Lateral Roentgenograms Research Articles

Anterior Cortical Impingement With 240 mm Cephalo-Medullary Nail (PFN and PFNA-2) in Intertrochanteric Femur Fracture Fixation in the Indian Population: A Problem Statement.

Trochanteric fractures are common in the elderly population, and their incidence increases twice every decade after age 50. Intramural fixation has achieved good clinical efficacy in the treatment of unstable trochanteric fractures, but there have been complications reported in the literature in the Asian population. Most complications arise from a mismatch between the increase in the anterior femoral bow with advancing age and the proximal femoral nails (PFN) on the market, which still have straight designs on the sagittal plane. The non-anatomic shapes of the PFNs sometimes make the surgeries difficult or may lead to an inadvertent intraoperative fracture around the tip of the nail, particularly if they impinge on the anterior cortex of the femur. The entry point on the greater trochanter was divided into three equal parts, i.e., anterior 1/3rd, middle 1/3rd, and posterior 1/3rd on the lateral X-rays. Patients with posterior 1/3rd entry were excluded from the study as it is known that posterior positioning of nail entry can cause an increased incidence of anterior nail impingement. The AI was measured using the best available preoperative lateral roentgenogram of the femur using the incidence cortex (AI cortex) angle. This angle was measured using two tangential lines drawn parallel to the anterior cortex of the femur, proximal and distal to the most bowed point of the femur. We recommend that there is a need to introduce anterior curvature in the sagittal plane corresponding to the femoral bow in a 240 mm cephalomedullary nail to decrease complications. We also consider the use of either a short (i.e., 180 mm) or a long cephalomedullary nail in the Indian population, as the height of the population is shorter as compared to the western population, and the role of a 240 mm cephalomedullary nail is doubtful in the Indian population.

Radiological comparison of acetabular anteversion on cross-table lateral roentgenograms and computed tomograms functional outcomes in total hip arthroplasty

Introduction: Orientation and Alignment of prosthetic components are vitally important for the stability of total hip arthroplasty. Poor acetabular positioning is one of the many issues implicated with persistent pain due to impingement, dislocation, edge loading and liner fracture, which may be lead to patient dissatisfaction after total hip arthroplasty. Material and methods: Post-operative radiological analysis of the version of acetabulum through X-ray images and CT images was performed. Pre & post-operative scoring according to Modified Harris Hip Score (HHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Oxford Hip Score (OHS) was documented. Results: A total of 55 patients were included in the study. The mean anteversion angle calculated on cross-table lateral radiograph by Woo and Morrey's method was 22.410 (Range 16-560), compared to CT Scans measured was 28.640 (Range 11.10-50.100). Conclusion: Majority 69.09 % of patients had excellent functional outcomes in a range of 11.1-360 of anteversion compared to Lewinnek’s safe zone. It suggests that there is flexibility in positioning the acetabular component than previously believed. If one has to err, it should be towards more anteversion. Infact to avoid dislocation, more anteversion is required to guard against unwarranted activities on part of the patient.

Fabellar prevalence, degeneration and association with knee osteoarthritis in the Chinese population

The fabella is a sesamoid bone of the knee that can degenerate in some patients with osteoarthritis. The purpose of this study was to examine the prevalence and degeneration grades of fabellae in the Chinese population and to analyse their relationships with subject ages and knee osteoarthritis grades. The anteroposterior and lateral knee roentgenograms of 1150 subjects were recruited from the institutional database. The Kellgren-Lawrence scoring system was used to evaluate knee osteoarthritis. The degeneration grades of fabellae were scored in lateral roentgenograms by screening their shapes, sizes, subchondral sclerosis and osteophyte formation. The prevalence and degeneration of fabellae among ages, genders and knee sides were analysed by the Pearson Chi-Square test, and their relationships with knee osteoarthritis were analysed by the Spearman nonparametric correlation test. The overall prevalence of fabellae was 48.6% in 1359 knees. There was no significant difference in fabellar prevalence between the two sides (χ² = 0.025, P = 0.87437) and genders (χ² = 3.647, P = 0.05617), while the prevalence increased with the increasing ages of the subjects (χ² = 213.868, P < 0.001). The fabellar degeneration grades were correlated with age (r = 0.5288, P < 0.001) and knee osteoarthritis scores (r = 0.6892, P < 0.001). These results suggested that the fabellar prevalence and degeneration grades were correlated with age and knee osteoarthritis scores.

