Roentgenographic Parameters Research Articles

Predictive value of sagittal craniocervical roentgenographic parameters for HRQOL after craniocervical fusion.

Loss of "physiological" sagittal alignment following craniocervical fusion (CCF) for degenerative disease may be associated with loss of horizontal gaze, dysphagia and poor HRQOL. This study reports on sagittal craniocervical roentgenographic predictors of HRQOL (SF-36) in patients following uncomplicated CCF for fresh upper cervical traumatic (UCT) injuries. Twenty-two consecutive adult patients (group P) aged 50 ± 16years, who had undergone CCF for fresh unstable C1 and C2AO/type UCT injuries, were evaluated 39 ± 12months postoperatively with upright lateral cervical roentgenograms and SF-36as HRQOL measure. Physiological data for cervical sagittal alignment and SF-36 were taken from an age-matched control group (C) of 30 individuals aged 52 ± 12years. Several commonly used sagittal cervical roentgenographic parameters were tested as potential predictors of the SF-36 domains in both groups. Roentgenographic predictors for each of the nine SF-domains were calculated using stepwise multilinear regression analysis (MLRA). The roentgenographic predictors in patients included (1) the angle created by McGregor's line and the inferior surface of the axis (OC2a) for physical function (PF, P = 0.049), role limitations due to physical health (RLPH, P = 0.004),role limitation due to emotional problems (RLEP, P = 0.004), emotional functioning (EF) (P = 0.012), social functioning (SF) (P = 0.028) and general health (GH, P = 0.041). (2) The angle formed between a horizontal line and the superior endplate of T1-vertebra (T1-slope) was predictor for SF (P = 0.017) and pain (P = 0.021), and (3) the angle between McGregor's line and the line that links the center of the C1 anterior arch and the apex of cervical sagittal curvature (PIA) was predictor for health change (HC, P = 0.002). This study showed that postoperative OC2a, PIA and T1-slope safely predict HRQOL outcomes (SF-36) following CCF for fresh trauma. It seems theoretically that the adequate restoration of the upper cervical alignment including C1-C2 upper cervical lordosis (OC2a) and PIA, in interaction with T1-slope, is important for postoperative HRQOL scores close to physiological values. The authors speculate that C0-C4 fusion restores horizontal gaze and allows for painful regain of pre-trauma quality of life. Spine surgeons should realign and stabilize the craniocervical junction taking in consideration these roentgenographic predictors.

Quality of Life in Adult Patients Receiving Cervical Fusion for Fresh Subaxial Cervical Injury: The Role of Associated Spinal Cord Injury.

Purpose To study postoperative Health-Related Quality of Life (HRQOL) after instrumented fusion for fresh subaxial cervical trauma and the effect of spinal cord injury (SCI). Methods From a total of 65 patients, 17 (26%) patients suffered on admission from SCI. Twenty-five patients underwent anterior, 25 posterior, and 15 circumferential cervical surgery for a single cervical injury. Sagittal roentgenographic parameters were measured in 65 age-matched asymptomatic controls and in patients on admission, eight months postoperatively and at final follow-up (lower C2-C7 curvature, cervical sagittal vertical axis (cSVA), spinocranial angle (SCA), T1-slope, neck tilt (NT), thorax inlet angle (TIA), cervical tilt (CT), cranial tilt (CrT), and occiput–C2 angle (C0-C2)). In the last evaluation, SCI patients were compared with their counterparts without SCI using national validated HRQOL instruments (SF-36 and neck disability index (NDI)). Results Fusion included an average of 3 vertebrae (range 2-4 vertebrae). All 65 patients were followed for an average of 5.5 years, (range 3-7 years) postoperatively. In the last evaluation, 10 (15.4%) patients with incomplete SCI improved postoperatively at 1-2 grades. At the last observation, patients with SCI showed poorer HRQOL scores than their counterparts without SCI. In particular, each SF-36 domain score was correlated with SCA, T1-slope, cSVA, and CT. At baseline, patients showed higher NT, CrT, and C0-C2 angle than controls. Eight months postoperatively, cSVA, NT, TIA, and cranial tilt (CrT) were increased in patients. In the last observation, there was difference in the sagittal roentgenographic parameters between patients with SCI compared to those without SCI. Patients aged ≥55 years had postoperatively increased cSVA, NT, and CrT compared to their younger counterparts. Conclusion At the final observation, HRQOL scores were lower in patients with SCI than in their non-SCI counterparts, obviously because of the associated neurologic impairment. SF-36 scores correlated with several sagittal roentgenographic parameters. These correlations should be taken in consideration by spine surgeons when performing cervical spine surgery for fresh cervical spine injuries.

