Appropriate levels for instrumentation and fusion in scoliosis have been a matter of debate among surgeons since the introduction of operative management of this deformity. We set out to examine the hypothesis that the amount of correction achieved in all planes during surgical instrumentation of a curve should be less than, or comparable to, the degree of correction attainable at any non-instrumented adjacent curve. An algorithm was designed to facilitate preoperative planning and intraoperative performance of spinal fusion procedures in the management of scoliosis. To test the validity of the hypothesis and the proposed algorithm, measurements were taken from the preoperative radiographs of 200 patients. The dimensions of the curves were obtained from an initial set of four X-ray films: (1) standing anteroposterior film of the whole spine, (2) standing lateral film of the whole spine, (3) two properly performed side-bending films including each curve of the spine. With this data, a plan was designed using the algorithm. The results of this plan were compared with the actual results of the surgery, which were revealed only at this stage. All patients in whom actual instrumentation levels fell within those predicted by the proposed algorithm had no imbalance at follow-up. All patients whose actual instrumentation levels were short of those recommended by the algorithm showed obvious imbalance on final postoperative standing radiograph.

Familial dysautonomia (FD) is a rare autosomal recessive disease occurring in Jews of Ashkenazi descent, with only some 500 recognized cases. The causative gene was identified on chromosome 9. FD is of considerable orthopedic interest, because of the prevalence of skeletal deformity. About 90% of surviving dysautonomic children will develop a spinal curvature, commonly a scoliliotis. The scoliotic curve is usually kyphotic rather than lordotic, and appears during the first decade of life. Fifty-one of the 90 reported cases of familial dysautonomia in Israel involved patients who were seen at the scoliliotis clinic for assessment and treatment of their spinal deformities. Most of the patients presented with a scoliotic deformity associated in 37 cases with an increased thoracic kyphosis. In our series orthotic treatment and physiotherapy were found to be minimally successful at best. Surgical treatment of the spine was performed in 13 of 51 patients in this series. A retrospective review of these patients' charts and radiographs was carried out. Six years of follow-up are reported. The primary indication for surgery was progression of the spinal curve. Only posterior spinal fusions were performed. Anterior transthoracic procedures were avoided in spite of the significance of the kyphotic deformity, because of the frequency of pulmonary complications. Harrington distraction and compression instrumentation was used. Three-millimeter compression rods were used in a distraction mode in thin, young children. “Harri-Luque” segmental sublaminar wiring technique and Wisconsin spinous process segmental wiring was used in some. In all cases, the spine fusion was supplemented by bank bone only, to avoid the additional trauma of graft removal. We believe that surgical intervention is advantageous, if done early in the evolution of spinal deformity. Greater technical difficulties and a higher complication rate were encountered in this series relative to the problems usually seen after spinal deformity surgery in children; this is all the more important in a disease in which general anesthesia is an additional major complicating factor. It is hoped that the improved physical condition now seen after early gastrostomy and fundoplication will aid in reducing this high complication rate. Only a small degree (about 25%) of correction was achieved in the majority of patients. Some of this apparent rigidity derived from the inability to apply sufficient instrumental corrective force because of the friable osteoporotic bone. After surgery, there was a marked decrease in the frequency of pneumonia and an improvement in the degree of ataxia, for reasons not understood, which led to an obvious improvement in the quality of life.

Twenty patients treated for eosinophilic granuloma of the spine were studied. Only 40% demonstrated the classical radiographic picture of vertebra plana. In 60% a lytic lesion of the vertebral body or the posterior elements was found. Seven patients underwent surgery; the indications were neurological involvement or failure of the biopsy to disclose the diagnosis. At an average follow-up period of 7 years, 17 patients are well and alive with no residual spinal pain, neurological compromise, recurrent disease, or extraskeletal involvement. Vertebral body collapse underwent some regeneration but did not regain full body height. In several patients this resulted in a local deformity. In patients with unifocal spinal eosinophilic granuloma, watchful observation with no treatment other than spinal support is warranted. In patients with neural involvement or multifocal lesions, a more active treatment, including surgery, may be indicated.