Pathology and management of flexible flat foot in children

We describe the pathology and treatment of flexible flat foot in children. The flexible flat foot is seen in the overly flexible foot and usually involves hypermobility of the subtalar joint. It typically occurs in childhood and may continue to adulthood. The arch develops spontaneously during the first decade of life in most children and comes within the normal range observed in adult feet. We prescribed orthoses for the treatment of flexible flat foot patients. Lateral weight-bearing radiographs and ultrasonography were helpful for the evaluation of the flat foot. Bleck recommended the UCBL shoe insert in cases of flexible flat foot if the standing or lateral rentgenogram demonstrates a talar plantar flexion angle (TPF) of 45° or greater. Bordelon suggested that cases of flexible flat foot should be treated if the standing or lateral roentgenogram demonstrates a Meary's talo-1st metatarsal angle (T1-MTA) of −15°or greater. However, the radiograph of a young child's foot poses some difficulties in making an accurate evaluation, because of the radiolucent cartilage zone. In this situation, a sagittal image obtained by ultrasonography has proved to be a powerful aid to evaluate the type of the flat foot. We classified the flat foot into three types: talo-navicular sag (T-N sag), naviculo-cuneiform sag (NC sag) and talo-navicular and naviculo-cuneiform sag (Mixed sag) following the criteria of Tachdjian. We recommended the NC sag and Mixed sag groups to be treated by using orthoses, while we kept a status of watchful waiting for the T-N sag group. However, we should consider the increasing complaints of children and their parents during the orthotic treatment. A through discussion between the parents of patients and the pediatric orthopedic doctors is necessary before orthotic treatment is started.

Literature review of acquired patella baja

Patella baja is one of the complications after total knee arthroplasty (TKA). It refers to an abnormal location of patella occurred secondary to shortening of the patellar tendon or distal positioning of the patella relative to the femoral trochlea. Clinically, it can be classified into congenital, acquired, and a combination of the above two types. Acquired patella baja is the most common type and usually occur as a result of trauma or surgery. Acquired patella baja is also caused by elevation of the joint line after TKA, which refers to pseudo-patella baja. Presently, its etiology is still uncertain. Some studies report the following causes of patella baja, including extending of quadriceps femoris, contracture of patella tendon or patellar fat pad, and fibrosis of joint. The diagnosis is mostly based on the lateral roentgenogram. The following parameters, including Insall-Salvati ratio, Modified Insall-Salvati ratio, Blackburne-Peel ratio, Caton-Deschamps ratio and Plateau-Patella angle, are used to assist diagnosis for patella baja. With the progress of imageology, some literatures describe several methods based on magnetic resonance imaging (MRI). However, the diagnostic methods of patella baja are not entirely precise. Patella baja can lead to decreased range of motion (ROM), a decreased lever arm, impingement of the patella against the tibial polyethylene or tibial plate, which may result in anterior knee pain, rupture of the patellar or quadriceps tendons. The treatment of patella baja depends on determining the cause and distinguishing between patella baja and pseudo-patella baja. Patients with severe symptom or failed for conservative treatment should receive surgery. The corrective measures for patella baja include lengthening of the patellar tendon and proximalize osteotomy of tibial tuberosity. In addition, the therapies for pseudo-patella baja include reestablishing the joint line by use of distal femoral augment, replacement of the patellar implant or polyethylene insert.

BONE AND SOFT TISSUES INTEGRATION IN POROUS TITANIUM IMPLANTS (EXPERIMENTAL RESEARCH)