Posterior Occipitocervical Fusion for Unstable Upper Cervical Trauma in Old and Elderly Population, Although Decreases Upper Cervical Rotation, Does Not Significantly Increase Neck Disability Index.

Background Despite the research progress in the thoraco-lumbo-pelvic balance, cervical spine balance has only recently gained increasing interest. To our knowledge, there is a lack of research regarding sagittal occipitocervical spine balance restoration following posterior occipitocervical fusion (POCF). Purpose The primary outcome measure is the evaluation of sagittal cervical alignment roentgenographic parameters and the secondary is the functional outcome (NDI), following POCF for upper (C1 & C2) cervical trauma (UCT) in coexistence with upper cervical spine degeneration. Patients and Methods. Twenty old and elderly patients aged 62 ± 12 years with evident upper cervical degeneration, who received POCF for upper C1 & C2 unstable cervical spine injuries, were included. C2-C7 lordosis, C2-C7 SVA, spinocranial angle (SCA), T1-slope, neck tilt (NT), thorax inlet angle (TIA), cervical tilt (CT), cranial tilt (CrT), and C0-C1 angle were measured. The subfusion angle was used to study the behavior of the unfused cervical segments below fusion. The Neck Disability Index (NDI) was used for the functional outcome evaluation. 29 age-matched individuals were used as controls for radiographic analysis and self-reported functional status comparison. Results The roentgenographic data were measured 3 and 39 ± 12 months postoperatively. Twelve patients showed no disability, and eight showed mild disability. Postoperatively, the patients stood with less C2-C7 lordosis, SCA, and CT (P < 0.02) but with higher NT (P < 0.02) in comparison to the controls. The patient's neck disability (NDI) was increasing as TIA increases (P=0.023). Subfusion angle seems to adapt to C2-C7 lordosis (P < 0.0033) and C0-C2 angle (P < 0.003) without any changes till the last evaluation. Conclusions POCF sufficiently restored occipitocervical sagittal balance along with functional outcome similar to controls in adult and elderly individuals with evident upper cervical degeneration. We do not recommend POCF for young active individuals without occipitocervical pathology, but in contrary, we recommend the removal of the spinocranial connection hardware after cervical fusion is completed.

Transpedicular vertebral body augmentation reinforced with pedicle screw fixation in fresh traumatic A2 and A3 lumbar fractures: comparison between two devices and two bone cements

This retrospective study compares efficacy and safety of balloon kyphoplasty (BK) with calcium phosphate (Group A) versus KIVA implant with PMMA (Group B) reinforced with three vertebrae pedicle screw constructs for A2 and A3 single fresh non-osteoporotic lumbar (L1-L4) fractures in 38 consecutive age- and diagnosis-matched patient populations. Extracanal leakage of both low-viscosity PMMA and calcium phosphate (CP) as well as the following roentgenographic parameters: segmental kyphosis (SKA), anterior (AVBHr) and posterior (PVBHr) vertebral body height ratio, spinal canal encroachment (SCE) clearance, and functional outcome measures: VAS and SF-36, were recorded and compared between the two groups. All patients in both groups were followed for a minimum 26 (Group A) and 25 (Group B) months. Extracanal CP and PMMA leakage was observed in four (18%) and three (15%) vertebrae/patients of group A and B, respectively. Hybrid fixation improved AVBHr, SKA, SCE, but PVBHr only in group B. VAS and SF-36 improved postoperatively in the patients of both groups. Short-segment construct with the novel KIVA implant restored better than BK-fractured lumbar vertebral body, but this had no impact in functional outcome. Since there was no leakage difference between PMMA and calcium phosphate and no short-term adverse related to PMMA use were observed, we advice the use of PMMA in fresh traumatic lumbar fractures.

