Association of reduced factor VIII with impaired platelet reactivity to adrenalin and collagen after total thyroidectomy.

Twenty-one thyroprival patients, previously submitted to total thyroidectomy for tumours, were investigated during stabilized L-thyroxine supplementation and at the end of a 20-25 day "no-therapy" period, necessary for a 131I total body scintigraphy. During supplementation therapy a lower than normal mean beta-thromboglobulin (beta-TG) release level was found, the other blood clotting and platelet function tests being normal. After substitution therapy withdrawal, platelet function tests showed reduced adrenalin aggregation, increased collagen threshold aggregating concentrations, decreased beta-TG release values and reduced aggregation to ristocetin, whereas blood clotting tests showed prolonged aPTT values and reduced levels of factor VIII:C and vWf:Ag. We conclude that in acquired hypothyroidism the lowering of factor VIII:C and vWf:Ag (acquired von Willebrand disease) is associated with impaired platelet reactivity not only to ristocetin but also to collagen and especially adrenalin. In the patients investigated these changes were almost completely corrected by substitutive therapy with L-thyroxine at clinically effective doses.

Surgical treatment of giant-cell tumor of the spine. The experience at the Istituto Ortopedico Rizzoli.

We reviewed the cases of nine patients with a giant-cell tumor of the vertebrae. All segments of the spine can be affected by the tumor, but there was a predilection for the lumbar segments in our series. Pain was present in all patients. The maximum duration before the diagnosis was made was three years and the minimum, forty-five days (average, 12.2 months). In six patients a neural deficit was also present. One patient was treated many years ago by radiation therapy alone; three patients were treated by decompressive laminectomy; two, by excision of the lesion and postoperative radiation therapy; and three patients underwent lesional but extensive excision as well as arthrodesis without any preoperative or postoperative radiation therapy. We have obtained good results with the latter treatment; after follow-ups of sixty, twenty-six, and twenty-four months in three patients the pain and the neural symptoms subsided, while roentgenographic examination showed no evidence of local recurrence. In all patients the autogenous bone grafts appeared to be incorporated, without any secondary deformity. We concluded that, due to the development of better surgical techniques, the surgical approach is probably the best modern treatment for a giant-cell tumor located in the spine.

The surgical treatment of late instability of flexion-rotation injuries in the lower cervical spine.

The authors reviewed 12 cases of anterior dislocation of the lower cervical spine due to flexion-rotation trauma, with late instability after closed treatment. The 12 patients were treated at the Instituto Ortopedico Rizzoli between 1977 and 1982. Epidemiology, causes, type of lesion, and associated complications were studied. After an average period of 3 years (range: 2-6), correction appeared stable in all of the patients. In 4 patients, posterior stabilization with plates was performed after presurgical correction in a halo-thoracic cast. In 4 patients, reduction with combined, treatment consisting of anterior release and posterior stabilization with plates was performed after failure of presurgical correction. Finally, in 4 patients, stabilization was obtained with anterior fusion alone without reduction of the dislocation.

Implants of heterologous demineralized bone matrix for induction of posterior spinal fusion in rats.

The authors tested the osteoinductive capacity of powdered heterologous (bovine) demineralized bone matrix in rats. The first part of the study concerned a monolateral posterior spinal implant after decortication of three vertebrae, using as a control area the animal's contralateral side, in which neither bone graft nor any other material were placed. In another group of rats, a comparative evaluation was made of powdered heterologous demineralized bone matrix and fresh autologous bone. In the same animal, autologous bone was implanted to realize a thoracic posterior fusion and demineralized bone matrix, to induce a posterior fusion in the lumbar area. All data obtained suggested a good osteoinductive activity of heterologous powdered demineralized bone matrix. The two posterior spinal fusions done in the same animal with heterologous demineralized bone matrix or autologous bone, respectively, had similar callus development and required the same time for formation.

Posterior lumbar apophyseal fractures.

From 1984 to 1987, nine patients with posterior lumbar apophyseal fracture underwent surgery. The clinical pattern was characterized by vertebral rigidity and leg pain in all cases, with associated nerve root deficit in three cases, neurogenic claudication in one, and paraparesis in one. In all patients, treatment consisted of removal of a bony and/or cartilaginous fragment. In eight patients, it was done through a posterior approach (unilateral laminotomy with partial facetectomy in six cases and bilateral laminectomy in two) and in one with paraparesis by means of hemicorporectomy followed by anterior fusion. At follow-up (minimum, 2 years), all patients showed complete regression of the painful symptoms, with a total recovery in cases with neurologic problems. The only complication was an incomplete cauda syndrome; this appeared immediately after the operation and regressed completely with conservative treatment after 6 months.

Surgical correction of dystrophic spinal curves in neurofibromatosis. A review of 56 patients.

STUDY DESIGN: A presentation of the results from 56 patients with dystrophic spinal deformities caused by neurofibromatosis surgically managed from 1971 to 1992. OBJECTIVES: To focus on the need for combined anterior and posterior fusion in the presence of severe spinal dystrophic changes. SUMMARY OF BACKGROUND DATA: It has been stated that the most effective management for dystrophic curves is early and aggressive surgery. METHODS: The patients were divided into two groups: Type I scoliosis (kyphosis < 50 degrees) and Type II kyphoscoliosis (kyphosis > 50 degrees). Results were evaluated in relation to the type of surgery performed: single posterior instrumented fusion or preplanned combined anterior and posterior fusion. RESULTS: At a mean follow-up period of 15 years (range, 5-22 years), all patients appeared to be stabilized, after a total of 120 surgical interventions. In Group I, the posterior instrumented fusion failed in nine patients (47%), and in Group II it failed in seven patients (63%). The preplanned combined anterior and posterior fusion failed in two patients (33%) in Group I and in four patients (20%) in Group II. The failure incidence of the posterior instrumented fusion alone and of the planned anterior and posterior fusion was 53% (16 patients) and 23% (6 patients), respectively. CONCLUSIONS: The severe dystrophic curve with anterior vertebral scalloping always requires combined anterior and posterior stabilization, particularly in younger patients, even if the sagittal curves have not become pathologic by the time of presentation.