Aim. It’s common that revision arthroplasty of the large joints demands replacing of bone defects of irregular geometrical shapes and simultaneous restoring of support ability and ability to integrate surrounding muscular and tendinous structures into an implant that is required for a complete restoration of joint function.The purpose. To experimentally study the process of integration for muscular and bone tissue as well as tendinous and ligamentous structures into porous titanium materials.Material and methods. During in vivo experiment the authors created a standardized bone defect in 6 rabbits of chinchilla breed at the point of patella ligament attachment as well as a delamination area of muscular tissue in latissimus dorsi. Both knee joints and both latissimus dorsi were used in each animal. Study group included titanium implants with three-dimensional mesh structure. Control group — solid titanium implants with standard porosity. Titanium implants were produced by additive technologies with preliminary prototyping. The porosity corresponded to trabecular metal, striations — 0.45, pores size —100–200 microns. Study and control components were implanted in the identical conditions into the corresponding anatomical sites. Postoperative AP and lateral roentgenograms of knee joints were performed for all animals. Morphological research was conducted on day 60 after the implantation and strength properties were studied at day 90 after the implantation.Results. The authors observed bony ingrowth into implant pores with minimal volume of fibrous tissue, a distinct connective integration was reported represented by a dense fibrous tissue in the pores of components implanted into the muscular tissue. Testing of fixation strength of the study implants demonstrated a clearly superior strength of soft and bone tissue integration into the experimental mesh implants produced using additive technologies.

Lower lung field tuberculosis.

,, h the lobe. It was not until the 1920stat the influx of reports became more apparent and informative (3-6). With the use of posteroante­ rior and lateral roentgenograms, the terminology about the loc~tion of the lesions became more specific, and ias late as 1946 some writers used the term basal tuberculosis. The terms lower lobe and lower lung field tuber­ have seen more usage recently. It is here that the writers wish to explain why the over-all heading of lung field tuber­ culosis was chosen, and what is meant by this terminology. The lung fields are considered that area on a posteroanterior chest film that ex­ tends below an imaginary horizontal line traced across the hila and including the parahilar re­ gions. In the early part of this study, in the 1930's and early 1940's, lateral films were taken so infrequently that the exact topographic loca­ tion of the lesion was difficult; therefore, the term lung field tuberculosis is preferred. Those patients selected in the last 20 years had 10be disease which was confirmed by lateral films and/or topographic studies.

Reliability and reproducibility of classifications for distal radius fractures

The aim of this study was to evaluate the interobserver reliability and intraobserver reproducibility of the Universal, AO, Fernandez and Frykman classifications for distal radius fractures. Fifty standard sets of posteroanterior and lateral roentgenograms of displaced distal radius fractures were classified two times by two groups of evaluators at 2-month intervals. The first group consisted of 10 orthopedic surgeons with a minimum of 5 years of experience. The second group consisted of 10 orthopedic residents in their first two years of practice. Interobserver reliability and intraobserver reproducibility were assessed using Cohen's kappa test. None of the classifications achieved good- very good reliability levels. The Fernandez classification had a moderate and the others had a fair interobserver agreement kappa coefficient. All classifications had fair kappa intraobserver agreement although the Frykman and Fernandez classifications had better results. None of the classification systems were superior in terms of reliability and reproducibility. The reliability and reproducibility rates of all four classifications were insufficient.

Who is in danger? Impingement and penetration of the anterior cortex of the distal femur during intramedullary nailing of proximal femur fractures

Intramedullary nail (IMN) perforation through the cortex of the distal femur is a risk of intramedullary stabilization of proximal femur fractures. This study was performed to identify information that is available before operation that can pick out patients at risk for this complication. A retrospective review of records and roentgenograms of 150 patients treated with intramedullary stabilization of a proximal femur fracture during a 4-year period at a Level I trauma center was performed. The position of the tip of the IMN in the distal femur was measured on postoperative lateral roentgenograms and grouped into anterior, middle, or posterior one third positions. Patients in whom the tip of the nail contacted or penetrated through the anterior cortex were designated as having cortical impingement. Nail tip position was in the anterior one third of the distal femur in 71 (47%) of 150 patients, and 38 (25%) of these patients fit the definition for cortical impingement. The radiographic femoral angle of incidence strongly correlated with an anterior nail tip position (p < 0.0001) and cortical impingement (p < 0.0001). Shorter patients were also more likely to have cortical impingement (p < 0.005), and patients less than 160 cm in height had a 49% likelihood of impingement. A starting point in the posterior one third of the greater trochanter increased the likelihood of having an anterior nail tip position as well (p < 0.007). Of the 150 patients in whom an IMN was used for stabilization of a proximal femur fracture, 71 (47%) had the distal part of their nail positioned in the anterior one third of the distal femur. Patients who are shorter and/or had an increased femoral bow as measured on a lateral roentgenogram are more likely to have an anterior nail tip position or cortical impingement. Posterior starting points should be avoided to prevent this complication. Prognostic study, level III; therapeutic study, level IV.

