectively. Final evaluations showed that nine patients (21.9%) had no change in their curves, while 10 patients (24.4%) had spontaneous correction. Four patients developed superficial (n=2) and deep (n=2) infections following posterior instrumentation. Of these, three patients were successfully treated with debridement and antibiotic therapy, whereas one patient required implant removal in the eighth month. No neurologic deficits or systemic complications occurred during or after surgery. CONCLUSION: Surgical treatment may yield successful results in progressive congenital scoliosis when an appropriate surgical technique is selected based on the patient's age and the type of deformity.

Anterior radical debridement and anterior instrumentation in tuberculosis spondylitis.

The conventional procedure in the treatment of vertebral tuberculosis is drainage of the abscess, curettage of the devitalized vertebra and application of an antituberculous chemotherapy regimen. Posterior instrumentation results are encouraging in the prevention or treatment of late kyphosis; however, a second-stage operation is needed. Recently, posterolateral or transpedicular drainage without anterior drainage or posterior instrumentation following anterior drainage in the same session has become the preferred treatment, in order that kyphotic deformity can be avoided. Information on the use of anterior instrumentation along with radical debridement and fusion is scarce. This study reports on the surgical results of 63 patients with Pott's disease who underwent anterior radical debridement with anterior fusion and anterior instrumentation (23 patients with Z-plate and 40 patients with CDH system). Average age at the time of operation was 46.8+/-13.4 years. Average duration of follow-up was 50.9+/-12.9 months. Local kyphosis was measured preoperatively, postoperatively and at the last follow-up visit as the angle between the upper and lower end plates of the collapsed vertebrae. Vertebral collapse, destruction, cold abscess, and canal compromise were assessed on magnetic resonance (MR) images. It was observed that the addition of anterior instrumentation increased the rate of correction of the kyphotic deformity (79.7+/-20.1%), and was effective in maintaining it, with an average loss of 1.1 degrees +/-1.7 degrees. Of the 25 patients (39.7%) with neurological symptoms, 20 (80%) had full and 4 (16%) partial recoveries. There were very few intraoperative and postoperative complications (major vessel complication: 3.2%; secondary non-specific infection: 3.2%). Disease reactivation was not seen with the employment of an aggressive chemotherapy regimen. It was concluded that anterior instrumentation is a safe and effective method in the treatment of tuberculosis spondylitis.

[Neural axis abnormalities detected by preoperative magnetic resonance imaging in patients with type III idiopathic scoliosis]. / Tip III idiyopatik skolyoz hastalarinda manyetik rezonans görüntüleme ile saptanan nöral aks anomalileri.

OBJECTIVES: We investigated the presence of neural axis abnormalities by magnetic resonance imaging (MRI) in patients with clinically and radiologically confirmed absolute flexible thoracic curves (King-Moe type III). METHODS: Preoperative MRI scans of 84 patients (34 males, 50 females; mean age 14.1 years; range 11 to 17 years) with adolescent idiopathic scoliosis and a flexible thoracic curve (King-Moe type III) were prospectively evaluated to determine neural axis abnormalities. Clinical and radiologic indications for preoperative MRI examination were sought. All patients were treated with posterior fusion. All patients were intraoperatively monitored by means of motor evoked potentials by magnetic transcortical stimulation and somatosensory evoked potentials. The mean follow-up was 50.1 months (range 24 to 105 months). RESULTS: Neural axis abnormalities were detected in six patients (7.1%), including syringomyelia in five patients (5.9%) and diastometamyelia in one patient (1.2%). Of 84 patients, 51 patients (60.7%) had a relatively decreased spinal cord diameter, and an increased epidural distance. No clinical or radiologic indicators were found for preoperative MRI examination. No neurologic deficits developed during operation and in the postoperative period. CONCLUSION: The detection of neural axis abnormalities implies the necessity of intraoperative neurologic monitoring to minimize the risks for neurologic deficits. Where this is not available, preoperative MRI seems to be an essential tool in the prevention of surgery-associated neurologic risks.