[Surgical Treatment of Degenerative Lumbar Stenosis and Spondylolisthesis: Clinical Practice Guideline]. / Chirurgická lécba degenerativní lumbální stenózy a spondylolistézy: klinický doporucený postup.

PURPOSE OF THE STUDY This article presents the evidence and the rationale for the recommendations for surgical treatment of degenerative lumbar stenosis (DLS) and spondylolisthesis that were recently developed as a part of the Czech Clinical Practice Guideline (CPG) "The Surgical Treatment of the Degenerative Diseases of the Spine". MATERIAL AND METHODS The Guideline was drawn up in line with the Czech National Methodology of the CPG Development, which is based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. We used an innovative GRADE-adolopment method that combines adoption and adaptation of the existing guidelines with de novo development of recommendations. In this paper, we present three adapted recommendations on DLS and a recommendation on spondylolisthesis developed de novo by the Czech team. RESULTS Open surgical decompression in DLS patients has been evaluated in three randomized controlled trials (RCTs). A recommendation in favour of decompression was made based on a statistically significant and clinically evident improvement in the Oswestry Disability Index (ODI) and leg pain. Decompression may be recommended for patients with symptoms of DLS in the event of correlation of significant physical limitation and the finding obtained via imaging. The authors of a systematic review of observational studies and one RCT conclude that fusion has a negligible role in the case of a simple DLS. Thus, spondylodesis should only be chosen as an adjunct to decompression in selected DLS patients. Two RCTs compared supervised rehabilitation with home or no exercise, showing no statistically significant difference between the procedures. The guideline group considers the post-surgery physical activity beneficial and suggests supervised rehabilitation in patients who have undergone surgery for DLS for the beneficial effects of exercise in the absence of known adverse effects. Four RCTs were found comparing simple decompression and decompression with fusion in patients with degenerative lumbar spondylolisthesis. None of the outcomes showed clinically significant improvement or deterioration in favour of either intervention. The guideline group concluded that for stable spondylolisthesis the results of both methods are comparable and, when other parameters are considered (balance of benefits and risks, or costs), point in favour of simple decompression. Due to the lack of scientific evidence, no recommendation has been formulated regarding unstable spondylolisthesis. The certainty of the evidence was rated as low for all recommendations. DISCUSSION Despite the unclear definition of stable/unstable slip, the inclusion of apparently unstable cases of DS in stable studies limits the conclusions of the studies. Based on the available literature, however, it can be summarized that in simple degenerative lumbar stenosis and static spondylolisthesis, fusion of the given segment is not justified. However, its use in the case of unstable (dynamic) vertebral slip is undisputable for the time being. CONCLUSIONS The guideline development group suggests decompression in patients with DLS in whom previous conservative treatment did not lead to improvement, spondylodesis only in selected patients, and post-surgical supervised rehabilitation. In patients with degenerative lumbar stenosis and spondylolisthesis with no signs of instability, the guideline development group suggests simple decompression (without fusion). Key words: degenerative lumbar stenosis, degenerative spondylolisthesis, spinal fusion, Clinical Practice Guideline, GRADE, adolopment.

[Effects of Tranexamic Acid on Perioperative Blood Loss and Wound Hematoma Development in Lumbar Spine Surgery: a Prospective Randomized Study]. / Vliv tranexamové kyseliny na perioperacní krevní ztrátu a rozvoj hematomu v ráne u operací bederní pátere: prospektivní randomizovaná studie.

PURPOSE OF THE STUDY Tranexamic acid as a haemostatic agent is commonly used in multiple medical branches. Over the last decade, there has been a steep rise in the number of studies evaluating its effect, i.e. blood loss reduction in specific surgical procedures. The aim of our study was to evaluate the effect of tranexamic acid on reducing intraoperative blood loss, postoperative blood loss into the drain, total blood loss, transfusion requirements, and development of symptomatic wound hematoma in conventional single-level lumbar decompression and stabilization. MATERIAL AND METHODS The study included patients who had undergone a traditional open lumbar spine surgery in the form of single-level decompression and stabilisation. The patients were randomized into two groups. The study group received a 15 mg/kg dose of tranexamic acid intravenously during the induction of anaesthesia and then again 6 hours later. No tranexamic acid was administered to the control group. In all patients, intraoperative blood loss, postoperative blood loss into the drain, and therefore also total blood loss, transfusion requirements and potential development of a symptomatic postoperative wound hematoma requiring surgical evacuation were recorded. The data of the two groups were compared. RESULTS The cohort includes 162 patients, 81 in the study group and the same number in the control group. In the intraoperative blood loss assessment, no statistically significant difference between the two groups was observed; 430 (190-910) mL vs. 435 (200-900) mL. In case of post-operative drain blood loss, a statistically significantly lower volume was reported after the tranexamic acid administration; 405 (180-750) mL vs. 490 (210-820) mL. When evaluating the total blood loss, a statistically significant difference was also confirmed, namely in favour of the tranexamic acid; 860 (470-1410) mL vs. 910 (500- 1420) mL. The reduction of total blood loss did not result in a difference in the number of administered transfusions; transfusions were given to 4 patients in each group. A postoperative wound hematoma requiring surgical evacuation developed in 1 patient in the group with the tranexamic acid and in 4 patients in the control group, but the difference was not statistically significant with respect to the insufficient group size. No patient in our study experienced complications associated with tranexamic acid application. DISCUSSION The beneficial effect of tranexamic acid on reducing blood loss in lumbar spine surgeries has already been confirmed by numerous meta-analyses. The question remains in what types of procedures, at what dose and route of administration its effect is significant. To date, most of the studies have explored its effect in multi-level decompressions and stabilizations. Raksakietisak et al., for instance, report significant reduction in total blood loss from 900 (160, 4150) mL to 600 (200, 4750) mL following an intravenous injection of 2 bolus doses of 15 mg/kg tranexamic acid. In less extensive spinal surgeries, the effect of tranexamic acid may not be that distinct. In our study of single-level decompressions and stabilizations, no reduction in the actual intraoperative bleeding was confirmed at the given dosage. Its effect was seen only in the postoperative period in a significant reduction of blood loss into the drain, thus also in the total blood loss, although the difference between 910 (500, 1420) mL and 860 (470, 1410) mL was not that significant. CONCLUSIONS By intravenous application of tranexamic acid in 2 bolus doses in single-level decompression and stabilization of the lumbar spine a statistically significant reduction in postoperative blood loss into the drain and also total blood loss was confirmed. The reduction in the actual intraoperative blood loss was not statistically significant. No difference was observed in the number of administered transfusions. Following the tranexamic acid administration, a lower number of postoperative symptomatic wound hematomas was recorded, but the difference was not statistically significant. Key words: tranexamic acid, spinal surgeries, blood loss, postoperative hematoma.