Hypertrophic cardiomyopathy and their therapeutic management in a Lhasa apso dog

Case history and observation: A male, 3 years old Lhasa Apso dog was presented with the history of haematemesis, dehydration, exercise intolerance, poor appetite, lethargy, cough, seizures and syncope for more than 3 weeks. Lateral roentgenogram revealed enlarged heart. Based on radiographic examination alongwith history of seizures and syncope the condition was diagnosed as hypertrophic cardiomyopathy. Treatment: The dog was treated with oral diltiazem @ 1.5 mg/kg body weight, ramipril @ 0.5 mg/kg body weight and frusemide @ 2 mg/kg body weight orally along with fluid therapy. Clinical improvement was noticed from third day. Improvement in appetite and physical activity with complete alleviation of clinical signs was observed by continued diltiazem (1.5 mg/kg, orally) and ramipril (0.5 mg/kg). Result: It was reported that the dog continued to improve and became much brighter and active over next 25 days. Post treatment radiograph showed nearly normal size of the heart suggestive of clinical recovery. Conclusion: Thus it is conclude that hypertrophic cardiomyopathy can be comfortably managed by medicinal therapy in canines.

50 Years Ago in CORR: X-ray Projections of Anatomic Structures in the Cervical and Lumbar Vertebrae Raymond G. Tronzo MD CORR 1960;16:249-263

In contrast to the long bones, the spine consists of complex anatomic shapes. On plain radiographs, all three-dimensional shapes are projected, so that unrelated features will be superimposed and create images that may be confusing to interpret. The well-known “teardrop” on an anteroposterior projection of the pelvis is, in fact, a projection of the superior margin of the obturator foramen and the inner and outer tables of the pelvis. An example from the spine is the well-known, “Scottie dog” sign in which the “neck” is “broken” in the case of a defect of the pars interarticularis; the dog, however, is not an anatomic reality, but rather reflects superimposed unrelated shadows. Sometimes these projected images may give the impression of abnormalities (eg, lytic lesions) that in fact do not exist. Tronzo, in 1960, recognized the difficulty of interpreting these planar projections from the spine [1]. He obtained dry bone specimens of the cervical and lumbar spines and painted key features with a lead-based paint to make them more apparent on the radiographs. He commented, “It was impractical to differentiate the finer details of the vertebrae because they appeared as superimposed shadows that were of little clinical value. Therefore, in some areas, only the gross parts were outlined by the lead paint.” By comparing the bony specimens with the correlating radiographs, he was able to label all major structures as they appeared on the radiographs (Figs. 3 and ​and4).4). He also noted a case of a fracture-subluxation of C2 (Fig. 13), where “an experienced radiologist…(interpreted the image)…as a ‘fracture through a cyst of C2.’ The cyst is the transverse foramen of C2, which appears as an avoid radiolucency on roentgenograms. It does not always show up on lateral roentgenograms unless C2 itself is set perpendicular to the x-ray cone. Such a condition would happen by chance.” He notes other situations where apparent cystlike defects could be misinterpreted as Schmorl’s nodes. Even today, Tronzo’s article provides an excellent reference for those interpreting plain radiographs of the spine and makes a key point of the need for understanding detailed anatomy when interpreting such images. Fig. 3 Lateral view cervical vertebrae. (Reprinted with permission and ©Lippincott Williams and Wilkins, from Tronzo G. X-ray projections of anatomic structures in the cervical and lumbar vertebrae. Clin Orthop Relat Res. 1960;16:249–263.) Fig. 4 Lateral view cervical vertebrae. (Reprinted with permission and ©Lippincott Williams and Wilkins, from Tronzo G. X-ray projections of anatomic structures in the cervical and lumbar vertebrae. Clin Orthop Relat Res. 1960;16:249–263.) Fig. 13 Fracture through pars of C-2 with subluxation of the body. (Reprinted with permission and ©Lippincott Williams and Wilkins, from Tronzo G. X-ray projections of anatomic structures in the cervical and lumbar vertebrae. Clin Orthop Relat Res. 1960;16:249–263.) ...

