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Biomedical subjects

J Stulík

Publications and source records attributed to J Stulík.

At least 19 recordsLinked to original sources

PubMed2006

[Injury to major blood vessels in anterior thoracic and lumbar spinal surgery].

PURPOSE OF THE STUDY: The anterior approach to the thoracic and lumbar spine is used with increasing frequency for various indications. With the advent of prosthetic intervertebral disc replacement, its use has become even more frequent and has often been associated with serious complications. The aim of this study was to evaluate vascular complications in patients who underwent anterior spinal surgery of the thoracic and lumbar spine. MATERIAL: We performed a total of 531 operations of the thoracolumbar spine from the anterior approach. In 12 cases, after exposure of the body of the first or second thoracic vertebrae, we employed the Smith-Robinson technique to expose the cervical spine. We used sternotomy in six, posterolateral thoracotomy in 209, the pararectal retroperitoneal approach in 239, anterolateral lumbotomy in 58 and the transperitoneal approach in seven patients. The aim of surgery was somatectomy in 190 patients and discectomy in 341 patients. Sternotomy and transperitoneal approaches were carried out by a thoracic or vascular surgeon and all the other procedures were done by the first author. The indications for spinal surgery included an accident in 171, tumor in 56, spondylodiscitis in 43 and a degenerative disease in 261 patients. METHODS: All patients indicated for anterior spinal surgery were examined by conventional radiography in two projections, and this was completed by CT sagittal and frontal reconstructions of the affected region. Most patients also underwent MR imaging. The Smith-Robinson approach was used for exposure of T1 or T2. Sternotomy was indicated for treatment of T2-T4 and also T1 in the patients with a short, thick neck. Access to T3-L1 was gained by posterolateral thoracotomy, in most cases performed as a minimally invasive transpleural procedure. For access to the lumbar spine we usually used the retropleural approach from a pararectal incision or lumbotomy. We preferred the pararectal retroperitoneal approach in L2-S1 degenerative disease, L5 fractures, and L5-S1 spondylodiscitis. We carried out lumbotomy in patients with trauma, tumors and L1-L4 spondylodiscitis. The transperitoneal approach from lower middle laparotomy was used only in tumors at L5 or L4. For treatment of trauma and degenerative disease of the lumbar spine we preferred less invasive procedures, and for tumors and spondylodiscitis we used more extensive exposure because of the difficult terrain. The patients were followed up for 2 to 96 months (average, 31.4 months) after anterior spinal surgery. RESULTS: In 12 patients treated by the Smith-Robinson procedure and in six patients undergoing sternotomy, neither early nor late signs of any injury to major blood vessels or internal organs were recorded. The 209 patients with posterolateral thoracotomy were also free from any signs of vascular injury, but trauma to the thoracic duct was recorded in one case. We found injury to major blood vessels in three patients in the group treated by the pararectal retroperitoneal procedure. In the total of 531 anterior spinal surgery procedures this accounts for 0.56 %; of the 304 lumbar operations and 239 pararectal retroperitoneal operations it is 0.99 % and 1.26 %, respectively. In one patient the vascular injury was associated with trauma to the ureter. DISCUSSION: In our group of 531 patients we found a higher risk of vascular injury when the L4-L5 segment was treated, when less invasive surgery was used or when spinal anatomy was altered due to tumor or spondylodiscitis. All the complications were recorded in the first 250 patients. It should be emphasized that, because in five patients, the planned anterior spondylodesis would have been associated with high risk due to altered anatomy of the bifurcation of the aorta, these patients were treated by dorsal instrumented spondylodesis. We also avoided the anterior approach for revision spinal surgery and used the posterior approach instead. Vascular complications were treated in cooperation with a vascular or cardiac surgeon. In the most serious case, if a sophisticated cardiosurgical technique had not been immediately available, the patient would probably have died. CONCLUSIONS: The technique of anterior approach is safe only in the hands of experienced spinal surgeons with long experience. In institutions where anterior spinal surgery is not a routine method it is advisable to involve a vascular or cardiac surgeon. However, the most important point is to know when not to operate.

Adolescent↗

PubMed2006

[Spinal injuries in children and adolescents].

