Echinococcosis of the spine

Echinococcosis or hydatid disease affecting the spine is an uncommon manifestation of Echinococcus granulosus infection of the spine.More commonly found in endemic areas, it causes significant morbidity and mortality as it grows slowly and produces symptoms mainly by compressing the spinal cord.As diagnostic methods are non-specific, diagnosis and management are usually delayed until the disease is advanced, thereby therapy is usually unlikely.Treatment is usually surgical, aiming at cyst excision, spinal cord decompression and spinal stabilization.This article summarizes the clinical findings of echinococcosis of the spine, discusses the specific laboratory and diagnostic findings, lists the current treatment options, and reviews the patients' outcomes.The aim is to prompt clinicians to be aware of the possibility of echinococcosis as a possible diagnosis in endemic areas. Cite this article: EFORT Open Rev 2021;6:288-296. DOI: 10.1302/2058-5241.6.200130.

Spinal surgery in patients with Parkinson's disease: unsatisfactory results, failure and disappointment

Previous studies on spinal surgery in PD patients report an exceptionally high rate of complications. Failure and re -operation are frequent outcomes. This is a retrospective case series with the aim of establishing the rate of complications in patients with concomitant Parkinson’s disease.

Ten patients were subjected to spinal surgery from 2005 to 2009. The indications and type of operation varied. Cases of Failed Back Surgery and re-operation were sought. Follow – up was between 6 – 42 months. All 10 patients presented some clinical or radiological complication. The most common complications were screw pull – out and progressive spinal deformity. Re – operations were performed in 5 patients, while clinical and radiological results were poor in the majority of cases. Patients with Parkinson’s disease have a very high complication rate and often have to undergo revision surgery. This particular group of patients should be informed of the increased risk of failure and be closely followed – up on a regular basis.

Pathophysiology and biomechanics of the aging spine

AGING OF THE SPINE IS CHARACTERIZED BY TWO PARALLEL BUT INDEPENDENT PROCESSES: the reduction of bone mineral density and the development of degenerative changes. The combination of degeneration and bone mass reduction contribute, to a different degree, to the development of a variety of lesions. This results in a number of painful and often debilitating disorders. The present review constitutes a synopsis of the pathophysiological processes that take place in the aging spine as well as of the consequences these changes have on the biomechanics of the spine. The authors hope to present a thorough yet brief overview of the process of aging of the human spine.

The impact of bone mineral density on the degree of curvature of the lumbar spine

OBJECTIVE

The prevailing perception is that one of the causes of postural deformities is osteoporosis. Nonetheless, studies of the correlation between bone mineral density (BMD) and spinal curvatures have produced contradictory results. This study was undertaken in order to determine whether (BMD) is associated with the curvature of the lumbar spine.

METHODS

105 postmenopausal women, aged 45-76 years (average= 57.3 years), were examined. All the participants underwent DXA scanning and spinal radiography using the same equipment and techniques. Lumbar curvatures were measured using the Cobb method. Subjects were divided according to their T-score into osteoporosis patients (n=54) and controls (n=51). Statistical analysis was performed using one way ANOVA, Mann-Whitney as well as Pearson and Spearman rank correlations.

RESULTS

There were no statistically significant correlations between BMD and lumbar curvature angles either in the total sample or in either group individually. Furthermore, these angles were not significantly different between patients with osteoporosis and controls.

CONCLUSIONS

The reduction in BMD and the alteration of the lumbar curvature that are observed in elderly individuals are concurrent but not related phenomena. The findings of this study contradict the claim that reduced bone mineral density is the cause of postural deformities.

Informal in-hospital care in a rehabilitation setting in Greece: An estimation of the nursing staff required for substituting this care

PURPOSE

To explore: (a) the type and frequency of care-giving activities provided by family members in the Rehabilitation Setting (RS), (b) opportunities for family members to receive training in care-giving activities, (c) to what extent caregivers feel free to ask the nursing staff for help and (d) to estimate the number of nursing staff required to substitute this care and thus to estimate the money saved by the RS due to the in-hospital informal care.

METHOD

A convenience sample of 80 family members was selected. A questionnaire was developed to investigate several aspects of informal in-hospital care. Data was analysed using SPSS for Windows (Release 10.1).