Balloon Kyphoplasty Versus KIVA Vertebral Augmentation—Comparison of 2 Techniques for Osteoporotic Vertebral Body Fractures

Prospective, parallel-group, controlled comparative randomized study. This study compares the efficacy in sagittal vertebral height and wedge deformity restoration, polymethylmethacrylate cement leakage safety, and functional outcome of balloon kyphoplasty (BK) versus KIVA (a novel vertebral augmentation technique) implant for the augmentation of fresh osteoporotic vertebral body fractures. Minimally invasive vertebral augmentation procedures have been widely used to treat vertebral compression fractures caused by osteoporosis. The results of these trials are encouraging in augmenting the vertebra and reducing the wedge deformity. However, after BK, polymethylmethacrylate leakage remains common after A3.1 AO type fractures, with a frequency per vertebra into the epidural space up to 9.8% but less common (0.03%-5.6%) in A1.1 AO type fracture. KIVA is a novel percutaneous uniportal vertebral augmentation device that is designed to restore the vertebral body and reduce polymethylmethacrylate leakage. From a total 190 patients with osteoporotic fractures who were initially enrolled in this prospective randomized study, 10 patients were excluded (5 met exclusion criteria, 5 with evidence of metastasis). This study examined 82 patients (69 ± 11 yr) with 133 fractures who received KIVA and 86 patients (72 ± 9 yr) with 122 fractures that were reinforced with BK. Anterior (anterior vertebral body height ratio [AVBHr]), midline (midline vertebral body height ratio [MVBHr]), and posterior (posterior vertebral body height ratio [PVBHr]) vertebral body height ratio and Gardner segmental vertebral wedge deformity were measured preoperatively to postoperatively. New fractures were recorded at the final observation. The baseline anthropometric and roentgenographic parameters did not differ between the 2 groups. Any cement leakage was examined on plain roentgenograms and computed tomographic scan. All patients were followed for an average of 14 months (range, 13-15 mo) postoperatively. RESULTS.: At the final observation, both KIVA and BK restored significantly AVBHr, PVBHr, and MVBHr. However, only KIVA device reduced significantly the Gardner angle (P = 0.002). Residual kyphosis of more than 5° was measured significantly more (P < 0.001) in the BK than in KIVA spines. KIVA showed significantly lower (3%, χ2, P ≤ 0.05) leakage) [corrected] (paravertebral, intradiscal) rate per vertebra than BK (0.098%) in which because of intracanal leakage 2 patients developed acute paraplegia and were reoperated in emergency. New fracture rate was similar in both groups. Back pain scores (visual analogue scale), 36-Item Short Form Health Survey (Physical Function and Mental Health domains), and Oswestry Disability Index scores improved significantly in the patients of both groups. Both KIVA and BK restored in short-term similarly vertebral body height, but only KIVA restored vertebral body wedge deformity. KIVA was followed by significantly lower and harmless always extracanal leakage rate than BK. Longer observation is needed to show whether these radiological changes have any functional impact.

Colour Doppler ultrasonography for evaluation of anterior chest blood supply: the possible role of arterial blood supply to the costosternal junction in the aetiology of idiopathic scoliosis in female adolescents.