Unusual foreign body in the nasal cavity after craniofacial injury.

A 68-year-old man with severe craniofacial trauma underwent endoscopic surgery for nasal cerebrospinal fluid leak. During the operation, a plastic object in the shape of a spectacle lens was found wedged in the left nasal passage, which we extracted. As subsequently established from the patient's documentation, it was a dislodged acrylic implant originally placed at the base of the orbit which was surgically treated after an injury to the facial skeleton thirty-five years ago. What is also rare about this is the fact that the patient had been examined for many years at the otorhinology department for purulent discharge from the left nasal cavity and impaired ventilation. The patient had also undergone an endoscopic examination of the nasal cavity during which an intranasal tumor was even suspected, but it was not histologically confirmed.

[Coccygodynia: Case Reports and Literature]. / Coccygodynie: vlastní kazuistiky a prehled literatury.

Coccygodynia, or tailbone pain, is the most common in women after trauma (complicated childbirth, fall). This pain can be treated conservatively (by using analgesics, local injections, physiotherapy) or by surgical coccygectomy. In the presented article, a set of five female patients is evaluated, in whom, after the failing conservative therapy, coccygectomy was indicated for persistent coccygodynia. In all female patients, improvement of their clinical condition and alleviation of pain were reported. Coccygectomy has its place in the management of coccygodynia and in correctly chosen patients significant pain reduction can be expected. Key words: coccygodynia, coccyx, coccygectomy, trauma.

Sinonasal quality of life in patients after an endoscopic endonasal surgery of a sellar tumour.

Endoscopic endonasal approach uses the nasal cavity and paranasal sinuses to access the cranial base and may be a source of post-surgical morbidity in many patients with a sellar tumour. The objective of the presented study was to evaluate sinonasal quality of life and assess the effect of chosen reconstruction of the cranial base on the final condition. 65 patients, 33 male and 32 female who underwent an endoscopic endonasal surgery due to sellar expansion, were included into this prospective study. Sinonasal quality of life was evaluated using the Sinonasal Outcome Test-22 (SNOT-22) questionnaire before the surgery and six months after the surgery. Sinonasal quality of life was evaluated for the total cohort of patients and for patients after reconstruction (fascia lata, muscle) and without reconstruction. The minimum follow-up period was one year. There was no significant difference between the score (SNOT-22) before the surgery (average 14.4 points) and after the surgery (average 17.5 points), p = 0.067 in the whole cohort. Statistically significant differences were found in the following items-the need to blow nose, nasal congestion, loss of smell and taste, and thick discharge from the nose. The comparison of subgroups with and without the reconstruction yielded statistically significant differences in favour of patients with reconstruction in the following items-lack of high-quality sleep and feeling exhaustion. The endoscopic endonasal approach in patients with a sellar tumour is a gentle method with minimal effects on sinonasal quality of life over a period longer than six months. The most common complaints are the need to blow nose, nasal congestion, loss of smell and taste, and thick discharge from the nose. Cranial base reconstruction using the muscle and fascia lata seems to be a potential factor positively influencing sinonasal quality of life.

[Minimally Invasive Sacroiliac Joint Stabilization]. / Minimálne invazivní stabilizace sakroiliackého skloubení.

PURPOSE OF THE STUDY Sacroiliac joint dysfunction is defined as a permanent chronic pain originating from the sacroiliac joint, limiting the patient's daily activities. The purpose of this study was to evaluate the effectiveness of the minimally invasive sacroiliac joint stabilization by triangular titanium implants in patients with sacroiliac joint dysfunction. MATERIAL AND METHODS The prospective study evaluated the patients who had underwent a minimally invasive sacroiliac joint stabilization for sacroiliac joint dysfunction with the use of iFuse® implants. The surgery was performed solely under fluoroscopic guidance or together with the use of O-arm O2® mobile imaging system. The clinical condition, the Visual Analogue Scale preoperatively and one year postoperatively, previous surgeries in the lumbar spine region, the use of O-arm and occurrence of complications were recorded. The minimum follow-up period was 1 year. RESULTS The group was composed of 20 patients, of whom 4 men and 16 women. The mean age was 48.9 years. The surgeries covered 21 sacroiliac joints. Improvement of the clinical condition was reported in 17 cases (81.0%), no relief was observed in 4 cases (19%). The mean VAS score was 6.1 points preoperatively and decreased to 2.9 points postoperatively (p=0.0001). CONCLUSIONS The minimally invasive sacroiliac joint stabilization should be reserved for patients experiencing an intractable pain originating from the sacroiliac joint, in whom all non-operative therapy failed. Key words: minimally invasive sacroiliac joint stabilization, sacroiliac joint dysfunction, O-arm.

Primary Intracranial Sarcomas, Myxoid Meningeal Sarcoma - a Case Report and Literature Review.

