3D CT imaging of the lumbo-sacral spine after surgical treatment of L5-S1 spondylolisthesis by postero-lateral spondylodesis

Background. The aim of the study is the evaluation of the spatial imaging computed tomography (3D CT) of lumbo-sacral spine after surgically treated spondylolistesis L5-S1 with the postero-lateral spondylodesis using autogenic bone grafts.
Material and methods. Material comprises 9 patients treated surgically due to I degrees spondylolistesis caused by the L5 vertebra spondylolysis. In all cases postero-lateral spondylodesis was performed using autogenic bone grafts, taken from the iliac crest, placed on the transverse processes of the L5 vertebra and the sacral bone. The CT examination was performed in the period between 6 months up to 2 years after operation due to overloading lumbar pain.
Results. The bone grafts was localized correctly in 8 patients. In 1 person the upper side of the one bone graft was localized incorrectly, on the prominent transverse processus of the S1 vertebra, instead of the L5 one. The spatial reconstruction reveal the presence of osteophytes surrounding the ends of the bone grafts or the localization the fissure of the arch. In 2 cases the bone grafts were bigger on the left side, and the wide lower ends were connected with the dorsal surface of the sacral bone and were connected with the shorten due to surgery iliac crest
Conclusions. The CT examination with the use of the spatial option is very valuable in the lumbo-sacral spine imaging in patients treated with the postero-lateral spondylodesis due to spondylolisthesis L5-S1. The spatial images 3D CT are especially useful in imaging of the localization of the bone grafts, assessment of the wide of spinal canal and intervertebral foramens. The use of spatial imaging 3D is valuable supplement of standard CT examination in diagnosis of the patients complaining of the lumbar pain, treated surgically due to spondylolistesis.     

Results and observations on the research of circulating immunocomplexes in subjects with suspected autoimmune pathology

The authors have investigated the level of circulating immune complexes (CIC) in 409 patients (some hospitalized) suffering from disease in which the presence of CIC had been suspected. The 10% (forty-one) was positive, and clinical manifestations related have shown, in the majority of patients, a close relation with diseases in which there was, or it was possible to presume, an immunological pathogenic mechanism. Besides the authors examine a case with close association between high level of CIC and leptospirosis.     

Computed tomography diagnostic of the intervertebral disc degeneration and degenerative changes of the lumbo-sacral spine

Background. The aim of the work is problem of computed tomography diagnostic of the intervertebral disc degeneration and degenerative changes of the lumbo-sacral spine.
Authors present result of computed tomography examinations performed in 60 patients at the age from 18 to 69 years, suffering from chronic low back pain for 6 months at least.
Material and methods. Degenerative changes of the vertebra-disc junction on the levels of L3-L4, L4-L5 and L5-S1 were evaluated. The analysis of intervertebral disc changes and osteophytes presence on all of the investigated levels was chose as the assessment criterion.
Results. The pathological changes of the vertebra-disc junction on L5-S1, L4-L5 and L3-L4 levels were stated in 58 (96.6%), 55 (91.6%) and 47 (78.8%) patients, whereas the degeneration of the intervertebral disc was diagnosed in 50, 45 and 15 cases, respectively. Moreover, the vacuum phenomenon was present in connection with the degeneration of the intervertebral disc on L5-S1, L5-L4, L3-L4 levels in 29, 11 and 1 cases, respectively. The osteophytes' presence, as a single proof of the degenerative changes was diagnosed in 8 patients on L5-S1 level, whereas on L4-L5 level in 10 patients. In 32 cases osteophytes were localised on L3-L4 level.
Conclusions. In conclusion, the differences in morphology of the pathological changes are the result of different loading and various mechanisms generating these changes on particular levels.     