This prospective comparative study was carried out to investigate the blood supply to the anterior chest wall by measurement of several anatomical and haemodynamic flow parameters of the internal mammary artery, with the use of colour Doppler ultrasonography, in female scoliotics with idiopathic right convex scoliosis in adolescence. Previous investigations have postulated that asymmetry of the breasts in female adolescents may be linked with the development of right convex thoracic scoliosis. This breast asymmetry is supposed to be linked with anatomical and functional asymmetry of the internal mammary artery that is the main supplier to the mammary gland. However, no measurements of anatomical and haemodynamic parameters of the internal mammary artery have been made to justify or reject the hypothesis of asymmetric blood flow volume to the breasts and costosternal junction in female adolescent scoliotics. Twenty female adolescents with right convex thoracic scoliosis and 16 comparable female individuals without spine deformity were examined with roentgenograms (scoliotics only) to measure scoliosis curve, vertebral rotation and concave and convex rib-vertebra angle at three vertebrae (the apical, one level above and one below the apical vertebra). Doppler ultrasonography was used to measure, at the origin of the internal mammary artery, its lumen diameter, cross-sectional area, time average mean flow and flow volume per minute in scoliotics and controls, which were compared with each other. The roentgenographic parameters were compared with the ultrasonographic parameters in the scoliotics to disclose any relationship. The reliability of colour Doppler ultrasonography was high and the intra-observer variability low (ANOVA, P=0.92-0.94). There was no statistically significant difference in the ultrasonographic parameters of the internal mammary artery between right and left side in each individual as well as between scoliotics and controls. In scoliotics the right mammary artery time average mean velocity increases with the convex ( P<0.05) and concave ( P<0.01) rib-vertebra angle one level above the apical vertebrae and with the apical convex rib-vertebra angle ( P<0.05). The right internal mammary artery flow volume per minute increases with convex ( P<0.01) and concave ( P<0.01) rib-vertebra angle one level above the apical vertebrae and with the apical convex rib-vertebra angle ( P<0.05). Left internal mammary artery cross-sectional area increases with convex apical rib-vertebra angle ( P<0.01) and concave rib-vertebra angle one level above the apical vertebra ( P<0.01). Conclusively, this investigation showed that haemodynamic flow parameters of the right internal mammary artery and anatomical parameters of the left internal mammary artery are significantly correlated with the magnitude of rib-vertebra angles close to the apex of right thoracic scoliosis in female adolescents. This study did not find any evidence for side-difference in vascularity of the anterior thorax wall and, thus, it could not clearly justify previous theories for development of right thoracic scoliosis in female adolescents.

The association between arterial blood supply to the anterior chest and juxta-apical thorax-asymmetry-associated right thoracic female adolescent idiopathic scoliosis

This cross-sectional study was carried out to investigate the role of arterial blood supply to the anterior chest wall in the pathogenesis of idiopathic scoliosis in adolescent females. Previous investigations have postulated that there is some asymmetry of the breasts in female adolescents with thoracic scoliosis that may be linked with anatomic and functional asymmetry of the internal mammary (IMA) artery that is the main supplier to the mammary gland. For this reason the present study investigated several anatomic and hemodynamic flow parameters of the IMA with color Doppler ultrasonography (CDU). Twenty female adolescents with right convex thoracic scoliosis were examined with roentgenograms to measure scoliosis curve, vertebral rotation, and concave and convex rib-vertebra angle at three vertebrae (apical, and one level above and one below the apical vertebra). Sixteen comparable nonscoliotic females were used as controls. CDU measured the IMA lumen diameter, its cross-sectional area, time average mean flow, and flow volume per minute. In scoliotics the obtained roentgenographic and ultrasonographic parameters were compared with each other to disclose any relationship. The reliability of CDU was high and the intraobserver variability low (ANOVA, P=0.92–0.94). There was no statistically significant difference in the ultrasonographic parameters of the IMA between right and left side in each individual or between scoliotics and controls. In scoliotics significant (P<0.05–0.01) correlations were shown between anatomic and hemodynamic parameters of internal mammary artery and juxta-apical convex and concave rib-vertebra angle. This study showed that the blood supply to the anterior chest wall in female adolescent scoliotics suffering from right-convex thoracic scoliosis is significantly correlated with juxta-apical convex and concave rib-vertebra angles. Thus, although this study found no correlation between scoliosis characteristics and anterior wall blood supply, it theoretically supports the hypothesis of a possible correlation between juxta-apical thorax asymmetry and anterior chest-wall blood supply in idiopathic scoliosis.