BACKGROUND: Primary intracranial sarcoma is a rare disease. Due to the scarcity of evidence from randomized clinical trials, we follow the treatment guidelines of their extracranial counterparts or those published in case reports, while taking into consideration the specificity of radiotherapy within the brain, and the limit imposed on chemotherapy by the blood brain barrier. Nevertheless, surgery remains the golden standard of treatment for primary tumours, and also for recurrence. Even though there are usually narrow margins achieved in brain compared with the extracranial sarcomas. Despite significant effort, prognosis remains dismal. CASE: We present a 69-year old woman who was investigated for psychoorganic syndrome and paresis of the left hand. Magnetic resonance imaging revealed a tumour expansion in her frontal lobe with collateral oedema. Surgical resection was indicated. Histology of the specimen suggested a myxoid meningeal sarcoma. Early disease recurrence 4 months after primary resection was treated by reresection and 50 Gy of adjuvant radiotherapy to the tumour bed. Similarly, another recurrence 19 months after the second surgery was treated using the same approach. Systemic treatment has not been indicated so far. At this time, the patient is without evidence of any disease recurrence and continues with regular follow-up. CONCLUSION: Myxoid meningeal sarcoma represents a rare disease with a high risk of recurrence. Unfortunately, there is no clear recommendation for treatment algorithm. The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers.

[Metastatic Pituitary Disorders]. / Metastatické postizení hypofýzy.

BACKGROUND: Pituitary metastases are a rare complication of generalized cancer. Metastases to the pituitary gland occur in only 1% of patients operated on for sellar tumor. The most common presenting symptom in patients with pituitary metastases is diabetes insipidus, whereas this is rare in those with pituitary adenoma. MATERIAL AND METHODS: This publication presents the cases of two patients with pituitary metastases and a systematic review of the literature. English-language publications related to pituitary metastases and published from 1957 to 2016 were identified using the PubMed database. RESULTS: A total of 131 publications containing information about 259 patients (121 female and 138 male; mean age, 57.3 years) were identified. The most often metastasized breast carcinoma (24.6%) and lung carcinoma (23.8%), followed by thyroid carcinoma (11.3%), renal cell carcinoma (7.8%), hepatocellular carcinoma (4.3%), colorectal carcinoma (3.5%), and malignant melanoma (3.5%). The most frequent initial symptoms were manifestations of diabetes insipidus (39.6%), anterior pituitary deficiency (44.9%), perimeter disorders (51.6%), headache (37.6%), cranial nerve palsy (33.5%), and pseudoprolactinemia (16.7%). Radiotherapy (67.8%) and surgical treatment (63.9%) were the most frequently used treatment. CONCLUSION: The average survival time from the onset of metastatic disease was 11.8 months. Surgical therapy alone or in combination with radiation therapy does not prolong survival, but alleviates symptoms and improves quality of life.Key words: pituitary metastasis - diabetes insipidus - hypopituitarism - transsphenoidal surgery The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers.Submitted: 13. 1. 2017Accepted: 4. 4. 2017.

[Autologous cranioplasty with a bone flap preserved subcutaneously in the mesogastrium]. / Autologní kranioplastika deponovanou kostní ploténkou v podkozí mezogastria.

INTRODUCTION: Cranioplasty with autologous bone flap is indicated in patients who have undergone decompressive craniectomy. Although it is an elective procedure, literature data indicate complication rates of up to 30%. The aim of this paper is to present our experience with cranioplasty with the patients own bone flap stored subcutaneously in the mesogastrium. METHODS: We retrospectively analyzed a set of 92 patients who had undergone cranioplasty after decompressive craniectomy using autologous graft preserved subcutaneously in the mesogastrium. The patients were clinically and radiologically examined before the surgery, and six weeks and one year after surgery. We evaluated the incidence of acute complications - wound hematoma, and late complications - infection and bone resorption. The postoperative cosmetic effect and patient discomfort from the stored bone flap also constituted an important aspect. RESULTS: The frequency of complications in our study group was 25%. Late complications were the most common, occurring with a frequency of 13%. These were mainly resorption of the bone flap (4.3%) and infectious complications (4.3%). Acute complications occurred with a frequency of 10.9% in our patient group. The most serious complication was cerebral edema of unknown origin leading to death of the patient. Unsatisfactory cosmetic effect as well as discomfort at the site where the flap was stored occurred in two cases. CONCLUSIONS: Cranioplasty is associated with a higher risk of complications in comparison with other elective procedures. Nevertheless, we regard cranioplasty with subcutaneously preserved bone flap as an inexpensive and suitable alternative to cryopreservation or alloplastic materials.Key words: cranioplasty complications of cranioplasty autologous cranioplasty decompressive craniectomy.

Glioblastoma multiforme in patients with history of extracranial cancer: Case series.

OBJECTIVES: Significant progress in treatment strategies improves the expectations of patients with extracranial cancers. Metastases are the primary consideration in patients with cancer history. In the case of neurologic disorders, the patient should undergo brain MRI. A rationale is presented for surgery, whole-brain or stereotactic radiotherapy, or chemotherapy. Recently, we have encountered misdiagnosed primary malignant brain tumours in patients with oncologic history who had been admitted for surgery for brain metastases. The aim of our study is to evaluate the incidence of concurrent cancers, to assess the relationship between previous cancer staging and primary brain tumour evaluation as well as to determine treatment efficiency. METHODS: From January 2007 to December 2011, we prospectively followed up patients with concurrent history of both extracranial cancer and subsequent glioblastoma multiforme. Information was collected on the clinical condition, imaging, history of extracranial cancer, previous and present surgical and oncologic procedures, and GBM histologic, cytogenetic, and molecular genetic investigations. RESULTS: Five patients were recruited: three females and two males. The average patient age at the time of GBM diagnosis was 65.6 years. Three patients had a history of breast carcinoma, one of renal carcinoma and one of colorectal carcinoma. Following the diagnosis of carcinoma, three patients received chemotherapy and radiotherapy, one patient had radiotherapy alone, and one had no adjuvant therapy. In all the cases, surgery revealed primary GBM, with a standard occurrence of genetic abnormalities (Table 1). The average time from the diagnosis of extracranial cancer to that of GBM was 4 years. Four patients underwent chemoradiotherapy and one had palliative radiotherapy. Two patients completed oncotherapy and their OS was 27 months and 19 months, respectively. One patient had post-surgical progression of hemiparesis. One patient had pulmonary embolism during oncotherapy and one had paraplegia caused by a pathological fracture of vertebras T5 due to breast carcinoma metastases. The OS was 11.8 months (range 3-27 months). All the patients succumbed to GBM progression.