RESULTS

Cultural reasons and nursing staff shortage led 78.8% (n = 63) of the sample to provide informal in-hospital care. Oral and facial care (67.5%), help with getting dressed (62.5%), help with feeding (61.25%, n = 49), making patients' beds (57.5%, n = 46) and assistance with transferring patients from one hospital department to another (56.25%, n = 45) was provided on a daily basis by the subjects. 48.75%, (n = 39) changed sheets 1 - 2 times per week, while assistance with transfers from bed to wheel-chair and vice-versa (43.75%, n = 35) was provided 3 - 4 times per week. The estimated total time spent per week by the subjects on care-giving activities was 34,034 minutes that corresponds to a total of 75.6 working days or 15.12 working weeks. In order to substitute this care, the RS would need to hire 17 more assistant nurses, entailing a cost of from Euro 14,450 to Euro 20,060 per month.

CONCLUSIONS

Informal in-hospital care is provided by Greek families in the RS. Nursing care staff shortage combined with cultural factors are the main reasons for this phenomenon. However, it saves the RS and the Greek State money and policy makers should be looking for ways to overcome the nursing shortage.

The association of spinal osteoarthritis with lumbar lordosis

Background

Careful review of published evidence has led to the postulate that the degree of lumbar lordosis may possibly influence the development and progression of spinal osteoarthritis, just as misalignment does in other joints. Spinal degeneration can ensue from the asymmetrical distribution of loads. The resultant lesions lead to a domino- like breakdown of the normal morphology, degenerative instability and deviation from the correct configuration. The aim of this study is to investigate whether a relationship exists between the sagittal alignment of the lumbar spine, as it is expressed by lordosis, and the presence of radiographic osteoarthritis.

Methods

112 female subjects, aged 40-72 years, were examined in the Outpatients Department of the Orthopedics' Clinic, University Hospital of Heraklion, Crete. Lumbar radiographs were examined on two separate occasions, independently, by two of the authors for the presence of osteoarthritis. Lordosis was measured from the top of L₁ to the bottom of L₅ as well as from the top of L₁ to the top of S₁. Furthermore, the angle between the bottom of L₅ to the top of S₁was also measured.

Results and discussion

49 women were diagnosed with radiographic osteoarthritis of the lumbar spine, while 63 women had no evidence of osteoarthritis and served as controls. The two groups were matched for age and body build, as it is expressed by BMI. No statistically significant differences were found in the lordotic angles between the two groups

Conclusions

There is no difference in lordosis between those affected with lumbar spine osteoarthritis and those who are disease free. It appears that osteoarthritis is not associated with the degree of lumbar lordosis.

Fixation of Mitchell's osteotomy with bioabsorbable pins for treatment of hallux valgus deformity

We hypothesised that the use of bioabsorbable pins in Mitchell's osteotomy would improve the outcome of patients treated for hallux valgus deformity. A total of 68 patients underwent Mitchell's osteotomy to correct hallux valgus deformity: 33 patients (group A) underwent Mitchell's osteotomy augmented with bioabsorbable pins and 35 patients were treated with the classic operative procedure (group B). Hallux valgus angle (HVA), intermetatarsal angle (IMA), the American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal scale and the visual analogue score (VAS) for pain were measured preoperatively and postoperatively. There was no statistically significant difference between the two groups as far as the improvement of the IMA, HVA and AOFAS scale were concerned. Patients of group A had significantly less postoperative pain and returned to their previous activities earlier than patients of group B. The use of the pins did not improve the final outcome of the osteotomy. However, it allowed for faster rehabilitation due to less postoperative pain.

Fixation of femoral shaft fractures with a flexible bundle-type nail

In a prospective study, 31 consecutive patients with a femoral shaft fracture were treated with the Marchetti-Vicenzi intramedullary flexible bundle-type nail. Open reduction of the fracture was necessary in 25 of the 31 patients (81%). Twenty-five of the 31 fractures (81%) united within 2.5 to 6 months after the operation (mean, 4.2 months). Nonunion occurred in one patient (3.2%). Other complications included delayed union in five patients (16%), femoral shortening in five (16%), breakage of the distal pins in two (6.5%), and severe varus malunion in two patients (6.5%). Because of the high complication rate in this series, the authors no longer use the Marchetti-Vicenzi flexible nail for treatment of femoral shaft fractures.