Effects of thoracolumbosacral orthosis on spinal deformities, trunk asymmetry, and frontal lower rib cage in adolescent idiopathic scoliosis.

Prospective study. To document immediate and late changes in shape and balance of the thoracic and lumbar spine and lower rib cage on the frontal plane induced by treatment with a thoracolumbosacral orthosis (TLSO). The effect of TLSO on lateral plane of spinal deformity, frontal lower rib cage, trunk balance, and natural history are poorly understood. Twenty-four female adolescents with major thoracic and/or lumbar scoliosis, averaging 30 degrees and 26 degrees, respectively, were treated with a full-time TLSO program. Scoliosis, kyphosis, convex, and concave rib-vertebral angles T7 to T12, frontal trunk balance, frontal vertebral inclination, rotation and translation from T7 to L4-vertebrae were measured before bracing, 1 month after bracing, and biannually thereafter in brace and without brace for a 4-year period and reevaluated at the age of 20 years, at an average of 3.5 years after termination of bracing to measure any permanent changes. Thoracolumbosacral orthosis treatment corrected both thoracic and lumbar scoliosis and reduced lateral trunk shift at the expense of significant, although temporary reduced physiological thoracic kyphosis, increased lateral displacement of T7 to T10, increased frontal inclination of L2 to L4, and elevation of the apical concave rib in favor of reduction of lateral displacement of T11 to L4; decreased frontal inclination of T7, T9, and T11; and derotated L1 and L2 and thoracic apical vertebra without affecting drooping of the 7th to 12th ribs. In this series, there was marked inconsistency in the obtained changes in several of the roentgenographic parameters in the different evaluations, which is probably because of the empiric application of the TLSO during different periods of treatment. 3.5 years after termination of TLSO-wearing, all roentgenographic parameters remained to the prebrace values. Thoracolumbosacral orthosis program maintained the measured roentgenographic parameters at the prebrace levels in progressive adolescent idiopathic scoliosis, but it had no effect on the droop of the seven lower ribs. The TLSO treatment stopped progression of scoliosis and reduced the number of patients requiring surgery. Thus, it changed the natural history of scoliosis.

Correlative analysis of the sagittal profile of the spine in patients with beta-thalassemia and in healthy persons.

This prospective study compares several roentgenographic parameters of the thoracic and lumbar spine in patients with beta-thalassemia and in healthy persons who served as controls. Eighty-four patients with beta-thalassemia and 84 age- and gender-matched healthy persons were examined clinically and radiologically (thoracic kyphosis, lumbar lordosis, and vertebral and sacral inclination). Although there was a significant difference in the vertebral inclination from T6 to L1, L4, and L5 between patients and controls, thoracic kyphosis and lumbar lordosis did not differ in the two groups. The apical vertebra of the thoracic kyphosis in patients and controls was T7 and T6, respectively, whereas L4 was the apical vertebra of the lumbar lordosis in both groups. There were no age- or gender-related differences in the magnitude of sacral inclination, thoracic kyphosis, or lumbar lordosis in the patients with beta-thalassemia compared with controls. Lumbar lordosis was significantly correlated with sacral inclination in both patients with beta-thalassemia and controls. Beta-thalassemia does not affect sagittal profile of the thoracic and lumbar spine but it is associated by structural changes on the frontal plane of the spine that are expressed as a high prevalence of scoliosis.

Segmental Roentgenographic Analysis of Vertebral Inclination on Sagittal Plane in Asymptomatic versus Chronic Low Back Pain Patients