[Influence of Cervical Spondylotic Spinal Cord Compression on Cerebral Cortical Adaptation. Radiological Study]. / Vliv cervikální spondylogenní mísní komprese na korové funkce mozku. Radiologická studie.

PURPOSE OF THE STUDY: The aim of the study was to measure the sensorimotor brain adaptation activity, shown on functional magnetic resonance images (fMRI), in relation to the degree and extent of spinal cord compression or cervical spondylotic myelopathy (CSM) detected by cervical spine MRI. MATERIAL AND METHODS: Twenty-one patients (average age, 57 years; 9 men and 12 women) with anterior cervical cord compression detected on cervical MRI scans were included. On the images, the degree of spinal canal stenosis, the spinal cord compression based on the antero-posterior diameter of the spinal canal and on transverse areas of the cervical spinal cord and cervical spinal canal, and changes in spinal cord signal intensity were identified. Clinical examination included neurological status, Japanese Orthopaedic Association (JOA) score, Neck Disability Index (NDI) and pain intensity assessment using the Visual Analogue Scale (VAS). Electrophysiological tests involving motor evoked and sensory evoked potential (MEP and SEP) recording were conducted and, using fMRI, brain activity during movement of both arms was measured. Based on the transverse spinal cord area of above or below 70 mm2, the patients were placed into two subgroups. According to changes in spinal cord signal intensity, the patients were included into three subgroups with normal findings, incipient myelopathy and advanced myelopathy, respectively. Surgery was carried out from the anterior approach and involved cervical disc replacement. All examinations were performed again at 6 months after surgery. Pre- and post-operative results were compared within each set of subgroups and statistically evaluated. RESULTS: The average pre-operative values were found to increase post-operatively as follows: from 6.4 mm to 8.9 mm (by 39%) for the antero-posterior diameter of the spinal canal; from 129.3 mm2 to 162.8 mm2 (by 26%) for the transverse area of the spinal canal; from 72.6 mm2 to 87.4 mm2 (by 20%) for the transverse spinal cord area; and from 16.3 to 17.4 for the JOA score. The average NDI decreased from 37.9 to 23.7 and the average VAS fell from 6.4 to 1.5. All patients with the change of spinal cord signal that indicated advanced myelopathy also had relevant pathological findings on MEP/SEP examination and this was statistically significant. There was no significant difference in fMRI scans between the two subgroups established on the basis of transverse spinal cord area measurements. In the patients grouped by a change in spinal cord signals, the pre-operative fMRI showed a significantly higher brain activation volume in the subgroup with advanced myelopathy, as compared with the two other subgroups. Surgery resulted in a moderate reduction of the volume of active brain tissue in all three groups. In the patients with advanced myelopathy evaluated in relation to local changes in brain activation, surgery led to a significant decrease in activation volumes in the ipsilateral primary motor cortex and cerebellar hemisphere. There was also a significant increase in activation of the contralateral supplementary motor cortex. DISCUSSION: It is evident that the brain responds to spinal cord damage by increased activity, but with a certain delay. A slightly altered spinal cord signal intensity, such as in incipient myelopathy, apparently does not result in brain activation. On the other hand, significant changes in signal intensity in advanced myelopathy are related to deterioration of spinal cord function, as shown by MEP and SEP examination results, and an increase in both the volume and intensity of cortical motor activation as a compensation mechanism for myelopathy. CONCLUSIONS Hyperintense spinal cord signals on T2-weighted images correlated with the pathological spinal cord function detected by electrophysiological test in all patients. The transverse spinal cord area (around 70 mm2) showed no significant correlation with either sensory and motor brain adaptations or the results of SEP and MEP testing; therefore, as a criterion for indication to surgery it is of no value. The patients with advanced myelopathy, as detected by spinal cord MRI, had a significantly higher pre-operative cortical motor activation on fMRI than patients with normal findings or those with incipient myelopathy. In addition, the patterns of cortical motor activation altered significantly at 6 months after spinal cord decompression, which was shown by an increase or decrease in activation of the relevant motor cortex areas.

[Surgery for degenerative spondylolisthesis of the lumbar spine using intra-articular fusion. A prospective study]. / Operace degenerativní spondylolistézy bederní pátere metodou intraartikulární fúze: prospektivní studie.