PURPOSE OF THE STUDY: Spinal injuries in children are rare and account for a low proportion of all childhood injuries. Due to anatomical and biomechanical properties of the growing spine, there are great differences between spinal injury in childhood and adulthood. Because of higher mobility and elasticity of the spine and a lower body mass in children, spinal injuries are not frequent and represent only 2 to 5 % of all spinal injuries. In this retrospective study, the effectiveness of conservative and surgical treatment of injured spines in children is evaluated in a 10-year period. MATERIAL: All patients from birth to the completed 18th year of age treated in our departments between 1996 and 2005 were included in this study. The patients, evaluated in three age categories (0-9, 10-14, 15-18), were allocated to two groups according to the method of treatment used (conservative or surgical). The information on patients treated conservatively was drawn from medical records; the surgically treated patients were invited for a check-up. METHODS: We used conservative treatment in patients with stable spinal injury who had no neurological deficit and in patients with neurological deficit but without apparent injury to the skeleton. Surgery was indicated in patients with unstable spinal injury and in those with neurological deficit and apparent injury to the skeletal structures. Injuries to the cervical spine were treated conservatively using a Philadelphia collar or a halo-vest in more serious cases. For treatment of injury to the thoracolumbar spine, the Magnuson method was preferred, together with rest in bed until subsidence of acute pain, followed by application of a vest and active rehabilitation to strengthen postural muscles. When surgery was used, the procedure was selected on a strictly individual basis in patients under 12; in older patients it was carried out according to the adult treatment protocol. RESULTS: During 1996 through 2005, we treated a total of 15 646 patients with injury to the skeleton, aged 0 to 18 years. The spine was affected in 571 cases, which is 3.6 %. We used conservative treatment in 528 (92.5 %) and surgery in 43 (7.5 %) children. The period between surgery and evaluation ranged from 6 to 120 months (average, 46.3 months) in the patients treated conservatively, and from 6 to 66 months (average, 27 months) in the surgically treated patients. The group of patients treated conservatively consisted of 292 boys (55. 3 %) and 236 girls (44.7 %); of these 219 (41.5 %) were in the 0-9 year category, 251 (47.5 %) were between 10 and 14 years and 58 (11 %) were 15 to 18 years old. The average age in this group was 10.2 years. The most frequent cause of injury was a fall (277; 52.2 %), then sports activity or games (86; 16.3 %), car accidents (34; 6.4 %) and diving accidents (30; 5.7 %). Pedestrians were injured on 25 occasions (4.7 %) and other causes of injury were recorded in 76 patients (14.4 %). In all age categories, injury to the thoracic spine was most frequent (340; 64.4 %). Three and more vertebrae were injured (multi-segment injury) in 124 patients (23.5 %). The thoracolumbar spine was affected in 22 patients (4.2 %), and lumbar vertebrae were injured in 28 patients (5.3 %). Injury to the cervical spine, both upper and lower, was least frequent, including four (0.8 %) and 10 (1.9 %) patients, respectively. None of the patients in this group showed neurological deficit. The surgically treated group included 29 (67.4 %) boys and 14 (32.6 %) girls; two (4.7 %) children were between 0 and 9 years, nine (20.9 %) between 10 and 14 years, and 32 (74.7 %) between 15 and 18 years, with an average of 15.1 years for the whole group. The frequent causes of injury were car accidents and falls in 21 (48.8 %) and 14 (32.6 %) children, respectively. Other causes were infrequent. The upper cervical spine was operated on in five (11.6 %), lower cervical spine in eight (18.6 %), thoracic spine in 13 (30.2 %), thoracolumbar spine in five (11.6 %) and lumbar vertebrae in 12 (27.9 %) patients. Thirty-six (83.7 %) patients had fractures, five had dislocated fractures (11.6 %) and two (4.7 %) had a dislocation. Of the 43 children in this group, neurological deficit was recorded in nine (20.9 %); this included a complete spinal cord lesion, an incomplete spinal cord lesion and a nerve root lesion in three, five and one patient, respectively. DISCUSSION: The results of this study confirm, in the majority of aspects, the conclusions of previously published papers. In some of the characteristics described above, however, our results are different, which can be explained by some specific features of care for injured children in the Czech Republic. CONCLUSIONS: Childhood spinal injuries account for only 2 to 5 % of all spinal injuries and for 3.6 % of all skeletal injuries in children. Particularly at the age of 11 to 12 years, they differ significantly from spinal injuries in adults and therefore require different therapeutic approaches. The cervical spine is affected most often in younger children, while the thoracolumbar spine in older children. Multi-segment injuries are typical in the childhood spine, particularly in smaller children. Typically, children show SCIWORA and a more rapid improvement of neurological deficit than adults. Conservative treatment is preferred; surgery before 12 years of age is strictly individual, while after 12 years therapy is similar to that used in adults.

Adolescent↗

PubMed2006

[Spinal injury caused by a nail fired from a stud gun].

The patient, a 52-year-old male foreign citizen working as a construction worker, was attacked by his coworker who had fired a drive stud, 70 mm long, with reverse hooks from a powered gun at him; the stud pierced the worker's spine at the scapular level. The patient was taken to the nearest surgical ward. On the basis of clinical presentation and X-ray of the thoracic spine, the diagnosis of penetrating injury to the spinal column at the 7th thoracic vertebra level was made. Subsequently, the patient was admitted to the intensive care unit of our department. On admission the patients showed slight paresis of the right lower extremity and hypesthesia of the right thigh, but no other neurological deficit. After preoperative examination, the patient was operated on within six hours of the injury. Intraoperatively, a 3-mm-thick stud, piercing the T7 vertebral arch, was found on the left side, lateral to the T7 spinous process. After partial resection of the arch around the stud, the spinal canal was inspected. The stud passed paramedially on the right side through the dura mater and the centre of the spinal cord into the body of the 7th thoracic vertebra. The stud was gently removed. Subsequently, some sanguineous liquor appeared. The dura mater was sutured and the wound was closed layer by layer. The postoperative period was uneventful, and the patient was allowed to stand up on day 2. The drain was removed on day 4. Healing by first intention took place. At 6 weeks after surgery slight neurological deficit still remained. Key words: spinal penetrating injury, spinal gunshot injury.

Foreign Bodies↗

PubMed2005

[Harms technique of C1-C2 fixation with polyaxial screws and rods].