Circulating immune complexes in sarcoidosis

Circulating immune complexes (CIC) were detected in 100 out of 112 sera from 33 sarcoidosis patients. Five tests were used representing three different basic principles. All patients had detectable CIC at some stage of their disease. The three platelet tests detecting IgG complexes exhibited the highest positive titres in the acute cases. The ClqB-ELISA test, which detects complement fixing IgG complexes, was the test most frequently positive in the chronic cases. The presence of extra-pulmonary lesions or corticosteroid therapy did not influence the appearance or disappearance of CIC. No positive correlation was found between CIC and elevated levels of serum angiotensin-converting enzyme (ACE) and/or serum lysozyme (LZM). The evaluation of CIC in sarcoidosis requires a battery of different tests carried out at regular intervals during the follow up.     

Morphine or bupivacaine in controlling postoperative pain in patients subjected to knee joint arthroscopy

Background. We investigated the efficacy of intra - articular bupivacaine with morphine administration after knee joint arthroscopy.
Material and methods. The present study compared intra- arthicular bupivacaine with intra-arthricular morphine for postoperative analgesia in 56 patients (21 women, 35 men) (age 20-70, mean 39.8) undergoing knee joint arthroscopy.
Intraoperatively, the patients received anaesthesia spinaly (0.5 % Marcaine spinal ASTRA) and immediately following surgery received 10 ml intra-arthricular injection consisting either of 0.5 % bupivacaine (group I), 5 mg morphine + 0.9 % saline (group II).Postoperative analgesia was supporeted by intravenous doses of proefferalgan.
In all patients the visual analogue pain score (VAS), PaO2, systolic blood preassure (SABP), diastolic blood preassure (DABP), heart rate (HR), respiratory rate (f), supplemented analgesia and possible side effects were monitored postoperatively.
Results. Intra-arthricular administration of each solution was well toleratede and non side effects were noted.
There was non significant difference among the two groups in monitored parameters. The mean time of postoperative analgesia was 185,7 +/- 25.3 min for bupivacaine group and 390.3 +/- 35,4 min for morphine group.
Total amount proefferalgan supplamentation was the highest in group I.
Conclusions. Postoperative intra- arthricular injections of bupivacaine and morphine for patients undergoing knee joint arthroscopy can provide a safe and effective analgesia and therefore shound be recommended and widely implamented into the clinical use as a standard procedure.     

Clinical and radiographic evaluation of mechanical sufficiency of the operative treatment of pathological fractures in bone metastases

Background. Aims: Retrospective evaluation of mechanical sufficiency of applied surgical methods of bone metastases treatment according to authors' own scoring system.
Material and methods. 60 patients with bone metastases treated operatively in our Ward during 1989-2002. Mean age of patients was 62,5 years old. There were 39 women and 21 men. In 48 cases (80%) there were possible to diagnose primary localization of the tumor. We could not reveal primary focus of the tumor in 10 cases (20%). Localizations of bone metastases are as follow: femur - 49 cases, humerus - 10 cases, tibia - 1 case.
After local excision of metastatic tumor had been done the internal osteosynthesis and bone cement application was made in 45 cases, the internal osteosynthesis only was made in 7 cases, hip arthroplasty was made in 8 cases. Mean time of follow-up since surgical procedure was 8 months. Scoring system for radiographic and clinical evaluation of mechanical efficacy of operative fixation of pathologic fractures: grade I - good mechanical fixation, grade II - minimal loss of fixation, grade III - poor mechanical fixation, grade IV - relapse of pathological fracture.
Results. We had poor results in 5%, because of the death of 3 patients. In 58 cases (97%) we had very good or good results - no pain, good function and independence in daily activities (grade I and II in scoring system of mechanical efficacy of pathologic fracture fixation). In remaining 2 patients (3%) there was loss of mechanically stabile fixation of pathological fracture.
Conclusions. 1. Mechanical efficacy of the fixation of pathological fractures is good and lasting in 97% of cases. 2. Local complications rate was 2% and was due to mechanical unstabile fixation of pathological fracture.     