PURPOSE OF THE STUDY: The aim of the study is to present our surgical method of treating degenerative spondylolisthesis, which includes radical bilateral laminectomy to relieve compression on the spinal cord, transpedicular fixation of the segment and arthrodesis by bilateral intra-articular fusion. MATERIAL AND METHODS: This surgery was indicated in patients with grade I or grade II of degenerative sponylolisthesis with a 4-mm or more slippage. Our prospectively studied group consisted of 46 patients (17 men, 29 women; average age, 64.2 years; range, 39-84 years). Before surgery and at 1 year after the procedure, the intensity of axial pain and that of radicular pain were each assessed using the visual Analogue Scale (VAS). Difficulty in performing daily living activities was measured by the Oswestry Disability Index (ODI). The surgical procedure included laminectomy, partial medial facetectomy, foraminotomy to relieve pressure on the spinal nerve roots and transpedicular fixation to provide stability. Using a cutter, cartilage was separated off the cortical bone and, in order to facilitate fusion, bone cavities thus produced were filed with corticospongious grafts harvested from the removed vertebral arch with Kerrison forceps. At 1-year follow-up, dynamic X-ray was used to evaluate spine alignment and, on a CT scan, the degree of intra-articular fusion was assessed. Fusion was achieved when bone density measurement showed more than 350 Hounsfield Units (HU). For the measurements, the authors used their own modified method by means of a Region of Interest (ROI) analysis. The clinical and radiographic results were statistically evaluated. RESULTS: At 1 year after surgery, lumbar flexion-extension bending X-ray films revealed stability of the treated segments in all patients (100%). CT examination showed bone density higher than 350 HU at both joints, i.e., complete bone fusion, also in all 46 patients. The mean post-operative ODI score was significantly lower than its mean pre-operative value (23.6 vs 55.4), which was improvement by 57.4%. The differences in pre- and post-operative VAS scores were also statistically significant. The mean VAS score for low back pain decreased from 7.61 to 1.74, i.e., improvement by 77.1%, and the mean vAS score for radicular pain dropped from 6.98 to 1.24, i.e., improvement by 82.2%. Assessed by Odom's outcome criteria, the results were excellent in 26 patients and very good in 20 patients, and they were not related to age, gender or the spinal level treated. Any complications associated with the operative procedure or wound healing and requiring repeated surgical treatment were not recorded. DISCUSSION: The surgical technique described here has advantages over other methods in reliable achieving nerve decompression, joint fusion and spinal stability at low costs and short operative time. In addition, it avoids the necessity of harvesting bone from the iliac crest. CONCLUSIONS: At 1-year follow-up all patients showed better health conditions, with improvement in average scores for the ODI by 57%, for low back pain by 77% and for radicular and claudication pain by 82%. The technique of intra-articular fusion for treatment of degenerative spondylolisthesis resulted in solid bone fusion and spinal stability in all patients.

[Effects of spinal cord decompression in patients with cervical spondylotic myelopathy oncortical brain activations]. / Efekt dekomprese krcní míchy pri spondylogenní myelopatii na korové funkce mozku.

INTRODUCTION: The aim of this project was to compare and evaluate cortical sensorimotor adaptations as measured by brain fMRI (functional magnetic resonance imaging) in patients before and after surgery for cervical spondylotic myelopathy (CSM), i.e., after spinal cord decompression. MATERIAL AND METHODS: Study inclusion required evidence of CSM on MRI of the cervical spine, anterior compression of the spinal cord by osteophytes, or disc herniation. We measured the antero-posterior diameter of the spinal canal stenosis before and 3 months after surgery. Surgery was performed at one or two levels from the anterior approach with implantation of radiolucent spacers, without plate fixation. Each participant underwent two fMRI brain examinations, the first one preoperatively and the second one 6 months following surgery. Subjects performed acoustically paced repetitive wrist flexion and extension of each upper extremity according to block design. MRI data were acquired using 1.5 Tesla scanners. Statistical analysis was carried out using the general linear model implemented in FEAT 6.00 (FMRI Expert Analysis Tool), part of the FSL 5.0 package (FMRIB Software Library). The group differences were evaluated using paired t-test and the resulting statistical maps evaluated as Z-score (standardised value of the t-test) were thresholded at a corrected significance level of p <0.05. The study group consisted of 7 patients including 5 female and 2 male patients, with the average age of 55.7 years. Patients with cervical spondylogenous radiculopathy were evaluated as a control group. RESULTS: The analysis of mean group effects in brain fMRI during flexion and extension of both wrists revealed significant activation in dorsal primary motor cortex contralaterally to the active extremity and in adjacent secondary motor and sensory areas, bilaterally in supplementary motor areas, the anterior cingulum, primary auditory cortex, in the region of the basal ganglia, thalamus and cerebellum. After surgery, the cortical activations and maximum Z-scores decreased in most areas. Analysis of differences between sessions before and after surgery showed a statistically significant activation decrease during movement of both extremities in the right parietal operculum and the posterior temporal lobe. During left wrist movement, there was additional activation decrease in the right superior parietal lobe, the supramarginal gyrus, insular cortex, and the central operculum. In contrast, an activation decrease was detected in the left middle temporal gyrus during right wrist movement. CONCLUSION: An average difference of anteroposterior cervical spinal canal distance before and after surgery of CSM was 2.67 millimetres, representing a 40% increase; the cross-sectional area of the spinal canal increased by 37% and that of the spinal cord by 36%. Functional MRI of the brain revealed significant activation especially in primary and secondary motor cortex and sensory areas in patients with CSM. After surgical decompression of the spinal cord, cortical activations and maximum Z-score decreased in the majority of areas. We proved decreased cortical activation on functional MRI of the brain after surgery in patients with CSM (evaluated according to MRI of cervical spine), even at an initial stage of the disease.

[Use of artifiial bone in lateral interbody fusion of the lumbar spine: a prospective radiographic study]. / Pouzití umelé kostní náhrady pri laterální mezitelové fúzi na bederní páteri: prospektivní radiologická studie.