The clinical performance of a small diameter tibial nailing system with a mechanical distal aiming device

We present the clinical and radiographic results of a prospective study with the Orthofix tibial nailing system. The ease and safety of distal locking with the use of an improved targeting system was also evaluated. Sixty fresh tibial fractures in 60 patients with a mean age of 37.3 years (range 17-73 years) were treated. Eighteen of the fractures were grade I open fractures. All operations were performed in a conventional operating theatre on a simple transparent operating table, with reduction of the fracture performed under manual traction and manipulation of the fracture site. Hand reaming was then performed to ensure, where possible, the insertion of a nail of at least 9 mm in diameter. Fracture healing was observed at a mean of 17 weeks (12-28 weeks). No tibial non-unions occurred in our series, and only three fractures, two segmental and one severely comminuted, showed delayed union. No infection, either superficial or deep, was found and no cardio-pulmonary complications were recorded. Following surgery, all patients gained a full range of pain-free movement of the ankle and knee joints and only six patients (10%) complained of mild anterior knee pain. All patients returned to their previous jobs one month after fracture healing had been confirmed clinically and radiographically. Following nailing, no deviation from normal tibial alignment was detected. No mechanical failure of either the nails or the locking screws was recorded. The mean duration of operation (skin to skin) was 30 min (range 20-45 min) and the mean total theatre time was 55 min (range 40-75 min). The mean total intensification time was 5 s. In total, 120 distal locking screws were inserted using the external targeting device. All attempts at distal locking except five (4.2%) were successful with two failures in the same patient being a result of inappropriate use of the system. We conclude that this nailing system is clinically effective and that distal locking can be performed easily, without exposure to radiation.

Seven- to 20-year outcome of lumbar discectomy

STUDY DESIGN

A retrospective, follow-up study.

OBJECTIVES

To assess the effects of conventional surgery for lumbar disc herniation over an extended period of time and to examine factors that might correlate with unsatisfactory results.

SUMMARY OF BACKGROUND DATA

Although the short-term results of lumbar discectomy are excellent when there is a proper patient selection, the reported success rates in the long-term follow-up studies vary, and few factors have been implicated for an unsatisfactory outcome.

METHODS

One hundred-nine patients with surgically documented herniated lumbar disc were analyzed, retrospectively, by an independent observer. Long-term follow-up (mean 12.2 years) was done by a mailed, self-report questionnaire that included items about pain relief in the back and leg, satisfaction with the results, need for analgesics, level of activity, working capacity, and reoperations. Subjective disability was measured by the Oswestry questionnaire. Radiographic review was carried out in 66% of patients. End results were assessed using the modified Stauffer-Coventry's evaluating criteria. Several variables were examined to assess their influence to the outcome.

RESULTS

The late results were satisfactory in 64% of patients. The mean Oswestry disability score was 18.9. Of the 101 patients who had primary procedures, 28% still complained of significant back or leg pain. Sixty-five percent of patients were very satisfied with their results, 29% satisfied, and 6% dissatisfied. The reoperation rate was 7.3% (8 patients), about one-third of which was due to recurrent disc herniation. Sociodemographic factors predisposing to unsatisfactory outcome, including female gender, low vocational education, and jobs requiring significant physical strenuousness. Disc space narrowing was common at the level of discectomy, but was without prognostic significance.

CONCLUSIONS

The long-term results of standard lumbar discectomy are not very satisfying. More than one-third of the patients had unsatisfactory results and more than one quarter complained of significant residual pain. Heavy manual work, particularly agricultural work, and low educational level were negative predictors of a good outcome. These indicators should be used preoperatively to identify patients who are at high risk for an unfavorable long-term result.

Ten-year follow-up evaluation of a school screening program for scoliosis. Is the forward-bending test an accurate diagnostic criterion for the screening of scoliosis?

STUDY DESIGN

A 10-year follow-up evaluation of the effectiveness of school screening for scoliosis performed in a closed island population.

OBJECTIVES

To evaluate the diagnostic accuracy of methods used for screening scoliosis and to re-examine the long-term effectiveness of the school scoliosis screening program.

SUMMARY OF BACKGROUND DATA

The diagnostic accuracy of the forward-bending test and the long-term efficacy of the screening programs have not been clearly established.

METHODS

In 1987, 2700 pupils aged 8 to 16 years from the island of Samos were screened for scoliosis. The Adams forward-bending test, Moire topography, the scoliometer, and the humpometer were used. Radiologic evaluation of the spine was available for each pupil and the number of false-negative and false-positive results of the screening methods was calculated. Subsequently, sensitivity, specificity, and positive and negative predictive values were estimated for each screening technique. Pupils found positive for spinal deformity were then followed up regularly at yearly intervals. In 1997, all positive subjects attended a 10-year clinical and radiologic follow-up, and the remaining subjects were re-evaluated by a postal questionnaire and were clinically examined if necessary.