Degenerative changes in the spine, specifically disc degeneration and facet arthrosis, and osteoporosis are conditions that primarily affect the elderly and may significantly impact the quality of life. The relationship between osteoporosis and degenerative changes in the hip joint has been studied, but their correlation in the spine is not entirely clear. Two hundred ninety-four subjects older than 50 years of age were retrospectively studied for the existence of lumbar spinal degeneration and osteoporosis through radiologic examination for 3 clinical manifestations: (1) disc degeneration, (2) facet joint arthrosis, and (3) lumbar osteoporosis. Peripheral osteoporosis in the distal radius of the nondominant hand was measured using a single-photon bone absorptiometer. Results indicated that subjects with severe osteoporosis in the distal radius also had severe degenerative changes in the discs and the facets; those with mild osteoporosis in the distal radius showed a tendency to have a lesser degree of degenerative changes than the subjects without osteoporosis.

During the 10-year period 1981-1990, 59 patients suffering from spinal cord or cauda equina compression underwent anterior spinal decompression and in most cases spinal restabilization with methylmethacrylate cement and/or instrumentation. Follow-up in 55 patients showed that 75% were improved neurologically by the procedure, one-third of these showing complete recovery from the spinal cord compression. The results in younger female patients suffering from metastatic breast cancer were considerably better than those of older men with prostatic metastases. Other genitourinary system tumors also had a relatively poorer prognosis. There was a significantly better result for metastatic lesions of the thoracic or thoracolumbar spine than for lesions in the lumbar spine causing cauda equina paralysis.

The Journal of Bone and Joint Surgery. British volumeVol. 75-B, No. 2 ArticlesFree AccessThe subcapsular approach for lesions of the femoral neckR Mosheiff, GC Robin, Y Mattan, E SucherR MosheiffSearch for more papers by this author, GC RobinSearch for more papers by this author, Y MattanSearch for more papers by this author, E SucherSearch for more papers by this authorPublished Online:1 Mar 1993https://doi.org/10.1302/0301-620X.75B2.8444963AboutSectionsPDF/EPUB ToolsAdd to FavouritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InRedditEmail FiguresReferencesRelatedDetailsCited ByPERCUTANEOUS REMOVAL OF OSTEOID OSTEOMARadiologic Clinics of North America, Vol. 36, No. 3 Vol. 75-B, No. 2 Metrics Downloaded 10 times History Published online 1 March 1993 Published in print 1 March 1993 InformationCopyright © 1993, The British Editorial Society of Bone and Joint Surgery: All rights reservedPDF download

As the patient population grows, strategies for preventing osteoporosis and for improving its management are urgently needed. Coordinating the efforts of existing hospital programs may help to meet these goals.

Spinal imaging has rapidly evolved into a complex diagnostic field requiring specialized expertise. While many imaging modalities reveal portions of a topographic map of the spine necessary for surgery, only magnetic resonance imaging emerges as the imaging modality of widest and most efficacious first choice. With the increasing high-technology sophistication of modern imaging modalities, the spine surgeon must become completely conversant with the radiologic data produced by these imaging techniques. The authors present a logical approach to spinal imaging--an algorithm--based on etiologic classification and aimed at conserving medical resources and developing an optimal diagnostic pathway for spine injury and disease. Spine surgeons are urged to incorporate the interpretative insights of radiologists into the diagnostic process.

In the interval between 1983 and 1988, 14 patients were treated for pyogenic spondylitis complicated by neurologic compromise. There were nine males and five females aged 39-80 years. The average time between onset of symptoms and diagnosis was 2.8 months. Predisposing factors were diabetes mellitus in four patients and urinary tract infections in five patients. The infection was blood borne in all 14 patients. In two patients, the infection was superimposed on a recent vertebral fracture. The cervical spine was involved in one patient; the thoracic spine in seven; and the lumbar spine in six patients. Six patients presented with a Frankel B paralysis, six with a Frankel C paralysis, and two with grade D paralysis. The neurologic symptoms lasted between one day and six weeks before surgery. Twelve patients had anterolateral decompression. Two of the 12 patients had a second stage posterior stabilization. Two patients were deemed inoperable. All surviving patients were managed by parenteral antibiotics for three to six weeks followed by enteral route for a total of three to six months. All 12 operated patients had a significant neurologic improvement (one grade or more on the Frankel scale) with solid interbody fusion.