PURPOSE OF THE STUDY: The aim of the study was to evaluate the extent of fusion using synthetic ß-tricalcium phosphate as a bone substitute in extreme lateral interbody fusion (XLIF). MATERIAL AND METHODS: In this prospective study, patients undergoing XLIF with an Oracle cage filed with the artifiial bone ChronOs Strip (Synthes, USA) were evaluated. The group consisted of 61 patients, 33 women and 28 men, with an average age of 50.9 years (range, 21 to 73 years). A total of 64 segments were operated on. Stand-alone interbody fusion was performed in 14 segments, lateral plate fiation in 19, transpedicular (TP) fiation before XLIF was carried out in 14 and TP fiation after XLIF in 17 segments. At one-year follow-up, dynamic X-rays to exclude instability, and CT images were obtained in order to evaluate the extent of bone fusion outside the implant (complete fusion, partial fusion, no fusion) and inside it (% of the bone fusion surface area). In addition, bone mineral density following fusion mass bone quality (expressed in Hounsfild units [HU]) was assessed inside the implant at the site of ChronOs Strip placement, using a region of interest (ROI) analysis. For the evaluation of fusion bone quality inside the implant on CT scans with HU qualifiation, the authors propose the following scale: 1. no fusion (0-99 HU) 2. Uncertain fusion (100-190 HU) 3. Probable fusion (200-299 HU) 4. Reliable fusion (300 and more HU) All results were statistically evaluated in relation to the gender, age, treated segment, surgical diagnosis, method of fiation, implant height and intervertebral space reduction at one-year follow-up. RESULTS: Fusion outside the implant was complete in 18 segments (28%) and partial in 27 (42%); in 19 segments (30%) it was not detected. The bone fusion surface area inside the implant was 54.5% (0-100%) on the average. It was related to age and implant height; the surface area increased with increasing age and with increasing implant height. Solid bone fusion inside the implant, as assessed on CT images using HU, was reliable in 36 segments (56%), probable in 11 (17%), uncertain in 10 (16%) and was not detected in seven segments (11%). A signifiant relationship was found between the quality of bone fusion and the type of fiation. Of the segments treated by stand-alone XLIF, 29% showed no fusion while the segments managed by lateral plate fiation had 32% of them with probable fusion. Correlations were also found with the height of an implant (the higher the implant, the more reliable its fusion), with age (the higher age, the higher bone density) and with the spinal level (the lower level, the lower bone density). In 45 (70%) segments, bone mineral density inside the implant was higher than the density of surrounding spongious bone. The average density inside the implant was 333.7 HU (14-1075) and that of the surrounding bone was 244.6 HU (66-500). The intervertebral space was reduced by an average of 1.1 mm (0-6.2). All treated segments were found stable on dynamic X-rays. DISCUSSION: The use of a tricortical bone graft collected from the iliac crest is associated with pain at the harvest donor site in 2.8% to 39% of the cases, and this has been an impetus for many surgeons to use bone substitutes. In terms of the final outcome, i.e., solid bone fusion, the difference between the resorption rates of allogenous graft/artificial bone and ingrowth of autologous bone (from vertebral bodies) plays the most decisive role. CONCLUSIONS: The change of (3-tricalcium phosphate to bone tissue is not always reliable and this can largely be expected when the resorption rate of ChronOs strip is low, i.e., at higher patient age and with a higher height of the implant.The authors recommend increasing the probability of solid fusion in XLIF by using lateral plate fixation.The method of assessing bone fusion by measuring bone density on CT scans proved to be useful because of its objectivity, and it can replace the current assessments based only on subjective judgement.

[Intraarticular arthrodesis of the unstable lumbosacral spine - first results of the prospective study]. / Nitrokloubní artrodéza pri nestabilite lumbosakrální pátere - první výsledky prospektivní studie.

INTRODUCTION: The aim of this study is the presentation of surgical treatment of the unstable lumbosacral (LS) spine using the bilateral intraarticular facet fusion. MATERIAL AND METHODS: For surgical treatment patients were indicated with the degenerative instability of LS spine. We examined VAS (Visual Analogue Scale), ODI (Oswestry Disability Index), static and dynamic skiagrams and magnetic resonance imaging before surgery. Laminectomy for the decompression of the spinal stenosis and a transpedicular (TP) fixation were performed. Corticospongious bone chips from lamina were inserted into the intraarticular caves after the drilling of the facet cartilages. The study group consisted of 17 patients (the average age of 66 years), with a minimal follow-up of two years. One year after the surgery, we evaluated VAS, ODI, the improvement of walking distance, Odom criteria, complications, the stability of the spinal segment and the extent of the intraarticular fusion using Computed Tomography (CT). RESULTS: VAS for the axial pain was decreased from 6.8 (in average) before surgery to 1.5 (in average) after one year; the improvement was by 77.4%. VAS for the radicular pain was decreased from 6.3 (in average) before surgery to 1.6 (in average) one year after surgery; the improvement was by 74.6%. ODI was decreased from 52.1 (in average) before surgery to 23.4 (in average) one year after surgery; the improvement was by 55.1%. According to Odom criteria we evaluated 10 patients as excellent and 7 patients as good one year after surgery. The bone intraarticular fusion and the stability of the spinal segment according to CT scans and dynamic skiagrams were concluded in all patients (100%). The extent of the intraarticular fusion (facet area) according to CT scans was 89% in average. All patients improved their walking distance and there were no surgical complications. CONCLUSION: The intraarticular arthrodesis of LS spine was concluded in all (100%) patients during one year after surgery. After the concomitant laminectomy, the TP fixation and the intraarticular fusion of the unstable segment of LS spine we observed a decrease of the axial pain by 77%, the radicular pain by 75% and the improvement of functional ability by 55% in comparison to the status before surgery. According to the author this surgical method is safe, cheep, and effective in certain indications of degenerative disease of LS spine, at the same time.

[Percutaneous interspinous dynamic stabilization (in-space) in patients with degenerative disease of the lumbosacral spine - a prospective study]. / Perkutánní interspinózní dynamická stabilizace (In-Space) u nemocných s degenerativním onemocnením lumbosakrální pátere - prospektivní studie.