PURPOSE OF THE STUDY: The Harms technique of stabilizing C1-C2 by fixation with polyaxial screws and rods is a further option for atlantoaxial fixation from the dorsal approach. Harms and Melcher published this method in 2001, but the operation had first been performed by Harms in August 1997. The aim of this study is to evaluate the first results and try to assign the Harms C1-C2 fixation an appropriate standing in the in broad range of options for stabilization of the atlantoaxial complex. MATERIAL: Between December 2002 and January 2004 we carried out the Harms fixation of C1-C2 on 22 patients admitted to the Department of Spine Surgery, Motol University Hospital, 2nd Medical Faculty in Prague. Out of these, 18 patients were included in this study, 10 men and 8 women between 23 and 84 years of age (average, 55.4 years) followed-up longer than 6 months. In 14 patients we used the Harms technique as a permanent fixation of C1-C2 in order to achieve atlantoaxial arthrodesis and, in four patients, we applied it only for a period of 4 to 6 months without the use of bone grafts or their substitutions. We employed the permanent fixation to treat the following conditions: fracture of the atlas in three patients, type IIA comminuted fracture of the dens base in three patients, fracture of C2 categorized as "other" in two patients, atlantoaxial vertical instability in one patient with rheumatoid arthritis, malunion of the fractured dens in one patient, and complicated trauma to C1-C2 in four patients. The temporary fixation was used for type III displaced fractures of the dens in two and fixed atlantoaxial rotatory dislocations also in two cases. Only one patient showed signs of Frankel C neurological deficit on admission, the rest were without neurological findings. METHODS: All screws were inserted under an image intensifier always in lateral projection. First we retracted the greater occipital nerve in a caudal direction towards C2 with a fine raspatory and, using an awl, marked the entry point in the C1 lateral mass; a pilot hole, reaching through the anterior cortical bone, was made with a 2.5 mm drill. It followed a straight or slightly convergent trajectory in an anterior-posterior direction and parallel to the plane of the C1 posterior arch in the sagittal direction. Individual anatomical variations in the atlantoaxial complex of every patient were respected. The hole was tapped through the entire vertebral body, with the exception of osteoporous bone in which only the posterior cortical bone was treated with a screw tap. At this stage profuse bleeding usually arose from dissection around the epidural venous plexus along the C1-C2 joint. This was effectively controlled by a quick insertion of a screw and compression of the venous plexus with the screw head. To control bleeding by bipolar electrocautery is difficult and is always associated with a risk of nerve injury. Screws 3.5 mm thick, with polyaxial heads, were inserted bicortically into the lateral mass of C1. Subsequently, the intervertebral C2-C3 joint was localized and its medial border in the spinal canal was palpated. The entry point for placement of a C2 pedicle screw was marked with an awl at the point of intersection at a distance of 2 mm from the medial border and 5 mm from the caudal border of the C2 articular process. Under an X-ray intensifier in lateral projection, a hole was drilled approximately parallel to the screws inserted in C1, i. e., at an angle of 20 to 30 degrees cranially, up to and through the anterior cortical bone. In the transversal plane, the screws were situated in a convergent direction at an angle of 20 to 25 degrees. After all screws had been inserted, we reduced the antlantoaxial complex in the correct anatomical position by manipulating the patient's head or by directly adjusting the screws. Connecting 3.0-mm rods were then applied and fastened by cap nuts or inner nuts according to the instrumentation used. RESULTS: Operative time ranged from 35 to 155 min, with an average of 81 min. Intra-operative blood loss ranged from 50 to 1500 ml, with an average of 560 ml. The X-ray intensifier was used for a period of 0.4 to 2.6 min, with an average of 0.9 min. A total of 36 screws were inserted in the atlas; their length ranged from 16 to 34 mm (average, 30.6 mm). All screws were positioned correctly in the C1 lateral mass; two screws did not reach up to the anterior cortical bone and one protruded over it, but without causing clinical problems. Thirty-six screws were inserted in the axis. Their length ranged from 28 to 36 mm (average, 31.7) mm). Twenty-seven screws were correctly applied through the isthmus into the C2 anterior cortical bone, three were too short to reach it and five were placed too close to the vertebral artery canal. Of these, two protruded into the artery canal, but without clinical consequences. One screw inserted too medially passed into the spinal canal, but this also was without clinical response. Of the 36 screws inserted in C2, three (8.3 %) were malpositioned. Bony fusion at C1-C2 was the goal of this operation in 14 patients. At 6 weeks post-operatively, it was achieved in two patients, at 12 weeks in 12 patients and at 6 months in all 14 patients. The C1-C2 segment was stable at 12 weeks in all 18 treated patients. Four patients reported restriction of motion in rotation by 10 to 25 % after removal of the instrumentation. DISCUSSION: Operative time, longer at the beginning than with the Magerl technique, gradually shortened to between 45 and 60 min. Similar trends were seen when intra-operative blood loss and X-ray exposure were evaluated. Using the Harms and Melcher procedure we saved the greater suboccipital nerve. In contrast to these authors, however, we did not resect the atlantoaxial joint. Solid fusion was achieved in all our patients. Of the total of 72 screws inserted, only three (4.2 %) were assessed as malpositioned; however, when related to the 36 screws inserted in C2, this was 8.3 %, which indicates that insertion of screws in C2 was more difficult. We did not observe any clinical consequences in any of these cases. CONCLUSIONS: The Harms fixation of C1-C2 is a very effective technique for stabilizing the atlantoaxial complex. It enables us to provide temporary fixation without damage to atlantoaxial joints and to reduce the vertebrae after the screws and rods had been inserted, which is unique. These advantages compensate for a higher cost of the implant.

Adult↗

PubMed2005

[Combined atlantoaxial fractures].