Two homogenous groups of 120 volunteers and 120 low back pain (LBP) patients, age range 20-79 years, underwent a prospective roentgenographic segmental vertebral analysis of the thoracic and lumbar spine to compare several roentgenographic parameters useful for planning spine surgery. The following roentgenographic parameters were measured: thoracic kyphosis, lumbar lordosis, sacral inclination, distal lordosis (L4-S1), inclination of each vertebra from T4-S1, and relative vertebral inclination between adjacent vertebrae. Thoracic kyphosis increased (p < 0.0001) and sacral inclination decreased (p < 0.05) with age in the control group. Increased thoracic kyphosis correlated with decreased lumbar lordosis after the sixth decade in the control group (p < 0.01), less so in the LBP group (p < 0.05). Increased thoracic kyphosis was seen more in the LBP group than in the controls, but significantly solely in the sixth decade (p < 0.01). Lumbar lordosis was more increased in the controls than in the LBP group but significantly solely in the sixth decade (p < 0.001). The L5-S1 segmental lordosis was much more in the LBP patients than in the controls (p < 0.001). Lumbar lordosis was strongly correlated with sacral inclination in both groups (p < 0.0001) and it was significantly greater in the controls, particularly in the sixth decade (p < 0.001). Sacral inclination was significantly more in the female than in male volunteers (p < 0.05). Distal lordosis (L4-S1) represents 55% and 49% of total lumbar lordosis in controls and low back patients, respectively. Spine surgeons frequently deal with sagittal spinal deformities and the deviations of sagittal spinal curvatures and vertebral inclination in the sagittal plane, both in normal subjects and LBP patients should be clinically helpful.

Reciprocal angulation of vertebral bodies in the sagittal plane in an asymptomatic Greek population.

A prospective study conducted on several roentgenographic parameters of the standing sagittal profile of the spine in an asymptomatic Greek population. To perform segmental analysis of the sagittal plane alignment of the normal thoracic, lumbar, and lumbosacral spines and to compare the findings with those derived from similar populations. Until recently, little attention has been paid to the sagittal segmental alignment of the spine, and there are only a few studies (in French and American populations) in which radiographic analysis of sagittal spinal alignment is investigated. Ninety-nine consecutive asymptomatic Greek volunteers (38 men, 61 women), an average age of 52.7 +/- 15 years old (range, 20-79 years), were included in this prospective study, on the basis of several inclusion criteria. These volunteers were divided into six distinct age groups. The radiologic parameters, which were measured (by Cobb's method) on the lateral standing roentgenograms of the whole spine were: thoracic kyphosis (T4-T12), lumbar lordosis (L1-L5), total lumbar lordosis (T12-S1), distal lumbar lordosis (L4-S1), sacral inclination (measured from the line drawn parallel along the back of the proximal sacrum and the vertical line), pelvic tilting, vertebral body inclination, and relative segmental inclination between pairs of adjacent vertebrae. Thoracic kyphosis and lumbar lordosis (T12-S1, L1-L5) were not gender related. Thoracic kyphosis increased with age (P < 0.001), the lumbar spine (L1-L5) gradually became less lordotic as the thoracic kyphosis increased (P < 0.003), and total lumbar lordosis was not age related. Sacral inclination correlated strongly with both thoracic kyphosis (P < 0.002) and L1-L5 lordosis (P < 0.001). Pelvic tilting correlated strongly with L1-L5 lordosis (P < 0.0075), but did not correlate with thoracic kyphosis and age. Vertebral body inclination showed a narrow variability in T6-T12 and in L4 and a wide variability in T4, T5, L1-L3, and S1. Distal lumbar lordosis represents the 68.6% of the total lumbar lordosis. In the results of this study, a reliable table of reference for roentgenographic parameters in the sagittal plane of the spine was established in an asymptomatic Greek population. The parameters are similar to those used in previous studies. Thus, these data should be considered in preoperative planning and postoperative evaluation of achieved correction during restoration procedures of the spine in the sagittal plane.

Adult Idiopathic Lumbar Scoliosis

A retrospective study was conducted of patients with untreated adult-type idiopathic lumbar scoliosis. To construct a mathematical formula that provides accurate progression of an idiopathic adult lumbar scoliosis using initial roentgenographic parameters. Osteoporosis, lateral spondylolisthesis of L2-L4, and degeneration of disc and joint may contribute to a poor prognosis for lumbar adult-type scoliosis. Seven roentgenographic parameters taken from the standing roentgenograms of 91 patients with a scoliosis of more than 10 degrees Cobb angle and who were included in a follow-up for more than 2 years, were put into a multiple regression analysis to observe the relative weight of each in the progression of the scoliosis. Only lateral spondylolisthesis of the apical vertebra, Harrington factor, and disc index were related to progression of the scoliosis. Using the mathematical formula, the real progression of lumbar scoliosis can be predicted within an average of 0.85 degrees +/- 3.76 degrees.

