Use of nuclear medicine methods in surgical treatment of lumbar spine degeneration

INTRODUCTION

Chronic back pain (CBP) is a very common symptom. Multiple modalities are used in its evaluation. However, according to current evidence, none of them can be used with certainty to predict the success of fusion surgery. Given the growing experience with bone tissue examination using the methods of nuclear medicine, we have used this possibility in patients with CBP without disc herniation, degenerative spinal stenosis or instability.

CASE REPORTS

We present case reports of 11 patients who underwent lumbar fusion (during two years period) for degenerative disc disease or facet arthropathy with adequate activity on PET or SPECT/CT examination. Rolland-Morris Questionnaire (RMQ), Oswestry Disability Index (ODI), and Visual Analogue Scale (VAS) were filled out pre-operatively and 24 months after surgery.

RESULTS

Six patients after one-level stabilization for active osteochondrosis and one for active facet arthropathy improved on average by 82% (64-92%) in RMQ, by 72% (48-100%) in ODI and 75% (55-100%) in VAS. Results in cases after multilevel stabilizations were slightly worse, but still very significant in most parameters. Only one patient with the most severe morphological and clinical findings did not benefit from surgery.

CONCLUSION

In 10 out of 11 patients, the lower back pain and quality of life improved significantly after lumbar fusion performed in levels diagnosed by PET or SPECT/CT. These methods certainly have their place in the evaluation of CBP, especially in the case of unclear findings or multiple degenerative changes.

History, development and use of classification of thoracolumbar spine fractures

The main goal of this comprehensive paper is to clarify the way of thoracolumbar spine The main goal of this summary paper is to describe the way of thoracolumbar spine injury classification development and to provide a detailed description of two of the most commonly used classifications - the Thoracolumbar Injury Classification and Severity Scale (TLICS) and the AOSpine Classification for Traumatic Fracture of the Thoracolumbar Spine, including their comparison and clarification of the merits introduced by the second one. The paper also formulates a recommendation of a simple algorithm enabling even less experienced clinicians to distinguish between an injury indicated for conservative treatment and one that requires surgery.

Radiological analysis of the results of expandable implant insertion in one- to two-level cervical somatectomy

INTRODUCTION

The aim of the study was to radiologically analyse the results of expandable implant insertion in one- to two-level cervical spine somatectomy.

METHODS

A total of 28 patients undergoing one- to two-level somatectomy in cervical spine were postoperatively examined by CT. The following radiological parameters were studied: Cobb angle C2-7, segmental Cobb angle, implant subsidence and bone fusion.

RESULTS

The average Cobb angle of C2-7 in preoperative images was 13.7 degrees, 13.4 degrees in the early postoperative period (p=0.88), and 10.3 degrees (p=0.043) 2 years after the surgery. The average segmental Cobb angle in preoperative images was 4.4 degrees, 5.2 degrees in the early postoperative period (p=0.61), and 0.2 degrees (p=0.01) 2 years after the surgery. Significant implant subsidence was observed in 15 cases (53.6%). Grade I fusion was achieved in 6 cases (21.4%), grade II fusion in 12 cases (42.9%), and stable pseudoarthrosis (grade III) in 9 cases (32.1%). No cases of unstable pseudoarthrosis (grade IV) were detected.

CONCLUSION

Implantation of an expandable vertebral body implant in one- to two-level cervical spine somatectomy with ventral plate fixation is a fully acceptable way to reconstruct the ventral column of the cervical spine, providing sufficient long-term stability of the cervical spine and instrumentation and an adequate cervical spine curve.

[Anterior interbody fusion of the cervical spine with a zero-p spacer: radiographic results with a minimum follow-up of one year in a prospective study]

PURPOSE OF THE STUDY

The aim of this study was to compare the efficacy of anterior cervical microdiscectomy and fusion carried out using a newly designed interbody spacer with that of a standard cage plate construct in patients with symptomatic cervical spine spodylosis. The comparison was based on radiographic results and fusion rates.

MATERIAL

A total number of 113 consecutive patients were enrolled in this prospective study between October 2008 and July 2009. Mono- or bisegmental spondylosis was diagnosed in the patients in whom conservative treatment of cervicobrachial symptoms had had no effect. Patients with myelopathy were not included..