The femoral insertions of the anteromedial and posterolateral bundles of the anterior cruciate ligament: a radiographic evaluation

The aim of this radiographic study was to visualize the femoral insertion sites of the anteromedial (AM) and posterolateral (PL) bundle of the anterior cruciate ligament (ACL) on lateral radiographs in different angles of knee flexion to gain better understanding for arthroscopic femoral tunnel placement in ACL double bundle reconstruction. Four fresh cadaveric knees with an intact ACL were dissected to isolate the AM and PL bundle of the ACL. We obtained lateral radiographs of each knee over the range of 0°–90° flexion in 30° increments after painting the bundles with a radiopaque tantalum powder. The center of the radiographically marked femoral insertion was defined for each bundle on the lateral roentgenogram. We analyzed the relationship of knee flexion and the projection of the relative position of the femoral insertion sites of both bundles of the ACL on the lateral roentgenogram. The centre of the PL bundle visualized more anterior and distal than the centre of the AM bundle with the knee held in 90° flexion. The centers of the AM and PL bundle were horizontally aligned when the knee was flexed over 90°. The resulting images allow a radiographic description of the femoral insertion sites of both bundles in different angles of knee flexion. It is essential to be aware of the degree of knee flexion when drilling the femoral tunnels.

Measurement of tibial slope angle after medial opening wedge high tibial osteotomy: case series.

In the past, changes in tibial slope were not considered when planning or evaluating osteotomies, and success in high tibial osteotomy was related to the alignment and amount of femorotibial angular correction. The aim here was to measure changes in tibial slope after medial opening wedge tibial osteotomy and investigate the effect of tibial slope angle on the clinical results. Retrospective review study on a series of cases, at the Department of Orthopedics and Traumatology, Faculdade de Medicina de Marília (Famema), Marília, Brazil. Twenty-eight patients were studied, and a total of thirty-one knees. Lateral roentgenograms of the tibia were used pre and postoperatively to measure the tibial slope based on the proximal tibial anatomical axis. The clinical results were measured using the Lysholm knee score. There was an average increase in tibial slope angle after surgery of 2.38 degrees (95% confidence interval: +/- 0.73 degrees ). There was no correlation (r = -0.28) between the postoperative Lysholm knee score and the difference in tibial slope angle from before to after surgery (P = 0.13). Medial opening wedge tibial osteotomy led to a small increase in tibial slope. No significant correlation was found between increased tibial slope and short-term clinical results after high tibial osteotomy. Other clinical studies are needed in order to establish whether extension or flexion osteotomy could benefit patients with medial compartment gonarthrosis.

L'hyperdivergence est-elle une contre-indication dans le traitement précoce des classes II ?

Vertical growth pattern is supposed to have adverse effects on sagittal growth and is considered as a contra-indication for early treatment. The aim of this retrospective cohort study was to analyse whether early treatment of children with Class II malocclusion was able to achieve as an important sagittal correction on subjects with growth vertical pattern as on subjects without vertical pattern without modification of vertical growth. The study was composed of 123 children (110 months old in average), with Class II division 1 malocclusion : 34 children with excessive vertical growth pattern and 74 children without excessive vertical growth pattern, both treated with DAC appliance, and 15 not treated subjects with excessive vertical growth pattern. Data were collected at the start of the study (t(1)), after the active treatment (t(1')) and 29 months after t(1) (t(2)). A Pancherz cephalometric analysis was applied on the lateral roentgenograms. Differences were evaluated with t-test. Results show that DAC appliance may be an orthopedic appliance indicated to achieve correction in class II skeletal pattern by mandibular growth without augmentation of vertical dimension.

