[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.

[Long-term results of surgery for cervical spondylotic myelopathy using open-door laminoplasty]. / Dlouhodobé výsledky operacního resení cervikální spondylogenní myelopatie pomocí "open-door" laminoplastiky

PURPOSE OF THE STUDY Cervical spondylotic myelopathy (CSM) is a serious disease which, in its advanced form, can markedly disable the patient. The aim of the present work was a prospective evaluation of a group of CSM patients treated by open-door laminoplasty. MATERIAL AND METHODS We evaluated 89 patients (59 men and 30 women; average age, 62 years; range, 39 to 81 years) who underwent surgery in the years 2001 to 2011. The average follow-up was 76 months. The patients were examined neurologically, radiologically, by magnetic resonance imaging (MRI) or CT. All of them had quadruparetic disability and showed signs of myelopathy on MRI examination. We used a modified Hirabayashi technique of open-door laminoplasty. We evaluated the surgery time, intra-operative blood loss, neurological deficit on the modified Japanese Orthopaedic Society (mJOA) scale, intra- and postoperative complications, neck pain (NP) and extremity pain (EP) on the visual analogue scale (VAS) and a radiographic sagittal profile change after laminoplasty. RESULTS The average operative time was 117 minutes and the average intra-operative blood loss was 330 ml. The average mJOA score of 12.7 before surgery improved to 14.4. Two patients (2.25 %) showed persisting deterioration of neurological symptoms, conditions of six patients (6.75 %) were assessed as stable and the remaining 81 patients (91 %) showed varying degrees of both subjective and objective amelioration/improvement. Infection was recorded as the most frequent complication (7.8 %). C5 paresis reported in the literature did not occur in our group. One patient (1.1 %) had a moderate epidural haemorrhage. The pre-operative VAS NP score of 5.4 improved to 3.2 and the VAS EP score of 7.7 improved to 4.4. The average value for the radiographic sagittal profile changed from -18.2 pre-operatively to -16.5 post-operatively. CONCLUSIONS Laminoplasty remains the basic surgical option for CSM treatment, particularly in progressive cases of the disease, in multi-segmental disease, and in need to preserve or restore cervical spine alignment Key words: cervical spondylotic myelopathy, laminoplasty, Hirabayashi open-door technique, mJOA score, complications, VAS.

[Dynamic neutralization using the Dynesys system for treatment of degenerative disc disease of the lumbar spine]. / Osetrení degenerativního onemocnení bederní pátere metodou dynamické neutralizace systémem Dynesys.

PURPOSE OF THE STUDY: Degenerative disc disease (DDD) is a spinal condition resulting from degeneration of the intervertebral discs. It is associated with symptoms of sciatica, back pain and leg weakness and also with degenerative instability of the spine. To arrest the degenerative cascade of disc disease, and taking into consideration stress placed on the adjacent discs managed by decompression and stabilisation by instrumented fusion, the lumbar spine was treated by dynamic posterior stabilisation of the segments affected. Based on the classification described by Dubois et al., the Dynesys system was used. The aim of this study was to evaluate the mid-term results of this method in DDD patients. MATERIAL AND METHODS: In the 2002-2007 period, 102 patients (65 men and 37 women; average age, 54 years) underwent surgery for problems due to DDD manifested by pain, neurological findings and radiographic evidence of degenerative changes in the spine. The classification of age-related changes, as described by Dubois et al. and Kirkaldy-Willis, showed that type 4 and type 6 of DDD (64% disc degeneration with spinal canal stenosis) were most common. After surgery using the Dynesys system, the patients were followed up for an average of 36 months. Patient examination included: pre- and post-operative medical history, clinical, radiographic (including magnetic resonance imaging/MRI) and neurological examination, and the pain and functional status assessment using the visual analog scale (VAS) and Oswestry disability index (ODI), respectively. A total of 146 lumbar spine segments were surgically treated in 102 patients, the L4-L5 segment being treated most frequently, with a total of 61 interventions at this level. Radicular pain before surgery was reported by 40 patients. The average operative blood loss was 1013.8 ml and patients stayed in the hospital for an average of 13.8 days. There were 15 post-operative complications treated. After surgery, the patients participated in a. special rehabilitation programme and were allowed full weight-bearing after 3 months. RESULTS: At 36 months of follow-up, the improvement as against the pre-operative condition included a drop in the average VAS value from 7.3 to 4.7 and that in the average ODI from 54.5 to 39.9. The results were statistically analysed using ANOVA software and the t-test and Bartlet test (level of significance set at 0.05). The improvement in the patients' health status was statistically significant during all 3-year post-operative period. As shown by the MRI findings obtained from repeated examination in 26 patients, the use of the Dynesys system resulted in the post-operative disappearance of disc bulging and the restoration of the posterior longitudinal ligament and space in the lumbar spinal canal. The surgery had no positive effect on disc regeneration, but improved peridiscal marrow oedema of that lumbar segment in the way described by Modic et al. DISCUSSION: In patients with DDD, stabilisation of the lumbar spine by instrumented rigid fusion often results in increased biomechanical stress and damage to the segments adjacent to the area of fusion. The use of dynamic stabilisation devices, including the Dynesys system, reduces this potential risk. The Dynesys system is also effective in the treatment of DDD combined with spinal stenosis in elderly patients, as reported by other authors. A certain risk associated with Dynesys use may lie in disc height reduction in the anterior segment by up to 0.7 mm, thus producing a fulcrum pin effect. Despite this risk factor, dynamic stabilisation in DDD patients will considerably improve the quality of their lives. CONCLUSIONS: The results of 102 patients, with 146 segments treated by posterior dynamic neutralisation using the Dynesys system, show that this method improved subjective feelings, morphological findings and pain and functional status in the patients with DDD in the three-year post-operative period. This had a good effect on the quality of life in these patients.

