Biomedical subjects
Publications and source records attributed to G R Rechtine.
Two cases in which cervical spine overdistraction occurred with the use of skull traction are described. A summary of the clinical presentations and definitive treatment together with some bibliographic references are discussed. Finally, suggestions regarding how to avoid overdistraction when using skull traction are given.
A total of 18 patients with grade I or II degenerative spondylolisthesis fused three levels or fewer with autogenous bone graft were entered at three clinical sites. After 2 years, these patients were found to have a fusion rate of 89%. A statistical analysis of these results compared with those in the literature showed that patients with spondylolisthesis who underwent fusion with pedicle screw instrumentation were > 3 times more likely to fuse than comparable patients implanted without a pedicle screw/plate system. The pedicle screw/plate system used in this study was shown to be an effective method of facilitating lumbar or lumbosacral fusion with autogenous bone graft for adult patients with a primary indication of grade I or II degenerative spondylolisthesis.
STUDY DESIGN: A prospective, multi-center Investigational Device Exemption Study was carried out in the United States using a pedicle screw and plate system to perform a fusion in patients with degenerative disc disease or spondylolisthesis. The patients' pain function, complications, and fusion status were evaluated and compared with literature controls. OBJECTIVES: To study the safety and efficacy of the ISF pedicle screw/plate system. This article focuses only on those study patients with degenerative disc disease treated with autogenous bone grafts and compares the results to those of similar patients treated without instrumentation, as reported in the literature. SUMMARY OF BACKGROUND DATA: Twenty-eight patients were in the subgroup studied--patients with degenerative disc disease who had fusions with autogenous bone graft. This study was conducted at four clinical sites with a 2-year follow-up. Patient follow-up was greater than 95% at all time points. METHODS: To be considered a patient with degenerative disc disease, radiographs had to demonstrate a collapse of the disc, the presence of bone erosion, or the compression of the vertebrae as the primary spinal abnormality. Spinal fusion must have been the recommended surgical treatment for discogenic pain. The fusion status was evaluated by the operating surgeon and an independent reviewer. RESULTS: After 2 years, this subset of patients (n = 28) with degenerative disc disease who had lumbar/lumbosacral fusion with autogenous bone graft was found to have a pseudarthrosis rate of 0%. Eight articles in the literature were found to be valid noninstrumented literature controls with which this subgroup could be compared. The average pseudarthrosis rate in the control group was 32%. CONCLUSIONS: A statistical analysis showed that patients with degenerative disc disease who underwent fusion without pedicle screw instrumentation were over 24 times more likely to have a pseudarthrosis than comparable patients implanted with a pedicle screw/plate system. Regarding the most important goal in performing a spinal fusion--fusion of the spine--the pedicle screw/plate system used in this study was shown to be a safe and efficacious method of facilitating fusion with autogenous bone graft for this patient population.
Between 1986 and 1992, 32 thoracolumbar fractures in 32 patients were treated nonoperatively with 4-6 weeks on a rotorest bed followed by bracing with a thoracolumbosacral orthosis for a total of 3-6 months. The fractures were classified as 20 burst, six fracture dislocations, five severe compression fractures, and one gunshot wound. There were 12 multilevel fractures. Nine patients had incomplete neurological injuries and three had complete neurological injuries. The average age was 36.8 years (range 17-63) and the average follow-up was 22.3 months (range 12-60). Fifty three percent (17/32) of these had multisystem injuries including visceral trauma and long extremity fractures. There were only two complications; a deep vein thrombosis and a heel ulcer. Neither of these complications extended the patients' hospital stay. All nine of those with incomplete neurological injuries improved at least one Frankel grade. Fifteen of 24 patients who were employed returned to their previous jobs, and only nine patients had persistent back pain requiring medication. Surgical treatment of thoracolumbar fractures is often favored over conservative treatment in the multitrauma and neurologically injured patient because of complications related to bedrest. However, by using a rotorest bed and aggressive physical therapy, conservative treatment may actually result in lower morbidity.