INTRODUCTION: Interspinous spacers are supposed to reduce the segmental extension with a decrease in the expansion of yellow ligaments into the spinal canal, thus avoiding the dynamic narrowing of the spinal canal and compression of nerve roots. The aim of this study was to evaluate clinical outcomes and post-operative complications during one year in patients mostly having suffered from spinal stenosis and treated by In-Space interspinous spacer (Synthes, USA). MATERIAL AND METHODS: A total of 25 patients aged between 25 and 73 (average age 52.6) years, including 18 males and 7 females, with degenerative disease of the lumbosacral spine were indicated for surgery and prospectively followed up. The patients were operated on under general anaesthesia in the prone position, using a minimally invasive lateral percutaneous approach, under fluoroscopic control. The ODI and VAS values as well as X- rays (Range Of Motion and Sagittal angle of the operated segment) 6 and 12 months after the surgery were compared to each other and to those before surgery. The results were statistically analyzed. RESULTS: The average ODI of the group was 47.2% before surgery and 17.48% 6 months (22.76% 12 months) after surgery, showing a statistically significant improvement by 63% (52% after 12 months). The average VAS of the group was 6.64 points before surgery and 2.96 points 6 months (2.8 points 12 months) after surgery, which showed a statistically significant improvement by 55.4% after 6 months (57.8% after 12 months) when compared to preoperative status. After surgery the lordotic sagittal angle remained in all cases; one year after surgery the angle increased due to the slight sinking of some implants. The extent of segmental motion was minimally changed (6.1° 6 months and 7.24° 12 months after surgery). No serious complications occurred. The effect of interspinous implants proved insufficient in two cases (one year and two years after surgery) and conversion to arthrodesis or decompression was performed. CONCLUSIONS: 1. Percutaneous, minimally invasive insertion of an In-Space interspinous spacer is an effective and safe method of dynamic stabilization not accompanied by any serious complications. 2. ODI improved by 63% 6 months after surgery with a decrease in this effect 12 months after surgery. VAS for axial and radicular pain, as reported by patients, improved on average by 55.4% 6 months and by 57.8% 12 months after surgery. 3. In all cases, the lordotic sagittal angle remained after surgery and the extent of segmental motion from flexion to extension was minimally changed.

[Percutaneous dynamic interspinous stabilisation for the treatment of juxtafacet cysts of the lumbar spine: prospective study]. / Lécba juxtafacetárních cyst bederní pátere perkutánní dynamickou interspinózní stabilizací: prospektivní studie.

PURPOSE OF THE STUDY: To present the authors' philosophy on the surgical treatment of juxtafacet cysts of the lumbosacral (LS) spine, with its primary aim of dynamic lumbar stabilisation with an interspinous implant, inserted by a minimally invasive approach, without concurrent exploration of the spinal canal and cyst removal. MATERIAL AND METHODS: During a 20-month period, ten patients aged between 25 and 70 years (average age, 53.2 years) were indicated for surgical treatment of a juxtafacet cyst by percutaneous insertion of an In-Space interspinous spacer without surgical exploration of the spinal canal. The group comprised six men and four women. At a follow-up of 6 weeks to 18 months, each patient underwent MRI examination of the LS spine and the degree of cyst resorption was assessed. The visual analogue scale (VAS) scores, Oswestry Disability Index (ODI) and range of motion (ROM) values, and a sagittal angle (SA) of the segment treated obtained for the whole group at 3 to 18 months after surgery were compared with the pre-operative va - lues. The surgeon evaluated the effect of surgery on radicular and axial pain. RESULTS: Complete resorption of the cyst was found in seven patients (70%) and three (30%) showed partial resorption. Complete resolution of radicular symptoms was reported by five patients (50%); five experienced partial relief (50%). Lumbago was relieved completely in three (30%) and partially in seven (70%) patients. The average VAS score was 6.7 points (range, 4-10) pre-operatively and 3.5 (0-8) post-operatively, i.e. it decreased by 3.2 points, which meant an improvement by 48%. The average ODI value was 58.4% (range, 32-80) pre-operatively and 23.9% (0-70) post-operatively, i.e., it decreased by 34.5 percentage points and was an improvement by 59%. The average ROM measures were 5.65 degrees (range, 2°-10°) pre-operatively and 5.55 degrees (0°-19°) post-operatively. The average pre- and post-operative sagittal angles in normal lumbar lordosis were 7.1 degrees (1°-13°) and 6.2 degrees (1°-11°), respectively. DISCUSSION: The conventional surgical procedure involves cyst extirpation. However, the procedure only relieves nerve root compression but does not remove the cause of juxtafacet cyst development, which is due to facet joint degeneration and instability. This may results in persistent or recurrent clinical symptoms. On the other hand, a reduction of both mobility and loading of the intervertebral joints achieved by implantation of an interspinous spacer is the mechanism allowing for resorption of the cyst and resolution of symptoms. CONCLUSIONS: 1. The original method of treating juxtafacet cysts of the LS spine by an In-Space interspinous spacer, as presented here, was efficient in all patients and resulted in complete, or at least partial, resorption of the cyst. 2. Segmental mobility and spondyloarthritis are the major aetiological factors of juxtafacet cyst development. 3. Dynamic interspinous stabilisation will reduce loading of the intervertebral joints and will thus allow for cyst resorption and clinical symptom resolution. 4. Percutaneous implantation of an "In-Space" interspinous spacer is a minimally invasive method of dynamic stabilisation that means no restrictions in patients' activities and reduces the length of hospital stay.

[Dens fracture with concurrent subaxial cervical spine injury in patients with ankylosing spondylitis]. / Kombinace zlomenin dentu C2 a subaxiální krcní pátere u pacientu s ankylozující spondylartritidou.

Odontoid process fractures in patients with ankylosing spondylitis (AS) are rare and their finding together with subaxial cervical spine injury is a great exception. Neither the mechanism of such a combined cervical spine injury nor its surgical treatment has so far been reported in the relevant literature (MEDLINE). The authors present two such cases, one in a 30- and the other in a 74-year-old man. Both AS patients showed a common mechanism of injury sustained in a car accident, which involved hitting a solid barrier at 60 to 70 kilometres per hour, resulting in hyperextension of the cervical spine. In both patients the fractures were stabilised from the anterior approach: the dens fractures with one or two screws by the Magerl-Böhler method and the subaxial fractures with long-plate and screw fixation. At 2 post-operative years complete bone union of the subaxial spine was recorded in both patients; complete healing of the dens fracture was achieved in one patient while in the other partial fibrous union of the dens fracture occurred.