Changes of selenium, copper, and zinc content in hair and serum of patients with idiopathic scoliosis.

Our work aimed at extending the search for abnormalities of trace elements in patients with idiopathic scoliosis to the content of zinc (Zn), copper (Cu), and selenium (Se) in these subject's hair and serum. A total of 59 patients (54 girls and 4 boys) with idiopathic scoliosis, aged 13 on the average (range, 10-18 years), were examined. The degree of spine curvature deformity ranged between 12 degrees and 82 degrees . The hair of scoliotic patients under examination showed significantly increased content of zinc 263 +/- 108 microg/g (p < 0.01) and copper 46.2 +/- 37.1 microg/g (p < 0.01), and decreased content of selenium 0.194 +/- 0.114 microg/g (p < 0.01) in comparison with the control group. In scoliotic patients, the Cu/Zn ratio in hair (0.186 +/- 0.139) did not differ significantly from the values found in the probands of the control group (0.115 +/- 0.09). The Cu/Se ratio in this group of patients (254.9 +/- 215.9) was significantly higher (p < 0.001) due to a higher Cu value and a lower Se value in comparison with the controls (47.9 +/- 23.7). In comparison with controls, the serum selenium concentration in the group of scoliotic patients was significantly decreased p < 0.05 (0.74 +/- 0.13 micromol/L and 0.98 +/- 0.12 micromol/L). Various changes in the content of trace elements in biological samples taken from patients with idiopathic scoliosis are not accidental. What might bring about a shift in our knowledge is speciation of various forms of trace elements in the organism in relation to idiopathic scoliosis.

Idiopathic scoliosis and concentrations of zinc, copper, and selenium in blood plasma.

The concentration of zinc, copper, selenium, albumin, and ceruloplasmin in blood plasma and the activity of superoxide dismutase and glutathione peroxidase in erythrocytes were determined in a set of patients with idiopathic scoliosis (n=51). A significant decrease of selenium concentration (0.50 +/- 0.16 micromol/L) was found when compared with a control group (0.69 +/- 0.07 micromol/L) (p<0.01). The same levels of significance were found out for selenium levels corrected for albumin content. In a group of patients with a curvature over 45 degrees indicated for a surgical correction, the average plasma concentrations of selenium were significantly lower (p < 0.05) in comparison with a group of patients with a curvature below 45 degrees treated conservatively. The GSH-Px activity in erythrocytes was the same in both sets. In comparison with the controls, no significant differences were revealed in all of the other parameters. The detection of the decreased blood plasma concentration of selenium has suggested possible disturbance of well-proportioned distribution and of general optimal availability of selenium in the organism of patients with idiopathic scoliosis with likely effects on the process of synthesis and maturation of collagen affecting the axial skeleton stability.

[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.

[Tuberculosis of the upper cervical spine]. / Tbc postizení horní krcní pátere.

The authors present a case report on a 25-year-old female patient with the tuberculous spondylitis of 2nd cervical vertebra. For the treatment they choose a two-stage surgical procedure. Within the first stage they removed transorally the focus and filled in the defect in the body of the vertebra with autospongy bone grafts. In the second stage they stabilized the spine from the dorsal approach. Postoperative treatment in the plaster of Paris collar lasted three months. Thus the disease was quickly eliminated.