Alternative approach to evaluating lumbar lordosis on direct roentgenograms: Projection area per length squared

Several methods have been described to evaluate the degree of lumbar lordosis. However, suggested methods have used non-standardized terminology and landmarks to measure the degree of lumbar lordosis. In the present study a practical method for evaluating the degree of lumbar lordosis is described and, for this purpose, 24 lateral roentgenograms were obtained retrospectively from the archive of Department of Physical Medicine and Rehabilitation, Ondokuz Mayis University, Samsun, Turkey. The length between the superior and inferior angles of the first and fifth lumbar vertebral bodies, and the area behind the lumbar vertebral bodies, were estimated using the point counting and planimetry methods. A new unit, the projection area per length squared (PAL) was described on lateral roentgenograms. The planimetric approach was used as the gold standard in the present study. The point-counting method was also used to estimate the PAL and it was repeated three times to determine the variability of the technique. To evaluate the estimates' accuracy, the results of point-counting were compared with those of the planimetry methods. The PAL changed by between 3.93 and 13.59% for the examined subjects. A high correlation was also noted between the results of the point-counting and planimetry methods (r = 0.997). It is concluded that the PAL approach could provide accurate and reproducible data for evaluating the degree of lumbar lordosis and low back pain.

Traitement interceptif DAC : analyse structurale

The aim of this retrospective short and middle term study was to evaluate dental and skeletal effects during early class II treatment. Thirty subjects were treated with DAC appliance, 32 children were not treated. Data were collected at the start of the study (t(1)), after the active treatment (t(1')) and 28 months after t(1) (t(2)). L.D.V. and Tweed cephalometric analyses were applied on the lateral roentgenograms of the three groups. Differences for all the variables from t(1) to t(1') and t(2) were calculated and compared by t-test. Results suggested that DAC appliance was able to achieve twice more mandibular growth in the treated group than in the non treated group. Anterior total skeletal and matricial rotations were similar to control group. Early DAC appliance achieved overjet correction thanks to major skeletal participation (89%) and little dental participation (11%). During following-up stage, overjet relapsed partially as shown in other articles with other appliances. As a conclusion, DAC appliance may be an orthopedic appliance indicated to achieve correction in class II skeletal pattern without maxillary prognathism and with mandibular retrognathism.

Stage-specific Sagittal Spinopelvic Alignment Changes in Osteoarthritis of the Hip Secondary to Developmental Hip Dysplasia

A retrospective, age- and sex-matched radiographic study. To compare the sagittal spinopelvic alignment in patients with hip osteoarthritis (OA) stratified by stage with that of age-matched control groups. OA of the hip resulting from developmental hip dysplasia could be a cause of low back syndrome. OA of the hip may induce changes in sagittal alignment compared with healthy subjects. We studied 53 patients with OA of the hip secondary to developmental hip dysplasia, including 27 at the prearthritic/early stage (age, 34.0 years) and 26 at the advanced/terminal stage (age, 56.3 years). Comparisons were made with healthy females age-matched to each patient group (n = 13 and n = 15, respectively). Lateral roentgenograms of the lumbar spine and the hip joint were obtained in the upright position to determine pelvic inclination, sacral slope angle, lumbar lordotic angle (L1-L5), disc angle of L5/S1, and pelvic angle (by Jackson's method). Patients with pre/early-stage OA tended to have greater anterior pelvic inclination than healthy volunteers, although the difference was not significant. No significant differences were noted for other measurements. Lumbar lordotic and sacral slope angles were significantly greater in patients with advanced/terminal-stage OA than the control. Although lumbar lordotic and sacral slope angles decreased with aging in the healthy subjects, patients with OA retained the lumbar lordotic and sacral slope angles despite progression of OA with age. Pelvic inclination tended to increase in pre/early-stage OA patients. In healthy subjects, aging is associated with reduction of lumbar lordotic angle and tendency for posterior inclination of the sacrum. With aging, patients with OA maintained the lumbar lordotic angle and did not develop a posterior sacral slope angle.

Accuracy of pedicle and mass screw placement in the spine without using fluoroscopy: a prospective clinical study