PURPOSE OF THE STUDY: Combined fractures of the atlas and epistropheus account for 3 % of all acute injuries to the cervical spine. In relation to all C1 and C2 injuries this is 43 % and 16 %, respectively. The aim of this study is to evaluate a group of patients with combined C1-C2 fractures and to suggest an effective therapeutic procedure. MATERIAL: In the years 1996 to 2003, a total of 16 patients with trauma to the atlantoaxial complex were treated at the Orthopedic Department of the Third Faculty of Medicine, Charles University, Prague (1996-2001) and the Department of Spinal Surgery of the University Hospital in Motol, Prague (2001-2003). These injuries included a combined fracture of the dens (Anderson and D'Alonzo type II) and of the atlas posterior arch in six patients, a type II dens fracture combined with Jefferson fracture in two patients, a type III fracture of the dens with a lateral mass fracture in two patients, hangman's fracture with posterior arch fracture in three patients, a type II fracture of the dens with anterior arch fracture in one patient, a fracture of the C2 body with Jefferson fracture in one patient and a fracture of the C2 body with fracture of the lateral mass in one patient. Two patients were treated conservatively and 14 underwent surgery. On admission neurological deficit was found in five patients. METHODS: Fourteen patients were operated on. Direct osteosynthesis of the dens, with motion in the atlantoaxial complex preserved, was performed in five patients. Seven patients underwent C1-C2 fixation that, in one, involved the C1-C3 segments; five patients were treated by Harms fixation with polyaxial screws from the posterior approach, two by the Magerl or Gallie techniques and one patient required occipito-cervical fixation of C0-C2. The patient with a hangman's fracture combined with fracture of the atlas posterior arch was treated by discectomy of C2-C3, tricortical graft from the iliac crest and plate application. The patients used Philadelphia collars for 6 to 12 weeks according to the type of injury and their bone quality. RESULTS: Three patients (two undergoing direct osteosynthesis of the dens and one with occipito-cervical fixation) reported intermittent upper neck pain that required taking analgesics. The patient treated by occipito-cervical fixation repeatedly complained of restriction of rotational head movement by about 50 %. Radiograms of the cervical spine in both flexion and extension taken at 12- to 14-week follow-up all showed stable C0-C1 and C1-C2 segments. In the five patients undergoing direct osteosynthesis of the dens, complete bony union was found on X-ray and CT examination by 6 to 24 weeks postoperatively. Similarly, full instrumented fusion was achieved by 12 to 24 weeks postoperatively in the seven patients treated by dorsal fixation. The patient with anterior C2-C3 fixation showed, on X-ray images, a completely remodeled segment at 24 weeks after surgery. There was one intraoperative complication involving management of profuse bleeding from the venous plexus along the greater occipital nerve. No other complications related to the surgical procedure were recorded and no injury to the spinal cord, nerve roots or the vertebral artery was observed. None of the patients experienced any deterioration of neurological findings during the early postoperative period. One patient had to undergo resuturing of the operative wound from the posterior approach, because of subcutaneous necrosis that had failed to heal. No instrumentation failure or infection, regarded as late complications, were recorded. DISCUSSION: At our Department we prefer early operative treatment involving spondylodesis in the shortest segment possible, with special emphasis on preserving rotational C1-C2 movement. Therefore, in some cases, we use only temporary stabilization with removal of instrumentation after 3 to 4 months. In this group the most frequent fractures were those combined with type II fractures of the dens. In such cases we always prefer direct osteosynthesis of the dens or, if this is not possible, the Harms technique of C1-C2 fixation, possibly only temporary. We believe, in agreement with Guilot and Fesser, that a potential failure of conservative therapy may result in a longer convalescent period and that patients should always be informed about these issues. In contrast to Guilot and Fesser we treat combined hangman's fractures from the anterior approach, by discectomy, tricortical graft and plate application. CONCLUSIONS: Combined atlantoaxial fractures are serious, life-threatening injuries which, because of their diversity, require an individual approach to each patient. Early surgery is recommended with increasing frequency, particularly in the cases with persisting dislocation or instability. At the same time it is necessary to ensure that motion restriction of the cervical spine be minimal.

Adult↗

PubMed2005

[Surgical treatment for disorders of the cervicothoracic junction region].

PURPOSE OF THE STUDY: The complex anatomy of the cervicothoracic junction region makes a reliable assessment of plain radiographs in lateral projection difficult or even impossible, which may result in failure to detect fracture or other pathology in this region of the spine. The aim of this study was to evaluate the patients with spinal disorders in the region of the seventh cervical to the third thoracic vertebrae treated at our department. MATERIAL: During the period from November 2001 to June 2004, 34 patients with disorders of the C7-T3 region were treated surgically at the Department of Spinal Surgery, Motol Teaching Hospital, which accounted for 2.1% of the 1537 patients treated for spinal diseases in this period. Instability of the cervicothoracic junction was caused by tumors in 15 and by injury in 14 patients. Other diagnoses included deformity associated with rheumatoid arthritis (RA) in two patients, spondylodiscitis in one, and hemivertebral deformity at C7 and T1, each in one patient. The group included 16 women and 18 men between 8 and 75 years, with the mean of 52.3 years (after excluding the two children with hemivertebral deformity aged 8 and 9 years, respectively). The trauma subgroup had a significantly lower mean age (43.6 years) than the tumor subgroup (59.9 years). METHODS: We placed the patients in three groups according to the etiology of cervicothoracic junction disorder, namely, 1. tumors and spondylodiscitis; 2. injuries; 3. others. Group 1 included 16 patients, 15 with tumors and one with spondylodiscitis. Two patients were treated by dorsal stabilization, one by ventral stabilization and the rest underwent combined surgery. Of 14 patients in group 2, three were treated from the posterior approach, six from the anterior approach and five by the combined approach. All group 3 patients underwent surgery from the posterior approach, with two patients being treated without instrumentation. RESULTS: Of the 34 patients, only 33 were included; one was lost to follow-up soon after the operation. In group 1, no excellent, five very good, five satisfactory and two unsatisfactory outcomes were recorded. No intraoperative complications such as injury to the major vessels or nerve structures occurred; in one patient, profuse bleeding from arteries supplying a metastatic tumor had to be arrested. Late complications included loosening of the dorsal instrumentation in two patients, who required repeat operations. In group 2, there were six excellent, four good, two satisfactory and one poor outcomes. Late complications in one patient included loosening of the ventral instrumentation, followed by repeat surgery. Group 3 showed two excellent and two satisfactory outcomes; the latter were in the RA patients. Late complications involved one loosening of the dorsal instrumentation requiring repeat surgery. No injury to the major vessels or nerve structures was recorded in either group 2 or group 3. No deep infection was recorded in any of the three groups. DISCUSSION: The results of our evaluation are in agreement with those of other authors and, similarly to them, we had to deal with the difficult issues of diagnosis. Currently, we prefer, in addition to conventional X-ray examination, CT scans including sagittal and frontal reconstruction, recently completed with magnetic resonance imaging, in all patients with cervicothoracic junction disorders. This policy allows us to avoid delays in making correct diagnosis and to provide conditions for effective treatment. In stabilization from the posterior approach we use rod-screw fixation that, in the majority of cases, is not combined with thoracic fixation. Previously, we have inserted screws in the articular processes at the C7 level, but now we prefer transpedicular fixation. Complicated anterior surgical procedures, such as complete or partial sternotomy, are always performed with the assistance of a thoracic surgeon. A noticeably high number of patients with neurological deficit was seen also in our group. Postoperative care is always provided in cooperation with the spinal unit of our hospital. Intensive inter-disciplinary cooperation has an important role in that our patients have a minimum of complications in comparison with the literature data. CONCLUSIONS: Injuries and diseases of the spine at the cervicothoracic junction present a complex issue with a high potential for mistakes and complications. The principle of success lies in a high-quality X-ray examination, CT scans with sagittal and frontal reconstruction, and magnetic resonance imaging of the region affected. The complex anatomy of that region requires demanding surgical procedures, which can be performed only by a highly qualified and specialized team with appropriate facilities.