Low temperatures in post-operative knee rehabilitation in rheumatoid arthritis patients

Low temperatures were applied (in addition to kinesitherapy), in the form of injected air cooled to -75 C and CO2, to 22 patients (34 knees) recovering from total knee alloplasty or synovectomy. Each procedure lasted 5-7 minutes. The control group consisted o 22 patients (34 knees) treated with kinesitherapy only.
The range of active and passive flexion and extension in the operated knee joint was tested twice, once before the experiment began and once after the third week. During this period the subjective feeling of pain was also observed.
The results were analyzed statistically using the t-Student test. Upon comparison of the results obtained by patients from both tested groups, it can be stated that the addition of low temperatures to the program of post-operative rehabilitation of the knee enables:
- faster and more effective pain relief;
- faster increase in the range of movement, especially flexion, in the operated knees.
These results justify the conclusion that this method should be recommended in rehabilitation of the knee after surgery.     

Value of diagnostic methods in diagnosis of the disc disease

Background. Injury of the intravertebral disc after precise clinical evaluation should be confirmed by different radiographic methods. Although diagnostic methods have recently progressed, there are still problems with proper diagnosis concerning the level of pain provocation.
The aim of this study was a comparison of clinical signs of disc prolapse with different radiographic methods and intraoperative findings.
Material and methods. 180 histories of patient treated in the Orthopaedic Clinic of Medical Centre for Postgraduate Education between 1994-2002 were analysed. The most frequent was Lasegue's sign and spine movement limitation. All patients underwent lumbar spine x-ray in order to eliminate bone pathologies of vertebrae. Before making - of operative treatment a decision of magnetic resonance imaging or computer topography were always done. Radiculography was performed only in cases of multilevel disc hernitation and when clinical signs were not obvious.
Conclusions.
1.Clinical examination and first of all different intensity of pain (over 4 degrees in VAS scale) and radiographic imaging were followed by MRI or CT in order to confirm the diagnosis.
2.CT allowed to precise a diagnosis in the case of diagnostic uncertainty among patients with long history of back pain.
3.Compatibility of x-ray (narrowing of vertebral space) with intraoperative findings was 80%. Compatibility of MRI was 96%, and computer tomography 94%.
     

The impact of bisphosphonate therapy on the survival time of patients undergoing radiotherapy for bone metastases

Background. Bisphosphonates are form of medical therapy for bone metastases. Morbidity from bone metastases including hypercalcemia episodes, pain, pathological fractures and appearance of new metastases in skeletal system is decreased by bisphosphonate therapy. The aim of this article is to determine the influence of bisphosphonate therapy on survival time of patients irradiated due to bone metastases.
Material and methods. 305 patients irradiated due to bone metastases were assessed in this retrospective study. 94 of them were additional treated by bisphosphonates. Median survival time counted from the end of radiotherapy to the death of patients was assessed. Using U Mann Whitney test the influence of bisphosphonates therapy on survival time was determined. The significance level of p = 0,05 was accepted.
Results. The median survival time of patients irradiated due to bone metastases and treated by bisphosphonates was 8,1 month and 5,24 month in the group treated only by radiotherapy. Median survival time of pts with breast cancer and with unknown primary site of cancer who were treated by radiotherapy and bisphosphonates was significantly longer (respectively p = 0,001 and p = 0,016) as compared with the group with irradiated bone metastases only.
Conclusions. 1. Bisphosphonates therapy improved the median survival time in the whole group of patients irradiated due to bone metastases. 2. Statisticaly significant prolonged survival time was observed in groups of patients with breast cancer and with unknown primary site of cancer. Median survival time was prolonged in these groups about 5 months and 3,5 months respectively.     

The effect of specific transfusion therapy on the level of circulating immune complexes in hemophilia patients]

The level of circulating immune complexes (CIC) was measured in 108 hemophilic patients registered at the Republican Center for Hemophilia Treatment. High levels of CIC were detected in hemophilic patients of different age. The concentrations of CIC were higher in adult patients than in children. Formation of immune complexes in the test groups did not go beyond the framework of the physiological process, for the signs of vasculitis, which is an indispensable component of immunocomplex pathology, could not be identified. Higher levels of CIC in adults were related to a greater number of transfusions made throughout the life, particularly if the annual dose of the preparations infused exceeded 10,000 Units of factor VIII or IX. No significant correlation was established between the rise of CIC levels in the patients' serum and the biochemical alterations in liver function, detected in these patients. Therefore, CIC detected by the authors are not specific and lesions of the liver parenchyma in hemophilic patients are not determined by their presence.     