Background context Spinal instrumentation is accompanied by various problems, including screw malpositioning. One way of preventing this is the employment of intraoperative biplanar fluoroscopy. However, screw malpositioning despite the use of fluoroscopy has been reported, and exposure to radiation is another burden of this method. Therefore, the purpose of this article was to compare the results of instrumentation applications without using scopy versus the harmful effects of radiation exposed during spinal instrumentation. Purpose The aim of this article was to review the literature and this is the first prospective clinical study performed on this subject. Study design Patient report. Patient sample One hundred thirty-two patients with spinal instrumentations were included. Outcome measures Radiological investigation with computed tomography (CT) scans was performed 2 days after the procedure. Methods Craniosacral posterior spinal instrumentation was performed without using scopy at the Neurosurgery Clinic of Haseki Training and Research Hospital between January 2000 and January 2005. Postoperative CT analyses were performed to evaluate whether the 527 screws used during posterior instrumentation in a total of 132 patients were positioned correctly. In all cases, the screw applications were performed with regard to anatomic landmarks, whereas the distances were determined according to lesion localizations. Screw malpositioning and the functional effects and relations with interactions with neurovascular structures were examined. At the end of the operations, all patients were examined with direct lateral roentgenograms and CT scans for the evaluation of screw positions. Results According to their locations, 75 cervical screwing in 24 patients, 32 upper thoracic screwing in 7 patients, 30 midthoracic screwing in 7 patients, 306 thoracolumbar screwing in 54 patients, and 84 sacral screwing in 40 patients were performed by the senior spinal surgeon (KK). Among all posterior spinal instrumentation applications, the cervical region analyses revealed penetration of the medial wall of vertebral foramen with two (0.4%) screws, penetration of the lateral wall with one (0.2%) screw, and protrusion into the vertebral foramen without vascular penetration with one (0.2%) screw, whereas in the upper thoracic region there was penetration into the lateral pedicle wall with one (0.2%) screw and deviation toward the disc space through the superior end plate with two (0.4%) screws. In the midthoracic region, there was penetration into the disc space with two (0.4%) screws in only one case, whereas in the thoracolumbar complex, there was deviation toward the superior end plate with seven (1.4%) screws in four cases, deviation toward the disc space with two (0.4%) screws, medial wall penetration with six (1.2%) screws (two of which caused nerve root irritation in three cases), and penetration of the lateral wall of pedicle with four (0.8%) screws. In the sacral instrumentations, malpositioning occurred with only two (0.4%) screws because of deviation toward the medial wall. In summary, malpositioning occurred with 30 (5.6%) of the total 527 screws; none of the cases had neural or vascular damage. Two (1.5%) cases were revised for malpositioning and distance errors. The mean duration for preparation of screw introduction site and placement of the screw was 3 minutes. Infection occurred in only one (0.75%) case. Conclusions Screw application without fluoroscopy is performed with calculation of all essential anatomic details, and because of the reduction of surgery time, the absence of exposure to radiation, and very low infection rates as a consequence of reduced surgery time, it is a method recommendable for surgeons experienced with screw placement. Besides, its malpositioning rates are within acceptable limits. Because screw malpositioning is also found after biplanar fluoroscopy, the prevention of screw malpositioning requires knowing the anatomic landmarks accurately.

Smoking and degenerative changes of the cervical spine: a roentgenographic study

Background context Cigarette smoking has been implicated in low back pain and intervertebral disc degeneration; however, there is no conclusive evidence that cigarette smoking is an important contributing factor to intervertebral disc degeneration. Purpose The objective of this study is to determine whether heavy cigarette smoking is a contributing factor to the development and severity of degenerative disc disease of the cervical spine. Study design This is a comparative roentgenographic study of degenerative changes of the cervical spine in age- and sex-matched smokers and nonsmokers. Patient sample Two hundred asymptomatic subjects, 100 women and 100 men, were equally divided into 50 nonsmokers and 50 heavy smokers. Outcome measures A numerical grading system previously developed was used to grade the presence and severity of degenerative changes at each cervical level, and cervical lordosis was measured. This was performed on a lateral cervical spine roentgenogram. Methods A single lateral roentgenogram of the cervical spine was taken in each individual, and in the smokers a short questionnaire was administered to determine the amount and duration of smoking. The roentgenograms were read by the three authors. Average values of all three observers were used for statistical analysis. Results There were no statistically significant differences between smokers and nonsmokers. Conclusions Based on the evidence of the plain roentgenograms used in this study, we found no evidence to suggest that cigarette smoking is a causative factor in asymptomatic people in the development of degenerative disc disease in the cervical spine. Whether cigarette smoking has a significant effect in people with neck symptoms cannot be determined by this study.

THE CLASSIC: Pyogenic Vertebral Osteomyelitis

THE CLASSIC: Pyogenic Vertebral Osteomyelitis