RESULTS

Spinal deformity was found in 153 (5.66%) pupils. Scoliosis (defined as a spinal curvature > or = 10 degrees) was found in 32 pupils, for a prevalence of 1.18%. For scoliosis, the Adams forward-bending test showed a number of false-negative results (in five cases), for a sensitivity of 84.37% and specificity of 93.44%. The sensitivities of Moire topography, the humpometer, and the scoliometer were 100%, 93.75%, and 90.62%, respectively, and specificity was 85.38%, 78.11%, and 79.76% respectively. The negative predictive value of the forward-bending test was inferior to those of the other methods. During this scoliosis screening program, if cutoff limits for referral had been used, such as the asymmetry of two Moire fringes, a humpogram deformity of (D + H) = 10 mm, and 8 degrees of scoliometer angle, it would have been possible to reduce radiologic examination by 89.4%. Three (0.11%) pupils aged between 12 and 14 years with scoliotic deformities greater than 20 degrees underwent satisfactory nonoperative treatment with Boston braces. One pupil with a 40 degrees thoracic curvature, underwent satisfactory surgical treatment because of progression 1 year later. Of the 121 spinal deformities with an initial Cobb angle less than 10 degrees, 44 (35.8%), and of the 29 scoliotic deformities with an initial Cobb angle between 10 degrees and 20 degrees, 14 (48.3%) progressed (a Cobb angle difference of at least 5 degrees in more than one examination). Observation and physiotherapy were the only treatments applied to all except one of the pupils in these groups.

CONCLUSIONS

The Adams forward-bending test cannot be considered a safe diagnostic criterion for the early detection of scoliosis (especially when it is used as the only screening tool) because it results in an unacceptable number of false-negative findings. For the early detection of scoliosis, a combination of back-shape analysis methods can be safely used with the introduction of cutoff limits for referral being a useful procedure. The incidence of significant scoliosis is low, and its natural history seems to be independent of early detection. The wide-spread use of school scoliosis screening with the use of the forward-bending test must be questioned.

Operative treatment of unstable injuries of the cervicothoracic junction

The authors present their experience in the operative treatment of unstable lesions at the cervicothoracic junction. Ten patients, six men and four women, underwent operative procedures at the cervicothoracic junction (C7-T1) between 1990 and 1997. Six patients had sustained fracture-dislocations, three patients had metastases and one patient had a primary malignant lesion. All the patients had significant cervical pain and neurologic deficit. The spinal cord and nerves were decompressed in all cases. Posterior stabilization was accomplished using various types of implants including hooks, wires and rods. Anteriorly, the spine was stabilized with plates and screws. Partial or complete vertebrectomy was performed in five cases and a titanium cylinder or an iliac autograft replaced the vertebral body. Five patients were submitted to a posterior operation only, and the other five to bilateral procedures. In four of these a one-stage operation was performed and in the last case a two-stage procedure. The anatomic and biomechanical characteristics of the cervicothoracic junction require a precise pre-operative analysis of the local anatomy and the selection of the proper implants for anterior and posterior stabilization.

Post traumatic paraplegics living in Athens: the impact of pressure sores and UTIs on everyday life activities

This paper contains the findings of a scientific research which was done on post-traumatic paraplegics who live in the area of Athens. Greece, and measured the impact of pressure sores and UTIs on their everyday life activities. The target population was 127 individuals out of which 98 were observed and interviewed. A semi-structured questionnaire which consisted of two parts used; the first part of the questionnaire included general questions whereas the second contained the Sarno Functional Life Scale (SFLS) which is a tool measuring the level of independence of disabled people. Sixty-two per cent of the population was male. The mean age of the sample population at the time they had the accident which caused the paraplegia was 31.5, while the median was 28.5. The majority of the subjects comes from the lower socioeconomic class. Traffic accidents accounted for the 55% of the occurrences of paraplegia, falls for 37%, surgical complication for 4% and athletic activities for the remaining 4%. Forty-nine percent of the sample had been hospitalised in a rehabilitation centre. However, the multiple regressions used did not reveal any statistically significant relation between the hospitalisation in a rehabilitation centre and the paraplegic's scores in any of the Sarno Functional Life Scale's (SFLS) variables. Instead, the multiple regressions employed yielded paraplegics' scores in the SFLS's everyday life activities that were negatively related to age (P = 0.004) and pressure sores (P = 0.021). The paraplegics' scores on the SFLS's indoors activities are positively related to the years since injury (P = 0.048) and health education on daily fluid consumption (P = 0.003). The scores of the subjects on the SFLS's outdoor activities are positively related to the years of education (P = 0.008), the years since injury (P = 0.011), while are negatively related to pressure sores (P = 0.034) and UTIs (0.044). The subjects' scores on the SFLS variables regarding social relations had a negative relation to sex, (female) (P = 0.0001), age (P = 0.001) and pressure sores (P = 0.019), while they have a positive relation with the years since injury (P = 0.024).