Hydrogel dressings in the treatment of wounds with skin defect complications

Background. The purpose of the present study was to compare the performance of the Hydrogel dressing with that of traditional dressings in the treatment of wounds with skin defects.
Material and methods. 32 patients with traumatic skin defects were included in the study. 16 were treated with Hydrogel dressings, and 16 with traditional dressings. We compared the time required for complete epithelialization and the level of pain experienced on removal.
Results. The trial dressing demonstrated faster healing time (ave. 5-6 days faster). The patients from the experimental group experienced less during dressing changes.
Conclusions. We found that dressings demonstrated significantly faster epithelialization time in comparison with traditional wound dressings. The application of Hydrogel dressings enhanced patient comfort.     

Percutaneous vertebroplasty with methyl methacrylate bone cement in the treatment of spinal angiomas and neoplasms

Background. The authors report their own experience with percutaneous vertebroplasty. Percutaneous vertebroplasty is a technique which allows to inject acrylic surgical cement into the vertebral body. This is minimally invasive method indicated in treatment of certain spinal lesions affecting the vertebral bodies, as osteoporotic fractures, angiomas and focal neoplasms.
Material and methods. Since October 1999 the authors treated 7 patients with angiomas of the vertebral bodies and 11 patients with spinal neoplasms. Cement injections were realized under local anesthesia.
Results. In group of 7 cases with spinal metastases 3 patients declared important pain relief. All 7 patients with spinal angiomas declared no pain in follow-up.
Conclusions. Percutaneous vertebroplasty is well-tolerated by patients. Filling by cement is efficace in treatment of vertebral angiomas. Filling of spinal neoplasmatic lesions result in palliative pain relief.     

The informativeness of determining circulating immune complexes and immunoglobulins during immunization]

The authors suggest using measurements of the concentrations of circulating immune complexes (CIC) by the PEG precipitation method and of immunoglobulins by radial immunodiffusion technique for monitoring the patients after immunization with rhesus antigen (n = 20), with staphylococcal antitoxin (n = 59), and after renal allograft transplantation (n = 18). The results evidence that CIC level measurements by the PEG precipitation method are valuable in the monitoring of rhesus-immunized patients. The authors suggest including such measurements in the complex of tests for examination of rhesus-immunized donors.     

MRI of the intervertebral disc in lumbar disc disease

Background. MRI of the intervertebral disc in discopathy of the lumbar spine have been presented.
Material and methods. a group of 51 patients clinically diagnosed as discopathy of the lumbar spine were subjected to three MR imaging procedures. Imaging was performed before surgery, 6 weeks after surgery, and 12 weeks after surgery.
Results. The MRI was consistent with the surgery findings in 88.2% of cases. Instead, images taken 6 weeks after surgery were non-characteristic and difficult to differentiate. In the spinal canal tissue was visible with the image similar to nucleus pulposus herniation, granulation from a growing haematoma, or after surgery scar. Twelve weeks after surgery, the MR image is characteristic and correlated with the patient's clinical state.
Conclusions.
1. MRI image allows an evaluation of intervertebral disc healing after discectomy.
2.MRI 12 weeks post-surgery correlates with patient's clinical symptoms.
3.MRI with Gd-DTPA contrast enhanced allows a precise analysis of the causes of unsatisfactory results of operative treatment.
     