We analyzed the cases of seventy-three patients who were managed over a twenty-year period for rheumatoid involvement of the cervical spine and were followed for a minimum of two years, with an average follow-up of seven years. A neurological deficit did not develop in thirty-one patients (Ranawat et al. Class I) and paralysis developed in the remaining forty-two patients: Class II in eleven and Class III in thirty-one. Of the forty-two patients in whom paralysis developed, thirty-five had operative stabilization. Seven patients were managed with a soft cervical collar because they refused or were medically unable to have the operation; all of the had an increase in the severity of the paralysis. The posterior atlanto-odontoid interval and the diameter of the subaxial sagittal canal measured on the cervical radiographs demonstrated statistically significant correlations with the presence and severity of paralysis. All of the patients who had a Class-III neurological deficit had a posterior atlanto-odontoid interval or diameter of the subaxial canal that was less than fourteen millimeters. In contrast, the anterior atlanto-odontoid interval, which has traditionally been reported, did not correlate with paralysis. The prognosis for neurological recovery following the operation was not affected by the duration of the paralysis but was influenced by the severity of the paralysis at the time of the operation. The most important predictor of the potential for neurological recovery after the operation was the preoperative posterior atlanto-odontoid interval. In patients who had paralysis due to atlanto-axial subluxation, no recovery occurred if the posterior atlanto-odontoid interval was less than ten millimeters, whereas recovery of at least one neurological class always occurred when the posterior atlanto-odontoid interval was at least ten millimeters. If basilar invagination was superimposed, clinically important neurological recovery occurred only when the posterior atlanto-odontoid interval was at least thirteen millimeters. All patients who had paralysis and a posterior atlanto-odontoid interval or diameter of the subaxial canal of fourteen millimeters had complete motor recovery after the operation. In this series, although only patients who had a neurological deficit were operated on, we observed the range of the posterior atlanto-odontoid interval that was associated with poor or no recovery after the operation, and we identified the safe range on the basis of the patients in whom paralysis did not develop.(ABSTRACT TRUNCATED AT 400 WORDS)
The authors report 10 cases of spontaneous pyogenic spinal osteomyelitis encountered within a 3-year period. There were six women and four men, ranging in age from 60 to 84 years. Six cases occurred at the thoracic level, three at the lumbar level, and one in the cervical spine. No patient was diabetic, immunocompromised, or receiving steroid therapy, and none had a history of endocarditis or intravenous drug abuse. No patient had undergone previous spinal surgery. There were no instances of coexisting tuberculosis or malignancy. Contemporaneous cases with known predisposing factors have been excluded from this report; however, three patients did have a recent history of somatic infection, one with known sepsis. All 10 patients had been previously misdiagnosed, frequently by neurosurgeons and orthopedists as well as by internists and family practitioners. Three had undergone inappropriate or unnecessary surgical procedures, and two had received inappropriate radiation therapy. Seven cases were caused by Staphylococcus species. Gram-negative bacteria, or anaerobic infections. In the other three, no bacteriological diagnosis was made, secondary to prolonged antibiotic therapy before surgery. Each patient had developed symptomatic neural element compression, spinal instability, or both by the time of their referral. The patients with subcervical pyogenic spinal osteomyelitis underwent transthoracic or retroperitoneal decompression and corpectomy with simultaneous autologous bone grafting, followed by 6 weeks of bed rest and 6 weeks of intravenous broad-spectrum or organism-specific antibiotic therapy. They were then mobilized in orthoses for an additional 6 weeks. In no case were foreign implants employed or further stabilization procedures necessitated. One patient required an additional 6 weeks of antibiotics for recalcitrant Pseudomonas colonization. Despite the patients' advanced age and the extensive surgical procedures, there was no mortality and no neurological morbidity. All patients were asymptomatic or demonstrated objective improvement upon discharge from the hospital. In this subset of patients with spontaneous pyogenic vertebral osteomyelitis, the only predisposing factor was advanced age.
The correlation of posterior intervertebral (facet) joint tropism (asymmetry), degenerative facet disease, and intervertebral disc disease was reviewed in a retrospective study of magnetic resonance images of the lumbar spine from 100 patients with complaints of low back pain and sciatica. Of the 27 of 100 (27%) of patients discovered to have disc disease (either herniation of nuclear material or bulge) at the L4-5 level, an approximately equal number had facet tropism (14 of 27) as did not (13 of 27). Of the 27 of 100 (27%) patients noted to have disc disease at the L5-S1 level, slightly more (16 of 21) had facet tropism than did not (11 of 27). Of the 65 of 100 (65%) of patients who had facet degenerative disease at the L4-5 level, an approximately equal number had facet tropism (33 of 65) as did not (32 of 100). At the L5-S1 level there was slightly more of a difference, with 25 of 41 having facet degenerative joint disease and tropism and 16 of 41 without it. This study raises questions as to the significance of facet joint tropism in intervertebral disc disease and degenerative facet joint disease but did show that asymmetry of the posterior intervertebral joint is far more common than previously thought: 50% of patients were found to have asymmetric facets at the L5-S1 level and 42% at the L4-5 level.