Adolescent↗

PubMed2005

[Unilateral dislocations of the thoracic and lumbar spine].

Unilateral dislocation is a trauma typical of the cervical spine. Case reports on unilateral dislocation of the thoracic or lumbar vertebrae can be found in the relevant literature only rarely and they often describe this condition associated with multiple trauma or combined injuries. Although unilateral dislocation is an unstable injury with rotation involved, injury to the spinal cord or spinal nerve roots is not common. Diagnosis is based on radiographic and CT examination. Therapy includes open reduction and instrumented spondylodesis of the injured segment. The cases of two patients with unilateral dislocations in the thoracic and the lumbar spine, respectively, treated at the Department of Spinal Surgery, Motol Teaching Hospital in Prague, are reported here.

Adult↗

PubMed2005

[Purulent arthritis of the spinal facet joint].

Purulent arthritis of the facet joint is a rare affection. It occurs most commonly by hematogenous spread of microorganisms and the initiating agent is in most cases Staphylococcus aureus. Diagnosis is made predominantly by means of MRI and hemocultures, or culture of pus aspirated from the abscess with a needle. Conservative therapy consists in a long-term administration of antibiotics. In case of insufficient response to the treatment or development of a neurological deficit, the patient is indicated for surgical revision, drainage and, if necessary, for decompression of nerve structures. In addition to sepsis, a severe complication of the purulent arthritis of the facet joint is propagation of the abscess epidurally, intradurally or foraminally with the risk of the onset of neurological deficit. In their case series the authors present four cases of purulent arthritis of the facet joint diagnosed and treated at the Department of Spinal Surgery of the University Hospital in Motol, Prague.

Adolescent↗

PubMed2004

[Transarticular fixation of C1-C2: a multicenter retrospective study].

PURPOSE OF THE STUDY: Transarticular C1-2 fixation is a surgical alternative in treatment of atlantoaxial instability. Although the method provides very good immediate and long-term stability, it still involves several disadvantages. The group of patients as reported from various institutions are usually very small and hardly comparable. In order to objectively compare the results of the method, we collected the groups of patients treated in four institutions dealing with surgery of the cervical spine in Czech Republic. MATERIAL AND METHODS: During the 9-years period (1993-2001), the transarticular C1/2 fixation was performed in 80 patients (mean age 45.6 years, range 4-85 years). The procedure was indicated for atlantoaxial instability due to rheumatoid arthritis in 32 cases, pseudoarthrosis of the odontoid process in 15 cases, fracture of the odontoid in 8 cases, complex C1-C2 fracture in 7 cases, tumour in 5 cases, C1 fracture in 4 cases, os odontoideum in 3 cases, purulent osteolysis of the odontoid in 3 cases and instability due to tuberculosis in one case, respectively. Two patients underwent surgery for painful arthrosis of atlantoaxial joints only. Transarticular fusion was combined with posterior interlaminar fixation using autologous graft and wire in most of the cases. Clinical and radiological results were evaluated in the early postoperative period and 3, 6 and 12 months after surgery, respectively. The position of the screws in relation to lateral mass of the atlas was evaluated according to our own criteria as optimal, suboptimal, and misplaced. Long-term postoperative stability and bone fusion were also followed. The follow-up ranged from 3 to 99 months (mean 29.1 months). There were 72 patients available for long-term follow-up (i.e. more then 6 months). RESULTS: We inserted 150 screws; two screws were used in 72 patients, one screw in 6 patients while in two patients, the surgery had to be aborted without screwing. Optimal placement was achieved in 103 cases (68.7%), suboptimal because of too medial or lateral placement of the screws in 26 cases (17.3%), suboptimal due to a short screw in 9 case (6%) and a long screw in 8 cases (5.3%). Four screws (2.7%) were found misplaced (i.e. out of the lateral masses). Fusion was confirmed in 51 cases out of 72 operated on (70.8%) at 6-months follow-up, and in 55 cases out of 63 available for follow-up (87.3%) at 12 months, respectively. Segmental stability was achieved in all patients, even in cases with incomplete fusion as seen on radiograph. Furthermore, six screws in four patients were discovered to be broken, nevertheless without any clinical consequences. There were 4 cases of peroperative injury to th vertebral artery (i.e. 5% of patients, 2.7% of screws), one case of dural tear and one case of excessive blood loss from epidural venous plexus. These complications, however, did not cause any significant clinical consequences, either. Other postoperative complications included wound dehiscence in 3 cases, 2 cases of hardware failure due to wrong indication for surgery and 2 cases of persistent neck pain. DISCUSSION: Transarticular C1/2 fixation is known to be universal and stable technique suitable for the treatment of atlantoaxial instability. According to biomechanical studies, this method provides the best stability mainly in rotation and lateral flexion (inclination) when compared to other described methods of atlantoaxial fixation. The fusion rate is reported to vary between 90 to 100% if the posterior interlaminar fusion using bone graft and wire is simultaneously performed. The rare incidence of pseudarthrosis is usually considered to be related to a poor surgical technique as even only one screw should provide bone fusion if properly placed. Using strict evaluation criteria, the fusion rate in our sample of patients was 87.3% at 12 months, or, 92.1% if also controversial radiographs were included. The injury to the vertebral artery is the most serious complication of the method; its incidence in our group (5% of patients) is comparable to data from literature. We believe that most of these events happened because of individual anatomical variations of axis and vertebral artery were not adequately respected. CONCLUSION: Transarticular technique of instrumental atlantoaxial fusion is an effective method with multiple application in treatment of craniocervical and upper cervical spine instability. The gain of immediate stability with acceptable risk of possible complications is the major advantage of this procedure. The results of our multicentric retrospective study confirm the expected high fusion rate and are comparable to previously published reports.