Immunoglobulin isotypes in the circulating immune complexes of diabetic rats with and without proteinuria: a chronological study

Circulating immune complexes (CIC) have been postulated to contribute to the development of the secondary complications of diabetes mellitus. Therefore studies were performed to determine whether CIC are the cause of the consequence of the development of diabetic nephropathy. This was done by comparing the occurrence and concentration of CIC containing the different isotypes of immunoglobulins in control rats to those detected in streptozotocin-induced (Sz) diabetic rats that developed albuminuria (Group I) and that did not develop albuminuria (Group II). Only CIC containing IgM, IgG2b and IgG2c were detected in diabetic rats. By staging Group I albuminuric diabetic rats to a clinical reference point of albuminuria, there was no correlation between the occurrence or concentration of CIC containing any isotype of immunoglobulin and the onset of albuminuria. In all Group I albuminuric diabetic rats, the occurrences of all CIC were variable and their concentrations fluctuated during the development and early progression of nephropathy. However, after this group of diabetic rats progressed to overt nephropathy (marked by albuminuria and IgG proteinuria), CIC could be demonstrated in 100% of the animals. In diabetic rats that did not develop albuminuria (Group II), CIC containing IgG2b occurred earlier and more often than in Group I albuminuric rats. Similarly, the subclass IgG2c was detected in the CIC of Group II non-albuminuric rats more frequently and in higher concentrations than in Group I albuminuric rats. CIC containing IgM were detected in all 3 animal groups, however, in higher concentrations and occurrences in Group II non-albuminuric rats as compared to control and Group I albuminuric rats. The consistent elevation in CIC after the development of diabetic nephropathy, suggests that the CIC containing any immunoglobulin isotype either result from diabetic kidney, or from other deteriorating conditions associated with the diabetic state. The data also suggests that CIC are not involved in the onset or progression of diabetic nephropathy regardless of the isotypes of immunoglobulins contained within the CIC. However, there is an isotypic restriction in the immunoglobulins detected in the CIC of diabetic rats (IgM, IgG2b and IgG2c) that may signal some involvement of the immune system in the development of diabetic nephropathy.     

The evaluation of life quality after HBI performed due to multiple skeletal dissemination

Background. The aim of the study was an evaluation of life quality after HBI performed due to multiple skeletal dissemination.
Material and methods. Material consisted of 25 patients. 8 of them had one dose UHBI (6 Gy) and 17 LHBI (8 Gy). Patients underwent examination 2 weeks after irradiation and next once a month up to 6 months. The pain level, analgetics intake, quality of life (QL) and performance status (PS) were assessed.
Results. The improvement of QL, PS and decrease of pain level during equal analgetics intake were found. The best results concerned to prostate cancer. 92% patients had pain relief after treatment.
Conclusion. Obtained results allow to form conclusion that HBI is easy and efficient method of palliative radiotherapy for patient with multiple skeletal dissemination.     

Elevated serum immune complex levels in Pogosta disease, an acute alphavirus infection with rash and arthritis

Circulating immune complexes (CIC) were studied in Pogosta disease, an acute alphavirus infection with fever, rash and arthritis. The disease is caused by a virus antigenically closely related to Sindbis virus. 75 serum specimens from 25 patients with serologically verified infection were obtained from 1-87 days after the onset. Six different CIC detection methods were used and CICs were observed in all patients at least with one test. Tests based on CIC binding onto human platelets followed the natural course of the disease and maximal values were observed between 10-15 days after onset. Slightly elevated levels were observed 2-3 months after onset. The mean conglutinin binding test values were slightly elevated during the whole follow-up period. The severity of arthritis did not directly correlate to CIC levels. C3c and C1q-binding test were positive only in a few cases. Latex and enzyme immunoassay tests for rheumatoid factors gave low positive values in some of the sera. Agarose gel electrophoresis of serum proteins revealed non-specific changes in alpha 1-alpha 2 interzone characteristic of an acute infectious disease. The presence of CIC in the sera of patients with Pogosta disease may indicate body's natural clearange mechanisms of viral antigens. CIC may have a pathogenic role in the prolonged arthritis, even though no direct correlation with CIC levels and severity of arthritis was observed.     