Spinal cord decompression and stabilization in malignant lesions of the spine

20 patients with neurologic deficit and pain from malignant spinal tumors (7 primary) underwent 28 decompression and stabilization procedures. Their mean age was 57 (30-74) years and 11 were women. Indications for stabilization were pathological spine fractures or a previous spinal decompression procedure. An anterior procedure was used in 2 patients with disease limited to 1 or 2 levels. A posterior procedure was used in 10 patients with widespread disease and unsatisfactory condition. Anteroposterior procedures in 1 or 2 stages were performed on 8 patients in satisfactory general condition with a malignant lesion at 1 or 2 levels and an unstable spine. Patients were submitted to radio- and/or chemotherapy postoperatively. Survival of patients treated for primary malignant tumors averaged 30 months and was 11 months for metastatic disease. 16 of the patients, especially those with nonmetastatic disease, had substantial relief of pain. Neurologic recovery was achieved in all of the anterior and combined anterior-posterior procedures and in 60% of the posterior decompressions. Complications included failure of the instrumentation in 2 cases, skin breakdown in another 2 and dislodgment of the autograft in 1.

Anteriorly displaced transverse fractures of the sacrum in adolescents: report of two cases

A fracture of the sacrum at the level of the first and second segments, with forward displacement of the first segment, is a very rare injury in adolescents. The cases of two patients, who both suffered a displaced transverse fracture of the sacrum with resulting neural disturbance, are reported here. We consider that these unstable fractures may be treated surgically, by extensive laminectomies of the lumbosacral area and posterolateral fusion. Stabilization of the displaced fracture is possibly preferable, because it provides the prerequisites for early mobilization and reduces pain.

Correlation of spinal canal post-traumatic encroachment and neurological deficit in burst fractures of the lower cervical spine (C3-7)

Burst fractures of the lower cervical spine (C3-7) are often associated with severe neurological injury. During the last 5 years (1987-1992) we operated on 11 patients who had sustained burst fractures together with neurological deficit. The operations were performed through an anterior approach. The burst vertebra was excised, and the defect was filled with bone graft. Implants (plates and screws) were used in 10 cases. The preoperative examination was conducted by computed tomography and revealed that in 4 patients with complete tetraplegia (Frankel grade A) there was more than 50% spinal canal narrowing, whilst in the remaining 7 patients, with various levels of incomplete tetraplegia, there was less than 50% spinal canal narrowing, resulting in considerable improvement. The above results support the hypothesis that a correlation exists between the magnitude of the spinal canal encroachment, the initial neurological deficit and the final outcome.

Double level fractures of the cervical spine

Sixteen cases of double level fracture of the cervical spine treated at the Orthopaedic Clinic of Athens University from 1970 to 1983 are presented. These comprise 5.5% of all cervical fractures. The aetiology, mechanism of injury, neurological complications and management of these injuries is discussed. Awareness of double level fracture in the cervical spine will alert the clinician to a more careful examination allowing earlier diagnosis and treatment of these injuries. The problems in management are stressed.

Effect of hip dislocation on the blood supply to the femoral head. An experimental study in rabbits

This work consists of a series of experiments which were made in order: a) to examine the possible alterations of blood flow to the reduced femoral heads of rabbits, after inducing a closed dislocation of their hips and b) to determine the influence of the early or late reduction of the dislocated femoral heads on their blood flow. The estimations of blood flow to the normal and reduced femoral heads were made using radioactive microspheres. The findings are as follows: a) The blood flow of the femoral heads of the reduced hips was never interrupted completely. b) The initially decreased femoral head blood flow progressively increased, in association to the time elapsed from the reduction. c) No statistically significant difference was found in the femoral head blood flow between hips reduced in early and those reduced late. d) Pure traumatic dislocation of the hip can only rarely be the cause of aseptic necrosis of the femoral head.

Vascular compression of the duodenum (cast syndrome) associated with the treatment of spinal deformities. A report of six cases

Vascular compression of the duodenum, the so-called cast syndrome, which is due to the mechanical compression of the third part of the duodenum from the superior mesenteric artery, was developed postoperatively in six patients treated for their spine deformities. The early recognition of the clinical signs of the obstructive ileus and the proper conservative treatment proved efficient for five of the patients, and only in one laparotomy and duodeno-jejunostomy were inevitable due to the severity and persistency of the symptoms. The purpose of this report is to record these cases describing the clinical manifestations, the treatment, and the pathogenesis of the vascular compression of the duodenum which may occur during the treatment of the spine deformities.