Cervical spine instability is a rare finding in achondroplasia. We present the previously unreported case of C2-C3 subluxation producing progressive quadriparesis in an achondroplastic infant. Operative treatment with appropriate fusion was performed, and an excellent result was obtained.

Reports of spondylolysis in vertebrae other than those of the lower lumbar spine are rare. We report 32 patients with upper lumbar spondylolysis who have been studied clinically, radiologically and scintigraphically. Twenty patients had bilateral lesions, and seven of those with unilateral lesions had structural changes or anomalies in the opposite posterior arch. Positive scans were found to be associated with a short clinical history, and indicated stress-related lesions. Our findings suggest that mechanical factors may play a role in the aetiology of spondylolysis in the upper lumbar spine similar to that which they play in the lower lumbar spine, and that local structural anomalies may contribute to abnormal loading of these vertebrae.

The relationship between osteoarthritis and osteoporosis of the hand was examined in a random sample of the Jewish population in Jerusalem. It was found that osteoporosis and osteoarthritis of the hand showed differing prevalences, only rarely coexisted, and that there was neither a positive nor a negative correlation between them (p greater than 0.05). This would strengthen the contention that these are two independent and unrelated disease processes.

That the efferent limb of the "clubbing reflex" may be humoral is suggested by observations of hormonal factors being associated with clubbing.Patients with bronchial carcinoma and hypertrophic pulmonary osteoarthropathy have been reported to have raised concentrations ofgrowth hormone.3Clubbing has also been described in association with a case of thyroid carcinoma and primary hyperparathyroidism.4 Lam et al reported two cases (in brothers) with pachydermatoperiostosis, hypertrophic gastropathy, and complicated duodenal ulcers.5In these cases the serum concentrations of gastrin were normal but concentrations of pepsinogen 1 and 2 were raised.The clubbing associated with the Zollinger-Ellison syndrome in our patient, which regressed after resection of the tumour, was probably due to some substance produced by the tumour.Gastrin itselfwas unlikely to be the substance, as vagotomy, which may abolish clubbing, is often associated with raised serum concentrations of gastrin.Moreover, tumours such as gastrinomas, which are from the APUD cell series, are known to secrete many peptides, only some ofwhich have been characterised.1 Hal GH, Laidlaw CD'A.Further eerimental evice implicating reduced ferritin as a cause of digial clubbing.CiSci 1963,24:121-6.

The authors report the case of a 15-year-old female who presented with a history of vague but constant pain about the medial aspect of her right knee. X-ray established the presence of an expanding lesion in the medial tibial plateau. Computerized axial tomography (CT) and magnetic resonance imaging (MRI) were used in the evaluation of the lesion. The authors compare the preoperative CT and MRI findings with the microscopic histopathology of the amputation specimen and note that the CT scan underestimated the extent of the microscopic tumor boundaries, whereas MRI showed altered activity beyond these boundaries.

Thirty-four femoral necks from human cadavers were measured by techniques assessing bone density and bone mineral density, and by the Singh index. These methods are based on photon interaction with biological components and can be applied noninvasively for clinical evaluation of changes in skeletal status. Trabecular bone volume, mineralized bone volume, and relative osteoid volume were evaluated histomorphometrically using undecalcified histologic sections obtained from the same samples. The trabecular and mineralized bone volumes showed significant correlations with the bone density and mineral density. These results enhance the validity of recently developed photoninteraction techniques for evaluating bone properties.

RIVKIND, A MD; MARGULIES, J Y MD; LEBENSART, P MD; SHERMAN, Y MD; ROBIN, G C FRCS Author Information

During open reduction of thoracolumbar fracture-dislocation, the normal constraints to distraction and lengthening may be ruptured and allow instrumentation to exert deleterious traction of the spinal cord. An interspinous wire across the unstable segment together with a Harrington rod may be used to prevent potential overdistribution of the spinal cord. Thirty-six patients with fracture-dislocation of the thoracolumbar spine were treated by open reduction with Harrington rods and interspinous wiring. Of 15 patients with a partial cord lesion, four made complete recovery, and nine of the remaining 11 became ambulators. Six patients with a complete paraplegia did not improve; 15 patients remained neurologically intact following the procedure. The compressive wire and Harrington rods act in concert and enable correction of kyphosis and restoration of vertebral and discal height while protecting the cord against traction. The technique is safe and does not add to operative time.