Triple Arthrodesis Using Internal Fixation in Treatment of Adult Foot Disorders

Forty adult patients with 44 fused feet were evaluated at an average of 4.9 years after triple arthrodesis. The average age of the patients at operation was 41 years. All operations were performed by a specific technique using rigid internal fixation with screws. Outcome was graded using the clinical criteria of Hallgrimsson as modified by Angus and Cowell. Function was evaluated according to modified Arthritis Impact Measurement Scales (AIMS). Radiographic evaluation included measurement of lateral talocalcaneal angle, lateral talometatarsal angle, and anteroposterior (AP) talometatarsal angle on standing or simulated weight-bearing radiographs. Thirty-four feet had good results, six had fair results, and there were four failures. The average patient could function painlessly on flat surfaces in nonstrenuous activities and had only occasional mild pain with more vigorous activities. In roentgenographic parameters, there was an average improvement of 17 degrees in the lateral talometatarsal angle, 11 degrees improvement in the lateral talocalcaneal angle, and an improvement of 18 degrees in the AP talometatarsal angle. There were two pseudarthroses, no recurrences, and two unsatisfactory corrections. When carefully done, triple arthrodesis can restore an adult patient with a disabling foot disorder to normal function and minimal pain.

Spondylolysis and spondylolytic spondylolisthesis

The purpose of this paper is to review the current concepts on spondylolysis and spondylolytic spondylolisthesis. The two are very closely connected, and both result from a growth disturbance of the lumbosacral vertebrae, linked to the human biped standing position, and depending on genetic and environmental factors. Pars defect occurs usually in early childhood. The primum movens of lumbosacral deformities in spondylolisthesis is the slippage and its biomechanical consequences for the growing vertebrae. Most cases are asymptomatic but symptomatic cases can be very disabling. Major clinical symptoms are presented here, as are the roentgenographic parameters usually required for the assessment. Most cases do not require surgery. However, surgical procedures have been widely developed in the last 60 years for the cases resistant to non-operative treatments. They are presented here in a logical order, from the most physiological to the most aggressive. Isthmic repair is reliable but requires very strict local conditions. Excision of the loose arch alone should no longer be practised especially in young patients. Fusions in situ are widely used, especially by the posterior approach, but owing to unfavourable biomechanical conditions, a significant amount of pseudarthrosis is reported as well as slip progression in young patients. Additional internal fixation is recommended. Associated reduction allows placement of the spine in the best mechanical conditions for a stable fusion. Several procedures have been reported, involving either single or staged approaches. Either anterior and posterior fusion associated with reduction seems to give the best results, in spite of some few cases of transitory neurological involvement. Resection of the olisthetic vertebra associated with reduction and fusion is a therapeutic alternative in very severe cases in young people. Elective indications are given at the end of the Discussion on the basis of current procedures, according to the type of lesion and the category of patient.

Congenital Hip Dislocation

In the treatment of congenital dislocation of the hip, reduction must be obtained and maintained to provide the proper stimulus for resumption of normal hip joint growth and development. Subluxation and avascular necrosis must be avoided, as degenerative joint disease is certain to occur. Acetabular dysplasia leads to degenerative joint disease with time, although no roentgenographic parameters are predictive. "Normal" hip joint anatomy may fail to develop, depending on the age of the patient at reduction and the growth potential of the acetabular cartilage. However, as normal anatomy as can be achieved should be restored at the age of maturity. This should provide the best possible mechanical environment to avoid exceeding the pressure tolerance level of the hip joint articular cartilage, thereby avoiding degenerative joint disease.