Adolescent↗

PubMed2004

Initial peptide mass fingerprinting analysis of proteins obtained by lysis of Coxiella burnetii cells.

Whereas the complete genome of Coxiella burnetii (C.b.), the etiological agent of Q-fever, has recently been published (Seshadri et al., Proc. Natl. Acad. Sci. USA. 100, 5455-5460, 2003), the C.b. proteome is still under study. Using the bioinformatic approach, we found in total 309 proteins on two dimensional electroctrophoretic images of C.b. whole cell lysates. Eighteen major protein species were subjected to peptide mass fingerprinting and identified as the products of 6 known open reading frames (ORFs): the chaperone DnaK (heat shock 70 K protein), chaperonin 60 K (GroEL protein, heat shock protein B), DnaJ-like protein djlA (mucoidy activation protein mucZ), elongation factor Ts (EF-Ts), ribosomal protein L7/L12, and chaperonin 10 K (GroES protein, heat shock protein A).

Bacteria↗

PubMed2003

Comparison of the abundance of 10 radiation-induced proteins with their differential gene expression in L929 cells.

PURPOSE: To determine whether radiation-induced changes in protein abundance can be correlated with their differential gene expression in a murine fibroblast L929 cell line. MATERIALS AND METHODS: L929 cells were irradiated with 6 Gy. Cell lysates were collected at different points in time (20 min, 12, 24, 36, 48 and 72 h). The extracted proteins were separated by two-dimensional gel electrophoresis and quantified using computerized image analysis. Proteins exhibiting a differential expression equal to or more than twofold were identified by mass spectrometry following trypsin digestion. From these, 10 proteins characterized by large changes of radiation-induced abundance were selected in order to measure their corresponding gene expression using RTQ-PCR (real-time quantitative polymerase chain reaction). RESULTS: Up to 15-fold changes in the abundance of these 10 proteins were associated with no detectable changes more than twofold on the gene expression level. However, one gene (VEGF-D) showed a significant (p=0.005) up-regulation (1.8-fold). CONCLUSIONS: Deducing protein abundance from mRNA expression levels and vice versa appears to be of limited use. Furthermore, examination of transcriptional and translational changes provides different but complementary information.

Animals↗

PubMed2003

Proteomic analysis of radiation-induced alterations in L929 cells.

In this study we examined the protein expression profiles in X-irradiated L929 cells to get insight into how mammalian cells respond to radiation-induced cell damage. L929 cells were irradiated with the dose of 6 Gy and cell lysates were collected at different time intervals (20 min, 12, 24, 36, 48 and 72 h). The extracted proteins were separated by 2-DE and quantified using computerized image analysis. Proteins exhibiting significant abundance alterations when comparing irradiated to unirradiated cells were identified by mass spectrometry. Using the proteomics approach we detected 47 proteins that exhibited a significant radiation-induced increase or decrease in the course of 72 h. From this group of spots 28 proteins were identified by mass spectrometry and of these 24 proteins exhibited minimally 2-fold differences in mean abundance values in comparison to controls. The identified proteins represent diverse sets of proteins participating either in protective and reparative cell responses or in induction of apoptosis and oncogenesis. The results document that proteomics is a useful method for unravelling the molecular mechanisms involved in cell reaction to ionizing radiation.

Animals↗

PubMed2003

Gamma irradiation results in phosphorylation of p53 at serine-392 in human T-lymphocyte leukaemia cell line MOLT-4.

Exposure of human leukaemia MOLT-4 cells to ionizing irradiation led to apoptosis, which was detected by flow cytometric analysis and degradation of the nuclear lamina. The multiple signalling pathways triggered by either membrane or DNA damage play a critical role in radiation-induced apoptosis. The response to DNA damage is typically associated with the p53 protein accumulation. In this study, we proved that the transcriptionally active p53 variant occurs in the MOLT-4 cells and its abundance alteration is triggered in the gamma-irradiated cell population concomitantly with phosphorylation at both the serine-392 and serine-15 residues. The p21 upregulation followed the p53 phosphorylation process in irradiated MOLT-4 cells.

Apoptosis↗

PubMed2003

[Injuries of the lower cervical vertebrae--the monocortical stabilization technique].