Indications and range of surgery in the treatment of spine metastatic tumours

Background. Spine is the most common place of metastatic tumors in the skeletal system. Due to diagnostic problems and the risk of quickly increasing neurological defects, the treatment of metastatic spine tumors is a significant clinical problem. The goal of surgical treatment is decreasing pain, neurological improvement and achieving full spinal stability.
Material and methods. Material consists of 31 patients with metastases in spine, who underwent spine surgery. Tumors were placed in thoracic spine at 48% patients, at lumbar spine - 42% patients, and at cervical spine in 10% patients; one level was involved in 56% cases, two or more levels - in 44 % cases. Qualification for surgery contained: the type of primary tumor, the amount of metastases to the spine impairment of spinal biomechanics and overall patient's condition of the. Corporectomy with anterior stabilization (intervertebral cage) was performed at 13 patients, and with additional anterior implants at 2 cases. At 8 patients, with destabilization of posterior spinal column, in spite of corporectomy, posterior stabilization was done. Surgery from posterior approach was performed in 3 cases.
Results. After operation, we noted pain relief at 34% of patients, while in 14% of them transient increase of pain occurred. Neurological status worsened after surgery at 1 patient. We achieved proper spine stabilization, without the need of use of external orthoses at 30 patients. At one patients, reoperation with change of implants and the range of stabilization was necessary. The amount of complications correlated with patient's general condition at the time of surgery.
Conclusions. 1. The main condition of success in operative treatment of spinal metastatic tumors is individual patient's qualification for surgery, including the extent of disease and general patient's condition. 2. Good stabilization with use of implants is a necessary element of surgery of spinal metastases from both anterior and posterior approach.     

Results of conservative treatment of "pilon" fractures

Material and methods. From 1996 to 2002 30 cases of distal tibia epiphysis fractures (pilon fractures), including 4 cases of open fractures, were treated by conservative technique. According to the Rüedi-Allg?wer AO classification, there were 13 patients with type I fractures, 9 type II and 8 type III fractures. Follow up examinations were performed from 4 moths to 4 years.
Results. Long-term results (mean 3 years) have been assessed in 8 cases as good, 12 as fair and 10 as bad. In 23 cases osteoarthritis of talotibiae joint has been found. In 16 cases there were deviations of bone axis (15 degree of varus). The range of movement of the joint was limited in all patients. In 18 cases there was no dorsiflexion. In one case shortening of the treated leg 2 cm has occured.
Conclusions. The conservative treatment is effective for pilon fractures type I and II. The majority of bad results was found in type III due to the severe destruction of the articular surfaces. In that cases we recommend treatment by external fixation with corrections of deformation.     

Strontium-89 in palliative treatement of painfull bone metastases

Background. Bone metastases are observed in 30-70% of patients with cancer. Pain is most frequent symptom that requires regular control and treatment. Systemic palliative radionuclide therapy using beta-emitters is alternative method for analgetic drugs and external beam radiotherapy. The aim of the study was to establish efficacy and risk of side effects of radionuclide treatment in patients with painful osseous metastases.
Material and methods. Sr-89 therapy was performed in 33 patients 13 women and 13 men aged 42 to 79 years (mean 61) with cancer and bone metastases confirmed in MDP-Tc99m whole body scan. Prostate cancer was primary tumour in 18 patients, breast cancer in 12, urinary bladder cancer in 2 and renal cancer in 1 patient.
After intravenous administration of 150 MBq of strontium-89 chloride patients were observed during
3 months and more. Changes in blood counts, intensity of pain, drugs intake, life activity and duration of pain relief was evaluated from 0 to 3 points. Overall Response Index was very good if total points amounted 10-12, good - 7-9, satisfying - 4-6, poor - 2-3 and no response 0-1 points. Myelosuppression was evaluated according to Common Toxicity Criteria by WHO.
Results. Very good response in 6 patients (18%), good in 15 (46%), satisfying in 6 (18%), poor in 2 (6%) and no response in 4 (12%) patients. Transient haemotoxicity post Sr-89 therapy was observed in 16 patients (48%), in 11 patients it was grade I CTC, in 1 grade II CTC, in 3 grade 3 CTC and in one man grade IV which required treatment. Duration of life after therapy was between 21 to 138 weeks (mean 58 weeks). Therapy was repeated in 16 (48%) patients after more than 3 months. Third dose was injected in 2 patients (6%).
Conclusions. Palliative strontium-89 treatment of painful osseous metastases is effective therapy with very mild haemotoxicity.