Although computed tomography (CT) is a valuable tool for evaluating spine trauma, it's usefulness is limited. Horizontally oriented fractures of the cervical spine, particularly type 2 fractures at the base of the odontoid process, may be difficult to detect with CT. Our case report illustrates a false-positive diagnosis of this fracture and suggests that conventional polytomography is superior to CT for demonstrating this particular lesion when minimal displacement is present.
Scapular fractures, a relatively uncommon injury, most often result from major trauma. This paper categorizes the different types of scapular fractures; outlining clinical presentation, diagnosis, treatment, and complications. The importance of a good physical examination is stressed; as overlooking a soft tissue injury (i.e., pneumothorax, neurovascular tear, cerebral contusion) commonly associated with scapular fractures may be life-threatening. Scapular fractures are commonly treated nonoperatively. However, when glenohumeral joint function is impaired, surgery may be indicated after patient age, occupation, and clinical status are evaluated.
Numerous techniques and frames are available to position the patient on an operating table for elective lumbar spine surgery. We utilized the Heffington frame to position 27 patients with hips and knees flexed and abdomen free. This group was compared with those patients positioned prone during surgery. Our data indicate that average intraoperative blood loss is reduced by the use of such a frame, a finding that is attributable to maximal decompression of the abdomen. Complications related to the Heffington frame were not observed in our series of patients.
The magnetic resonance (MR) imaging findings in the cervical spines of eight patients with long-standing polyarticular rheumatoid arthritis were reviewed. Three pathologic conditions were readily demonstrated: anterior atlantoaxial subluxation (n = 6), atlantoaxial impaction (n = 6), and subaxial subluxation (n = 6). An abnormal soft-tissue signal was noted in the preodontoid space in six patients; this signal was thought to represent the associated inflammatory mass. MR imaging was useful not only for depicting the bony abnormalities in the cervical spine that are associated with rheumatoid arthritis, but also can directly show the effect of the disease process on the spinal cord and brain stem.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
In a prospective double blind study, 26 patients were evaluated for postoperative pain relief with use of epidural morphine. The variable in this study was the addition of paravertebral bupivacaine used in 14 patients. The addition of the bupivacaine did not have a statistically significant effect on lowering the analgesic requirement during the first 36 hours after surgery, the total dose of medication required during hospitalization, nor the time to the onset of supplemental pain medicine requirement. There were no problems with late respiratory depression. We conclude that the addition of paravertebral bupivacaine is not effective in decreasing the amount of pain medication that is required in lumbar laminectomy patients and adds very little to patients already receiving epidural narcotics.
Explore the source record for details and available documents.
Primary amyloidosis of bone is a rare disease process. When amyloid lesions do occur in bone, they are often associated with myeloma or other plasma cell dyscrasias. Because of its rarity and its protean clinical and radiographic picture adequate biopsy tissue for histopathologic studies is essential for accurate diagnosis. This case presents a 43-year-old man with nondescript back pain and an impressive radiographic lesion in his lower thoracic spine demonstrating the need for careful diagnostic evaluation and a high incidence of suspicion. When occurring primarily in a localized anatomic area, the prognosis for survival is excellent, and cure can be expected by local excision and reconstruction, as necessary.
Interpedicular distance, interfacet distance, midsagittal diameter, and cross-sectional area at the upper aspect of the fifth lumbar spinal canal were measured from the computed tomographic (CT) scans of the spine performed in a period of 1 year. The patients were divided into four groups. Group I (25 patients) was the normal control group. Group II comprised 29 symptomatic patients who were thought to have an L4-L5 herniated nucleus pulposus (HNP) by CT and did not undergo surgery. Group IIIA was made up of 24 patients who underwent an L4-L5 discectomy and had favorable results, and Group IIIB (3 patients) included those who failed to improve following surgery. The symptomatic patient with an L4-L5 HNP by CT who did not undergo operative treatment had a mean canal size as measured by midsagittal diameter and cross-sectional area that was smaller (P less than 0.05) than in a normal control group. In the patients who required an L4-L5 discectomy, these same measurements were smaller (P less than 0.001) when compared with the nonoperative group. In the three failure patients, all four measurements were significantly smaller than in patients in Group IIIA with the interfacet distance and the cross-sectional area differences being the greatest (P less than 0.001). The patients who are likely to undergo operative treatment have a midsagittal diameter that is less than 1.6 cm and a cross-sectional area that is less than 2.5 cm.(ABSTRACT TRUNCATED AT 250 WORDS)
Explore the source record for details and available documents.