PURPOSE OF THE STUDY: In contrast to the thoracolumbal spine, the cervical spine bears a lower biomechanical load and, therefore, anterior stabilization of a fracture is a definitive procedure in the majority of cases. What remains the matter of choice is screw fixation in the body of the vertebra involved. This may be either monocortical or bicortical. In this study, we evaluate a group of patients in whom fractures of the lower cervical spine were treated using the CSLP monocortical system (Synthes). MATERIAL: We included 68 patients in whom complete radiographic data were available and the surgery was performed more than 6 months earlier. This group comprised 49 men and 19 women with the mean age of 37.6 years and range of 12 to 79 years. In the first stage, all patients were operated on from the anterior approach. In 11 (16.2%) patients with type B or C injury, according to the AO classification, the procedure was completed by dorsal stabilization. The definite indication for surgery was any involvement of nerve structures or open fractures; kyphosis greater than 15 degrees, reduction by more that 50% of the proximal edge of the vertebral body, narrowing of the spinal canal by more than 50%, multiple wedge fractures and disc and ligament injuries associated with instability were considered conditional indications. METHODS: Any locked dislocation was reduced manually under X-ray guidance in the shortest possible time. Subluxations or fractures of the vertebral body were reduced by positioning the patient's body on the operating table. The standard procedure for subluxation management was distraction of the segment by applying a Caspar's distractor and subsequent microscopic discectomy up to the posterior longitudinal ligament. A tricortical bone graft was collected from the iliac crest. After its implantation, the distractor was released and the segment was fixed by a CSLP system (Synthes) with monocortical screws 14 mm long, usually used in a 2 + 2 configuration. In locked dislocation, in addition, the discission of the posterior longitudinal ligament and inspection of the dural sac were performed, and completed by dorsal stabilization with hook plates or a Cervifix fixator (Synthes) in one procedure under anesthesia. When the body of the vertebra was fractured, either partial or subtotal excision of it was carried out according to the type of fracture or when displaced fragments protruded into the spinal canal. A tricortical graft taken from the iliac crest was larger than in the treatment of subluxation but a plate was applied as in monosegmental fixation. In addition, the graft was fixed with special screws that had a porous surface and holes in the shank. Dorsal stabilization with hook plates or a Cervifix fixator was used for severe instability in type B or C injury. RESULTS: The normal range of cervical spine motion (flexion, extension, inclination, rotation) was found in 44 patients. Slightly limited movement (75% to 90% normal motion) was in 17 patients and seven were affected more seriously (50% to 75% normal motion). Of the 19 patients with neurological deficit, 13 showed improvement by 1, 2 or 3 grades of Frankel's classification in seven, four and two patients, respectively. The first signs of bone remodeling between the graft and covering plate, usually at the distal graft border, were found in 16 patients at 6 weeks and in the remaining 52 patients at 12 weeks. By 6 months postoperatively, all patients showed complete healing and incorporation of the tricortical graft. The cranial screws broke in one case (1.5%) but this had no effect on the treatment outcome. No complication related to the surgical procedure occurred intraoperatively. DISCUSSION: The very good results achieved with the use of the CSLP monocortical system in this study (98.5% fusion without broken screws or plates) are in agreement with relevant data reported in the Czech and foreign literature. The principal condition is a careful preparation of both the endplates of vertebral bodies and the graft. After insertion, this should stay in place without any tendency to extrude. If the graft is too long, it imposes an increased load on plates or screws that consequently act ventrally. CONCLUSION: Our experience and literature data suggest that the CSLP monocortical system is fully capable to stabilize the lower cervical spine after injury, supposing all procedures described above are completed. In more serious trauma and type B or C instability, the additional dorsal instrumented fusion is indicated.

Adolescent↗

PubMed2003

[Injuries of the atlas].

PURPOSE OF THE STUDY: Injuries of atlas account for 1-2% of all injures of the spine and for 7% of the injuries of the cervical spine. Fractures of atlas occur either as isolated fractures or in combination with the injury of the axis or occipital condyles. The aim of the work is to evaluate a group of patients with the injury of the atlas treated both conservatively and surgically. MATERIAL: Between January 1996 and October 2001 we treated at the Orthopaedic Department of 3rd Medical Faculty, Carles University in Prague 10 patients with the injury of atlas. Between November 2001 and December 2002 we treated at the Orthopaedic Department and Spondylosurgical Department of the Medical Faculty Motol another 5 patients with the injury of atlas. In 10 cases the fracture of atlas was isolated (anterior arch--once, 4 time Jefferson fracture, twice--fracture of massa lateralis), in 5 cases the fracture was associated with the injury of epistropheus (dens type II/posterior arch--twice, dens type II/Jefferson fracture--once, dens type II/massa lateralis--once, hangman fracture type II/posterior atlas arch--once). Teh group of patients included 9 men and 6 women of the average age of 46.6 years (range, 27-85 years). Eight patients were treated conservatively, 7 patients surgically. The most frequent cause of the injury was fall on the head or a severe downward violence in 7 cases, car accident in 4 cases, other causes vere identified in 4 cases. Neurological deficit upon admission was found out only in one patient (Frankel D). METHODS: In isolated injuries of the anterior or posterior arch of atlas we always proceeded conservatively. The cervical spine was fixed for 12 weeks in the Philadelphia collar. One isolated fracture of massa lateralis was also treated conservatively for 12 weeks in the Philadelphia collar. Another case of the same type of fracture was treated surgically by C1-C2 by the Magerl technique supplemented on the intact side by the Gallie wire loop. Two stable Jefferson fractures were treated by the halo vest applied for 12 weeks. Two unstable fractures were handled surgically, once by C1-C2 by the Magerl technique and once by C0-C2 occipitocervical fixation. C1-C2 associated injuries were treated in four cases surgically, three times by a direct dens fixation and once by C1-C2 fixation after Magerl supplemented with the Gallie wire loop. A patient with the associated hangman fracture type II and fracture of the posterior atlas arch refused the surgery and therefore was treated by the halo fixation for 12 weeks. Philadelphia collar was applied to the patients operated on. RESULTS: In the group of the conservatively treated, 3 patients complained of pain in the upper part of cervical spine and head requiring from time to time the administration of analgesics. All fractures healed within 12 weeks and the functional radiographs showed stable C0-C2 segments. As for complications, during the conservative treatment in one case a pyogenic secretion was recorded around the fixation elements of the halo apparatus requiring its removal after 8 weeks. The patient was further treated by a pelot fixation. In one case it was necessary to adjust twice the halo apparatus due to re-dislocation of the hangman fracture (associated hangman fracture of type II and posterior atlas arch). In spite of this the injury healed in C2-C3 subluxation, however, the fracture of atlas healed in a favourable anatomical position. In the group of the operated on, 2 patients complained of pain in the upper cervical spine requiring from time to time the administration of analgesics and one patient complained of a marked limitation of the range of motion by 50% (C0-C2 occipitocervical fixation). Also in this group stable C0-C2 segments were found out 12-14 weeks after the surgery. DISCUSSION: In our group of 15 patients the fracture healed, i.e. stable C0-C1 and C1-C2 segments, in all patients treated both conservatively and surgically. In the group of conservatively treated patients there occurred in one case re-dislocation of the fracture. However, the patient refused the surgery repeatedly. Apart from these case we found in neither group any severe complication. The ratio of conservative and surgical treatment was 8:7. CONCLUSION: Based on our own experience and the literary data we believe that suitable for the treatment of stable injuries of the atlas is conservative treatment, i.e. fixation in the Philadelphia collar for 12 weeks. In unstable injuries or intraarticular injures with dislocation we prefer surgical fixation of C1-C2 or C0-C2 in dependence on the type of injury. All associated injuries are indicated for surgical treatment.

