Extreme lateral interbody fusion relieves symptoms of spinal stenosis and low-grade spondylolisthesis by indirect decompression in complex patients

Spinal stenosis and low-grade spondylolisthesis produce symptoms of neural compression that can be treated with extreme lateral lumbar interbody fusion (XLIF) via indirect decompression. This study aimed to investigate whether the restoration of disc dimensions would relieve symptoms of radiculopathy, claudication and back pain. In this retrospective study, patients undergoing XLIF surgery for relief of radicular symptoms or degenerative disc disease were included. Radiologically proven changes were used to assess the modes of degeneration. Objective measures such as the Visual Analogue Scale (VAS) for back and legs and the Oswestry Disability Index (ODI) were used. Complications were collated post-operatively from clinical notes and outpatient appointments. Twenty-three consecutive patients were included, of whom 91% had spinal stenosis. The cohort presented with multiple comorbidities and 35% of the cohort had undergone previous lumbar surgery. There was a 61% improvement of coronal Cobb angle and an 11% correction of the lordosis sustained 1 year after surgery. Clinical outcomes at 1 year showed 39%, 50% and 60% improvements in the ODI, back and leg VAS scores respectively. 48% of patients had reduced sensation related to lumbosacral plexus manipulation and one retroperitoneal haematoma was conservatively managed. Minimally invasive spinal (MIS) XLIF resulted in effective restoration of disc dimensions via indirect decompression, providing good relief of clinical symptoms evidenced by significant improvement in clinical outcome scores. XLIF corrected scoliosis and improved lumbar lordosis significantly. Several plexopathies did not hinder long-term recovery. XLIF is highly suited to treating complex patients with multiple comorbidities and degenerative disease.     

Do columns or sagittal displacement matter in the assessment and management of Lisfranc fracture dislocation? An alternate approach to classification of the Lisfranc injury

AimThe classification of a Lisfranc injury has conventionally been based around Myerson's system. The aims of this study were to review whether a novel classification system based on sagittal displacement of the tarsometatarsal joint and breadth of injury as determined by a columnar theory was associated with functional outcomes and thus had a greater utility.PatientsWe retrospectively reviewed 54 Lisfranc injuries with a minimum follow up of two years at our Level One Trauma Centre. Each fracture was sub-classified based on our novel classification system which assessed for evidence of sagittal displacement and involvement of columns of the midfoot. Our primary outcome measures were the FFI and AOFAS midfoot scores.ResultsInjuries involving all three of the columns of the midfoot were associated with significantly worse functional outcome scores (FFI p = 0.004, AOFAS p = 0.036). Conversely, sagittal displacement, whether dorsal or plantar, had no significance (FFI p = 0.147, AOFAS p = 0.312). The best predictor of outcome was the quality of anatomical reduction (FFI p = 0.008, AOFAS p = 0.02).ConclusionColumn involvement and not sagittal displacement is the most significant factor in considering the severity Lisfranc injury and long term functional outcomes. This classification system has greater clinical utility than those currently proposed.     

Roussouly’s sagittal spino-pelvic morphotypes as determinants of gait in asymptomatic adult subjects

Sagittal alignment is known to greatly vary between asymptomatic adult subjects; however, there are no studies on the possible effect of these differences on gait. The aim of this study is to investigate whether asymptomatic adults with different Roussouly sagittal alignment morphotypes walk differently. Ninety-one asymptomatic young adults (46 M & 45 W), aged 21.6 ± 2.2 years underwent 3D gait analysis and full body biplanar X-rays with three-dimensional (3D) reconstructions of their spines and pelvises and generation of sagittal alignment parameters. Subjects were divided according to Roussouly’s sagittal alignment classification. Sagittal alignment and kinematic parameters were compared between Roussouly types. 17 subjects were classified as type 2, 47 as type 3, 26 as type 4 but only 1 as type 1. Type 2 subjects had significantly more mean pelvic retroversion (less mean pelvic tilt) during gait compared to type 3 and 4 subjects (type 2: 8.2°; type 3:11.2°, type 4: 11.3°) and significantly larger ROM pelvic obliquity compared to type 4 subjects (type 2: 11.0°; type 4: 9.1°). Type 2 subjects also had significantly larger maximal hip extension during stance compared to subjects of types 3 and 4 (type 2: −11.9°; type 3: −8.8°; type 4: −7.9°) and a larger ROM of ankle plantar/dorsiflexion compared to type 4 subjects (type 2: 31.1°; type 4: 27.9°). Subjects with type 2 sagittal alignment were shown to have a gait pattern involving both increased hip extension and pelvic retroversion which could predispose to posterior femoroacetabular impingement and consequently osteoarthritis.     