[Treatment of degenerative spondylolisthesis of the lumbosacral spine by decompression and dynamic transpedicular stabilisation]. / Operace degenerativní spondylolistézy lumbosakrální pátere dekompresí a dynamickou transpedikulární stabilizací

PURPOSE OF THE STUDY: The aim of the study was to present the effect and advantages of surgical decompression and dynamic transpedicular stabilisation in patients with degenerative spondylolisthesis of the lumbosacral spine. MATERIAL AND METHODS: This prospective study involved patients undergoing dynamic transpedicular stabilisation using Isolock or Isobar TTL (Scient X, France) systems. Between June 2003 and June 2009, 65 patients were treated and followed-up. They were aged 35 to 75 years (average, 57.17 years), and there were 32 men and 33 women. Follow-up ranged from 1 to 6 years. Based on indications for surgery they fell into two groups. Group 1 included 52 patients with grade I or II degenerative spondylolisthesis or retrolisthesis. Group 2 (control) consisted of 13 patients with degenerative disc disease or failed back surgery syndrome. The disorder had always been manifested by combined axial and radicular symptoms. Treatment included posterior decompression of nerve structures by laminectomy in conjunction with semi-rigid stabilisation, without fusion. Followup clinical (VAS, ODI), neurological and radiographic examinations were carried out at 6 weeks, 6 months and 1 to 6 years after surgery. The VAS and ODI results of both groups were statistically analysed and compared. RESULTS: During follow-up the ODI values decreased by 54 % (from 58.4 % to 26.8 %) and VAS values by 62 % (from 7.9 to 3.0) as compared with the pre-operative values, and this was statistically significant. When both groups were compared, the VAS values decreased significantly (by 5.61) in Group 1, as compared with Group 2 (decrease by 3.54). DISCUSSION: In the treatment of pseudospondylolisthesis, the semi-rigid stabilisation with spinal decompression, as presented here, is a convenient alternative to simple decompression without fixation or to various forms of instrumented or non-instrumented arthrodesis. A disadvantage associated with arthrodesis is a higher risk of ASD development; dynamic systems do not allow for reduction of spondylolisthesis and involve a change in sagittal spinal balance, and simple decompression carries the risk of slip progression and recurrent problems. CONCLUSIONS: The authors demonstrated that decompression combined with semi-rigid stabilisation had a very good effect on the clinical state of patients with degenerative spondylolisthesis (retrolisthesis) at medium-term follow-up. The procedure was less effective in other indications. Semi-rigid stabilisation with Isobar TTL or Isolock systems prevented the progression of anterolisthesis or retrolisthesis; none of the patients experienced instrumentation failure. Neither symptomatic restenosis nor disc herniation was found in the instrumented segment. Semi-rigid stabilisation can, if necessary, be converted to fusion or disc replacement.

[Multiple spinal myeloma and its surgical management]. / Mnohocetný myelom pátere a jeho chirurgická lécba.

INTRODUCTION AND AIM: The management of spinal multiple myeloma (MM) is a complex process, including causal treatment (i.e. efforts to suppress the tumor clone), as well as supportive therapy, including surgery. The aim of this article is to present retrospective evaluation of surgical indications in patients with MM or solitary spinal plasmocytoma. MATERIAL: A total of 10 patients (8 males and 2 females) aged from 32 to 74 years (the mean age of 53.3) were included in the study. The enrolment criteria were the following: patients operated for MM or solitary spinal plasmocytoma during the past 7-year period, with the minimum follow up period of 6 months. The procedures were indicated for progressing neurological deficit (Frankel score) and for axial spinal pain (VAS classification), not responding to conservative therapy. The extent of the disease was assessed based on plain x-ray, MRI and whole- body 18F-FDG PET/CT. Paliative vertebroplasty was indicated in patients with no neurological deficit to control pain, paliative laminectomy without stabilization in subjects with partial neurological lesions, with transpedicular fixation in concomitant pathological fractures or kyphotizations. More radical approach, i.e. the procedure included somatectomy, was indicated in patients with solitary plasmocytoma and in procedures on cervical or thoracolumbar regions. Control clinical and MRI examinations were performed at 6 weeks, at 6 months and then at yearly intervals. At the end of the study, the authors evaluated effectivity of the employed surgical procedures, based on all control findings, and the data were compared with prognostic scoring systems in surgery for spinal metastases (Tomita score, Tokuhashi modified score and Bauer score). RESULTS: No local relapses of the tumor or stabilization failure were detected. The effect of surgery on pain control and on prevention of neurological dysfunction was maintained over the follow up period. The authors concluded that all surgical procedures and their radicality were adequate in all subjects. The agreement between the authors approach (the procedure's radicality) and the Tomita score, the Tokuhashi modified score and the Bauer score were recorded in 50% of patients, 80% of patients and in 50% of patients, respectively. DISCUSSION: MM is characterized by increased oseteolysis, which is not followed by new bone formation. Despite successful conservative therapy of MM, the bone defects fail to heal, cause spinal pain and may result in spinal instability. These specific MM signs represent the principal factor in the decision- making process concerning indication for surgery. Furthermore, favourable prognosis, with survival times usually exceeding the required expected minimum survival time of 3-6 months, is yet another reason for indication for surgical therapy in patients with spinal MM. Due to advances in chemotherapy and the use of autologic grafts of peripheral stem cells and radiotherapy, the prognosis of patients have significantly improved in last 10 years. The mean survival time has increased from 2.5 years to 4.5 years. CONCLUSION: 1. Prevention or improvement of neurological dysfuction and pain control are the main indication criteria for surgery in MM. 2. Surgery should be considered in MM with osteolytic spinal disorder and because of favourable prognosis of the disease when surgery is used. 3. Surgical procedures, including paliative methods resulted in sufficient control of spinal stability in all the study subjects. 4. Using all scoring systems for spinal metastases could result in indications for unnecessary more radical procedures. However, Tokuhashi score appeared to be the most suitable existing prognostic scoring system.