Adult↗

PubMed2002

An ATP-dependent step is required for the translocation of microinjected precursor mRNA into nuclear speckles.

Nuclear speckles (speckles) represent a distinct nuclear compartment within the interchromatin space and are enriched in splicing factors. In a previous study (Melcák et al., 2001), it has been shown that the pre-spliceosomal assembly on microinjected splicing-competent precursor mRNA takes place in the speckles, and it has been suggested that the targeting of RNA into speckes consists of two interdependent steps, namely the diffusion process, followed by the energy-dependent translocation of RNA into the speckles. In the present study, we confirm the existence of these two steps and show that this latter translocation is ATP dependent.

Adenosine Triphosphate↗

PubMed2002

[Atlanto-axial rotation dislocation (case report)].

The authors present a female patient 45 years old, who had a car accident as a driver of a passenger car. Her car was hit from the left side by another car and the women hurt her head, neck and left shoulder. Due to pain in the region of the head and neck she was taken to the respective surgical out-patient department where they diagnosed the concussion of the brain of II degree and distortion of the cervical spine. The patient was treated conservatively by bed rest with the cervical spine fixed in the soft Schanz collar. After ten days she was discharged from the hospital and further followed up by a neurologist in the out-patient department. She underwent physical therapy focussed on the relaxation of muscles in the region of the cervical spine. Due to persisting pain in the region of upper cervical spine the patient was sent to the department of the first author six weeks after the injury. On clinical examination the head was inclined to the right and rotated to the left with pain in the region of the occipitocervical passage. Radiographs were made in the lateral and Sandberg projection. In the lateral projection the atlantodental distance was normal, the Sandberg projection showed an evidently asymmetrical location of the dens between the lateral masses of the atlas, asymmetrical size of the lateral masses and inclination of the head to the left. These basic projections alone showed an evident rotational atlantoaxial dislocation of I degree according to Fielding. The authors further added CT examination which showed rotation of C1 against C2 and asymmetrical location of the dens without dislocation from the anterior arch of the atlas. A conservative physical therapy was not successful and the patient felt worse. Twelve months after the injury a pre-operative traction by Glisson sling was introduced for five days with a gradual weight bearing up to 5 kg. A reduction followed from the dorsal approach and fixation of C1-C2 after Magerl combined with Gallie technique. The surgery was without complications and the post-operative radiographs showed a good position of the C1-C2 complex and a correct insertion of screws through atlantoaxial joints. The patient wore for six weeks a Philadelphia collar and another six weeks the Schanz collar. Standard and functional radiographs in flexion and extension made 12 weeks after the surgery showed bone bridging between C1-C2 arches and a stable atlantoaxial fusion. At the check one year after the surgery the patient had a limited rotation of the head by 25%, however, she was without pain and the inclination and rotation of the head was compensated. In the authors' view the use of Magerl technique of C1-C2 fixation is possible in case of a rotational atlantoaxial dislocation but difficult with regard to the changed anatomical conditions.

Atlanto-Axial Joint↗

PubMed2002

[Marginal indications for the Magerl method of fixation of C1-C2 (case report)].

The authors present a 4-year old girl who had a car accident as a passenger and hurt her head, chest and limbs as well as upper cervical spine. The patient with multiple injuries was taken to the FTN Centre of Children's traumatology, Prague. Here the basic vital functions were ensured and a diagnosis was made of contusion of the brain with quadriparesis and inhibition of the respiratory centre, contusion of the chest, epiphysiolysis of the distal femur and later also instability of C1-C2. A censor for measuring or intracranial pressure was immediately inserted with a subsequent reduction of the distal femur and elastic fixation. External lumbar drainage was performed in the next week instability of C1-C2 was not found out and therefore not treated. Three months after the injury a ventriculoperitoneal shunt for intracranial hypertension was inserted. MRI showed stenosis in the region of occipitocervical passage and dorsal decompression of craniocervical passage was performed which consisted in the removal of the posterior arch of C1 and a significant extension of foramen magnun dorsally and laterally to both sides. Due to persisting ligamentous instability of C1-C2 with a spastic quadriparesis and inhibition of the respiratory centre a surgical atlantoaxial stabilization was indicated, i.e. causal treatment of instability. Seven months after the injury Magerl fixation of C1-C2 was performed by 2.7 mm titanicum screws (Synthes). Preoperative stability of C1-C2 in the reduced position was satisfactory but with regard to iatrogenic instability the C0-C1 fixation was combined with occipitocervical fussion by Ransford loop extending over C0-C3. Further, the triangular flap of periost was overturned from the external occipital protuberance to C3 and all this was bridged by cortical cancellous bone grafts from iliac crest. After two months a check simple and functional x-ray examination showed a stable fusion of C0-C2. The neurological finding remained the same even after one year, i.e. a severe quadriparesis with the inhibition of the respiratory centre requiring artificial lung ventilation.

Cervical Vertebrae↗