METHODS

All patients underwent standard anterior microdiscectomy (at one or two levels). The novel anchored spacer Zero-P was used in 61 patients (group 1) and, in 52 patients, stabilisation was done using the interbody spacer Cornerstone and dynamic plate Premier (group 2). Lateral radiographic views of the cervical spine were obtained before surgery and at 6 weeks, and then at 3, 6 and 12 months after surgery. During follow-up, the cervical spine sagittal alignment (CobbC), segmental angle of the treated levels (CobbS), amount of segmental collapse and fusion rates were measured.

RESULTS

There was no significant difference in CobbC between the two groups during follow- up (p < 0.051). A significant difference in the first two values of CobbS was found (p < 0.001), but next changes in CobbS were without any difference in either group. The mean degree of interspace collapse was without any significant difference between the groups. The fusion rate was significantly higher in group 1 than group 2 nine months after surgery (p = 0.032), but was the same in both groups at 12 months after surgery (p = 1.0).

CONCLUSIONS

The anchored spacer Zero-P provides biomechanical stability for the cervical spine similar to the cage and dynamic plate construct. Efforts to improve the cervical stand-alone anterior fusion device and to eliminate disadvantages of plate systems should be studied in larger patient groups with longer follow-ups. Key words: cervical spine, interbody fusion, fusion rate, radiology, stand-alone implant, Zero-P.

[Results of the treatment of odontoid fractures by osteosynthesis with a single axial screw]

PURPOSE OF THE STUDY

The authors present the clinical results of odontoid fracture treatment, using a single axial screw, with the aim to compare their results with the findings of other relevant studies, with focus on the use of either one or two axial screws.

MATERIAL

Thirty patients were included in the study, 16 men and 14 women at an average age of 56.1 years. They had findings of type II and "shallow" type III fractures, as evaluated on the basis of Anderson and D'Alonzo classification, and combined fractures. All were managed by the method of direct osteosynthesis of the dens with a single axial screw from the anterior approach in the years 1998 to 2005.

METHODS

The retrospective, cross-study analysis was based on records and clinical notes from the outpatient department and on radiographic materials from the department of radiology at follow-ups of 3, 6 and 12 months after surgery. The criteria assessed included screw insertion, quality of fusion during follow-up, and intra-operative and early and late post-operative complications.

RESULTS

Insertion of a screw was regarded as optimal in 24 (80 %) cases and suboptimal in six (20 %) cases. None of the patients required screw re-insertion. Evident fusion present at 12 months post-operatively was achieved in 18 (86 %) and questionable fusion in two patients. Non-union was recorded in one patient. Repeat operation was not indicated in any of the cases. There were no intra-operative complications. In six patients early complications occurred. Three patients died due to causes unrelated to the surgical procedure. Two patients had infectious complications not directly related to the surgery. One patient suffered from temporary dysphonia due to vocal chord edema.

DISCUSSION

For direct osteosynthesis of the dens, one or two screws can be used. Both methods have been studied in terms of biomechanics and clinical outcome, but none of the studies showed any significant differences between the two methods. Also the available Czech studies have paid only marginal attention to this issue.

CONCLUSIONS

Based on the analysis of patients' data and literature reports we can conclude that osteosynthesis employing a single axial screw gives results similar to that using two screws. The available biomechanical and clinical studies have not shown any statistically significant differences between the two methods. The results of our study are in agreement with the relevant literature data published so far. .

[Results of reinnervation after peripheral nerve repair by a microsurgical technique used in 1996-1998]

PURPOSE OF THE STUDY

The authors present the results of a retrospective study of reinnervation after peripheal nerve repair by a microsurgical technique between 1996 and 1998. This is a development of a previous study by their colleagues.

MATERIAL

Between 1996 and 1998, 113 injured peripheral nerves were treated by epineuroperineural suture (Ethilon; thickness, 8/0-10/0) under a microscope. To achieve a homogeneous group, 12 median and 13 ulnar nerves were included and evaluated in this retrospective study. All nerves studied were completely severed at the distal forearm and had sharply cut ends.

METHODS

The results of reinnervation were retrospectively analyzed and classified according to the British Medical Research Council system (Seddon, 1972). The patients were followed up for 3 years. The patient's satisfaction with hand function was rated according our own classification. Tinel's sign and scar tenderness were evaluated.