Natural history of untreated idiopathic scoliosis after skeletal maturity.

A total of 187 random cases of untreated idiopathic scoliosis, seen from a minimum of 15 to a maximum of 47 years after the end of growth, were reviewed. All curves increased after skeletal maturity (average progression: 0.4 degrees per year). Thoracic curves tend to progress more than lumbar, lumbar more than thoracolumbar, and thoracolumbar more than double major curves. Pain was present in 114 cases (61%) and appeared more frequently in women, after pregnancies, and with fatigue. Cardiopulmonary symptoms were present in 42 patients (22%), especially those with thoracic and thoracolumbar curves greater than 40 degrees. Psychologic disturbances were found in 35 cases (19%), mostly female patients with thoracic curves greater than 40 degrees. The cosmetic appearance of these patients at long-term follow-up was better compared with that at the end of growth, even though the curves progressed. Patients with decompensation of the trunk at the end of growth seemed to improve with time. In an unselected group of patients with severe curves a mortality rate of 17% was found, twice as much as in the Italian general population.

Solitary plasmacytoma of the vertebral column. A report of 15 cases.

The clinical features and the treatment results of 15 patients with solitary plasmacytoma of the spine observed in a 28-year period (1950-1977) are reported. The signs at presentation were back pain in 4 cases and spinal cord compression in 11 cases. Three of these patients had paraplegia. Radiologically, the alteration encountered was an osteolytic lesion in all cases. The local treatment was radiotherapy in 11 cases and surgery plus radiotherapy in 4 cases. In 3 patients systemic chemotherapy was also employed. Seven patients are alive without signs of disease 3 to 9 years (mean 6 years) after diagnosis. Eight patients developed multiple myeloma in a period ranging from 1 to 8 years (mean 3.5 years). The relationship between multiple myeloma and solitary plasmacytoma of the spine, as well as the best treatment for the latter, are discussed.

[Cardiological findings in acromegaly]. / Rilievi cardiologici nell'acromegalia.

Acromegaly involves cardiovascular complications mostly due to the presence of hypertension, diabetes and atherosclerosis. However the appearance of cardiac decompensation and arrhythmias in the absence of predisposing factors tends to support the hypothesis of a specific myocardiopathy caused by excess GH. In order to assess the existence and course of subclinical cardiac alterations, 8 acromegaly patients were examined: 4 males and 4 females aged 31-56 with GH levels of 24-70 ng/ml (M + CD X 47 +/- 16) and no cardiovascular symptoms. One of the patients had moderate hypertension and 2 reduced glucose tolerance. The basal ECG showed sporadic ventricular extrasystoles in 2 cases and alterations compatible with left ventricular hypertrophy in another, while the effort ECG produced an asymptomatic depression of the ST segment in the hypertensive patient. The chest X-ray was normal in all cases. The echocardiography study investigated: the thickness of the interventricular septum (IVS = 13.9 +/- 2.8 mm), the thickness of the posterior wall of the left ventricle (LPW = 10.6 +/- 2.9 mm), the septum/posterior wall ratio (IVS/LPW = 1.3 +/- 0.2 the diastolic diameter (DD = 15.4 +/- 11.4 mm), the fraction of shortening (FS = 39.1 +/- 14.5%), the ejection fraction (EF = 64.1 +/- 18.4%) and revealed asymmetrical septal hypertrophy in 3 cases, concentric hypertrophy in another two. In two cases the DD and EF were distinctly altered. The patients were re-examined 2-4 years after surgical or radiation treatment. GH levels (M +/- SD = 10.3 +/- 10.1 ng/ml) were normal in 4 cases and still high, though lower in another two. The remaining two patients had borderline GH levels with high Sm-C. The ECG and chest X-ray were unchanged while echocardiography revealed a significant deterioration in heart function as far as DD (56.4 +/- 10.8 mm, p less than 0.05) were concerned with frankly pathological results in 4 and 3 cases respectively. These data confirm the view that most acromegalic patients present subclinical abnormalities in cardiac function and that the evolution of these is slightly influenced by the reduction in GH and Sm-C. levels. In fact, while the persistence of high GH and Sm-C. levels may explain the progression of cardiac alterations in some cases, it does not in others. It is also emphasised that echocardiography appears to be the most sensitive non-invasive technique for the diagnosis and follow-up of cardiac involvement in acromegaly.

[Osteoid osteoma of the spine. The experience of the Rizzoli Institute]. / L'ostéome ostéoïde de localisation rachidienne. Expérience de l'Institut Rizzoli.

The authors report their experience at the Rizzoli Institute in treating osteoid osteomas localized to the spine (40 cases). This clinical study confirms that osteoid osteomas are tumors of adolescence, which are often diagnosed late due to their spinal localization. The role of additional investigations, dominated by bone scan and computed tomography is discussed. Their use should decrease the diagnosis delay. Mean follow-up in this series was 4 years, and confirmed that surgical excision had a favorable outcome. The outcome of associated scoliosis was also studied (8 cases). After tumor excision, there were 6 complete or partial corrections. Two cases remained unchanged. Curvature worsening after excision was not encountered.