Slipped Capital Femoral Epiphysis

The traditional method of treating slipped capital femoral epiphysis by in situ pinning is being challenged. The complication of chondrolysis has been correlated with unrecognized pin penetration into the hip joint. Several studies have shown that black children may be more susceptible to developing chondrolysis. Fifty-five children (89% black) with 80 slipped epiphyses agreed to return for evaluation by the authors at an average of 3.3 years after in situ pinning. The results were classified according to clinical and roentgenographic parameters. The results were excellent or good in 56 (70%) of the 80 slips. Excellent or good results were found in 86% of mild slips, 55% of moderate, and 27% of severe. The complication of chondrolysis developed in three slips (4%) and avascular necrosis in two (3%). Poor pin position could be correlated with the complication in one of the three patients who developed chondrolysis and in both who developed avascular necrosis. Poor pin position was also associated with 12 (60%) of the 20 poor results. The majority of pin problems were secondary to technical problems associated with attempting in situ pinning from the lateral approach. In this study, black children were not more susceptible to chondrolysis than nonblack children.

Radiographic and Geometric Anatomy of the Scapula

In an effort to study anatomic parameters of the scapula that may be of clinical importance, scapulae were harvested from cadavers and stripped of their soft tissues. For each scapula, three roentgenograms then were obtained: a Y-scapular view, an axillary lateral view, and a glenoid fossa (or true anteroposterior) view. Computed tomographic pneumoarthrograms and randomly selected antero-posterior chest roentgenograms of skeletally mature adults were studied also to measure further roentgenographic parameters of the normal scapula. The geometric anatomy of the scapula is of fundamental importance in the pathomechanics of rotator cuff disease, total shoulder arthroplasty, and recurrent shoulder dislocation. This study presents in detail the exact geometry of scapula anatomy, giving precise figures for distances, angles, and radii of curvature of the scapula. All results then are discussed in terms of their clinical relevance to the above problems.

保存的に治療したペルテス病の成績 病早期におけるレ線因子の検討

We examined the correlation between roentgenographic parameters in the early stage of Perthes disease and the results at primary healing.Sixty-five patients with unilateral Perthes disease were treated conservatively.At primary healing, 8 patients showed poor results in femoral shape, and 18 showed poor results acetabular shape. Most patients who had poor femoral shape also showed poor acetabular change. Only one patient had poor femoral shape and a good acetabulum.The results tended to be worse with increasing age of patients and the larger the extent of disease involvement. We designated patients above 8 years of age at diagnosis with Catterall group 3 and 4 involvement and those between 5 and 8 years with group 4 involvement “the at-risk-group”.The only statistically significant finding from among all the roentgenographic evaluations performed at the fragmentation stage, was between the TDD difference over 3mm and “the at-risk-group”.In conclusion, patients over 8 years at diagnosis with Catterall group 3 and 4 lesions and those between 5 and 8 years with group 4 staging whose difference of TDD was above 3mm tended to have poor results.

Morphology and Biomechanics of the Hip. Study III: The Diseased Hip

The aim of this study was to define the characteristics of the diseased hip through a series of roentgenographic parameters measured on X-rays taken from a group of patients suffering from primary osteoarthritis. The arthritic hips were divided into three groups: superolateral OA, concentric OA, and medial OA. In light of the anatomo-roentgenographic characteristics this study proposes a new classification of osteoarthritis based on the direction of migration of the femoral head. Analysis of the data has highlighted the extreme polymorphism which characterizes the course and evolution of osteoarthritis and the serious modifications brought about in the hip-joint region. The clinical impression at the conclusion of this study is of a direct correlation between primary alterations of parameters of the hip and development of osteoarthritis.

Total Knee Arthroplasty at a Veterans Administration Medical Center

Total knee arthroplasty (TKA) was evaluated in 256 consecutive knees in a Veterans Administration hospital. Patient satisfaction and the effect of intercurrent illness were studied in addition to standard clinical and roentgenographic parameters. Evaluation of results show the superiority of condylar knee designs. In general, TKA was successful with a high degree of patient satisfaction.