RESULTS

17 patients (68%) achieved motor function M3 or higher and 16 patients (64%) had sensation S3 or higher. Better motor function was achieved after repair of the median than the ulnar nerve (M3 and higher in 91% and 46%, respectively). Better sensory recovery was achieved after repair of the ulnar than the median nerve (S3 and higher in 77% and 50%, respectively). Tinel's sign was positive in 68% of the patients; 10% of the patients complained of scar tenderness.

DISCUSSION

Our results are comparable with the studies published so far. The patients with median nerve lesions showed better improvement after repair than those with ulnar nerve lesions and the outcome was better in hands with injury to only one nerve than in those with both nerves injured. The factors that influence peripheral reinnervation and the recovery of hand function are discussed. The surgical technique used, patient's age, regenerative capacity of the peripheral nerve affected, the interval between injury and the definitive microsurgical procedure and the quality of postoperative care are considered to be most important.

CONCLUSIONS

Lesions of the peripheral nerve require special attention by a neurosurgeon competent to provide appropriate microsurgical treatment. The interval between injury and definitive treatment should be as short as possible. Postoperative care (rehabilitation and regular neurological examination) is also an important part of treatment.

Correlation of optotypes with the Landolt ring--a fresh look at the comparability of optotypes

The legibility of three selected sets of optotypes: (1) letters; (2) Snellen E; and (3) KOLT test have been compared to the Landolt ring in a study based on the German Standard DIN 58220, Part 2 and the International Standard ISO 8597. The letters were printed in the standard typeface used on German street signs (sans serif Linear-Antiqua, Typeface B). The main results are: 1. A set of letters can be selected in such a way that the differences in legibility displayed between different letters in the set are smaller than the ISO/DIN allowance of 0.05 logarithmic units of the visual angle, although the letters are not constructed according to the traditional 5 by 5 or 5 by 4 construction principles. 2. The eight letters C, D, E, K, N, P, U, Z are proposed for standardized visual acuity tests because of their almost equal legibility. 3. The height of the typeface used for this selected set of letters should be 5% less than the diameter of the Landolt ring in order to achieve the same legibility as the latter. 4. Both shape optotypes (Snellen E and KOLT test) must be approximately 15% smaller than the diameter of the Landolt ring in order to obtain comparable visual acuity scores.

[Experimental studies of autograft with cancellous bone in the diaphysis of long bone (author's transl)]

The acceptance of fresh autologous cancellous bone in a wedge-shaped diaphysial cortical defect was examined in 2 groups of 5 dogs microangiographically and histologically 1,2,3,4 and 6 weeks after transplantation. The main recanalisation takes place after one week from the medullary canal, two weeks later periosteal vessels are connected and finally three weeks later the tender vessels of the Haversian canal system within the cortex are being integrated. Histologically, after one week active formation of fibrous bone can be seen adjacent to numerous capillaries originating within the medullary canal. Simultaneously, considerable degradation of transplanted trabeculae by mono- or polynuclear osteoclasts takes place. Formation of new bone occurs according to newly built capillaries. After 4 weeks, transplanted trabeculae can be found only sparsely, the new fibrous bone is being remodelled into lamellar bone. After 6 weeks, the entire fibrous bone has been transformed into lamellar bone and is calcified. A trajectorial orientation of the Haversian system according to that of the host cortical bone can be recognized vaguely.

[The revascularisation of fresh homologous bone grafts in the diaphysis of long bones in dogs (author's transl)]

In two series each 5 X 2 grown up mongrel dogs we studied the healing process of fresh concellous and cortical homografts in a defect made in the diaphysis of the radius bone. The experiments cover microangiographical and histological weekly control in the first 6 weeks after transplantation. The results demonstrate that the fresh concellous homografts have a good revascularisation and produce early new bone in the first week. The revascularisation of the cortical grafts is delayed. The immune reaction, which begins after two weeks, is in concellous bone graft more vigorous than in the cortical graft. The reaction leads to vascular disruption prior to the degenerative and necrotic changes of the tissue cells in the grafts including the new bone formation. After overcoming the immune reaction the 2nd or the so called inductive phase of new bone formation starts. The integration of cortical grafts in the host bone is much slower than in concellous bone graft. The vigorous immune reaction followed by the avascular interval in the concellous homografts between the second and third week must be considered as a dangerous critical phase when using homografts in the clinic. Because of the less cell concentration in the cortical homografts there is less immune reaction. Revascularisation in cortical homografts is slow and consequently there is a delayed incorporation of the grafts in the clinical use.