Life-threatening endocrine emergencies during pregnancy – management and therapeutic features

Endocrine emergencies during pregnancy may be life-threatening events for both mother and fetus. Besides pregnancy-associated endocrine disorders, several pre-existing endocrinopathies such as type-1 diabetes and Grave’s disease or adrenal failure may acutely deteriorate during pregnancy. Since “classical” signs are often modified by pregnancy, early diagnosis and management may be hampered. In addition, laboratory tests show altered physiologic ranges and pharmacologic options are limited while therapeutic goals are mostly tighter than in the non-pregnant patient. Though subclinical endocrinopathies are more frequent and worth consideration due to their related adverse sequelae, this article focuses on endocrine emergencies complicating pregnancy.     

Utilization of bone impedance for age estimation in postmortem cases

In the field of Forensic Medicine the number of unidentified cadavers has increased due to natural disasters and international terrorism. The age estimation is very important for identification of the victims. The degree of sagittal closure is one of such age estimation methods. However it is not widely accepted as a reliable method for age estimation.In this study, we have examined whether measuring impedance value (z-values) of the sagittal suture of the skull is related to the age in men and women and discussed the possibility to use bone impedance for age estimation.Bone impedance values increased with aging and decreased after the age of 64.5.Then we compared age estimation through the conventional visual method and the proposed bone impedance measurement technique. It is suggested that the bone impedance measuring technique may be of value to forensic science as a method of age estimation.     

Dropped head syndrome after cervical laminoplasty: A case control study

Dropped head syndrome (DHS) is characterized by apparent neck extensor muscle weakness and difficulty extending the neck to raise the head against gravity. The aim of the present study was to elucidate possible risk factors for DHS after cervical laminoplasty. Five patients who developed DHS after cervical laminoplasty (DHS group) and twenty age-matched patients who underwent laminoplasty without DHS after surgery (control group) were compared. The surgical procedure was single-door laminoplasty with strut grafting using resected spinous processes or hydroxyapatite spacers from C3 to C6 or C7. Analyses of preoperative images including the C2–C7 angle, C7–T1 kyphosis, T1 tilt, center of gravity line from the head–C7 sagittal vertical axis (CGH–C7 SVA) were performed on lateral plain cervical spine radiographs. Preoperative T2-weighted MRI at the C5 vertebral level was used to measure the cross-sectional area of the deep extensor muscles. Widths of the lateral gutters were assessed postoperatively using CT scans of the C5 vertebral body. The average preoperative C2–C7 angle was significantly smaller in the DHS group compared with the control group. The average preoperative C7–T1 angle was significantly larger in the DHS group compared with the control group. The average preoperative CGH–C7 SVA was significantly larger in the DHS group compared with the control group. In conclusion, patients with more pronounced preoperative C2–C7 kyphosis, C7–T1 kyphosis, and CGH–C7 SVA are more likely to develop DHS following laminoplasty.     

Sulfur mustard causes oxidants/antioxidants imbalance through the overexpression of free radical producing-related genes in human mustard lungs

The aim of this study is to analyze oxidative stress (OS) and changes in expression of reactive oxygen species (ROS) producing-related genes in mustard lungs. Human lung biopsies provided from controls (n = 5) and sulfur mustard (SM)-exposed patients (n = 6). Changes in expression of dual oxidases (DUOXs), aldehyde oxidase 1 (AOX1), thyroid peroxidase (TPO), myeloperoxidase (MPO) and eosinophil Peroxidase (EPO) were measured using RT² Profiler™ PCR Array. OS was evaluated by determining bronchoalveolar lavage fluids (BALF) levels of total antioxidant capacity (TAC) and malondialdehyde (MDA). Higher TAC value was observed in BALF of controls compared with patients (0.138 ± 0.02683 μmol/l vs 0.0942 ± 0.01793 μmol/l), whereas a significant increase in MDA concentration was found in patients (0.486 ± 0.04615 nmol/l vs 0.6467 ± 0.05922 nmol/l). All ROS producing-related genes were overexpressed in the order AOX1> MPO> DUOX2> DUOX1> TPO> EPO. Upregulation of these genes may be a reason for overproduction of ROS, oxidants/antioxidants imbalance, OS and respiratory failures in mustard lungs.