Biomedical subjects
Publications and source records attributed to S Govender.
We report two cases of vertebral osteochondroma. In one patient a solitary cervical lesion presented as entrapment neuropathy of the ulnar nerve and in the other as a thoracic tumour associated with hereditary multiple exostoses producing paraplegia. We highlight the importance of an adequate preoperative evaluation in such patients.
Twenty-nine patients with pyogenic vertebral osteomyelitis were reviewed retrospectively after an average follow-up of 3.7 years. We identified 17 patients with predisposing factors (10 diabetes, 4 urinary tract infection, 2 HIV-positive, 1 rheumatoid arthritis). No patient presented with a febrile illness. The lumbar spine was involved in 15 patients. Eighteen patients had neurological impairment at presentation. Eleven patients who were neurologically intact had needle biopsies and the remaining 18 patients who were neurologically compromised had an open decompression. Staphylococcus aureus was cultured in 14 patients. Although spinal tuberculosis is relatively common in our environment it is important to obtain a tissue diagnosis in order to exclude pyogenic vertebral osteitis.
Post exercise lymphocytopenia is well documented and attributed to egress of lymphocytes from the vascular compartment. Recent studies have reported exercise induced DNA damage in leukocytes and have questioned a possible link to apoptosis. Eleven subjects underwent a ramped treadmill test to exhaustion. Venous blood samples were taken before, immediately post exercise, and 24 and 48 hours after exercise. Single cell gel electrophoresis revealed evidence of single strand DNA damage in 10% of lymphocytes immediately after exercise, but not at other times. Fluorescent microscopy showed three patterns of DNA distribution, similar to those seen in apoptosis, at all times after exercise. Three subjects underwent the same exercise protocol, and lymphocytes were prepared for flow cytometry to determine apoptosis using the TUNEL method. Flow cytometry revealed lymphocyte apoptosis in 63% of lymphocytes immediately after exercise and 86.2%, 24 hours after exercise. Lymphocyte apoptosis is documented for the first time after exercise and may in part account for exercise induced lymphocytopenia and reduced immunity.
A prospective study was undertaken to evaluate the triple wire technique in 34 patients who had sustained bifacet cervical spinal dislocations. Skull traction was applied on admission in all patients and the dislocation as gradually reduced under sedation. The operation was undertaken as soon as the general condition of the patient permitted. A triple wire construct utilizing an iliac graft was used in all cases. The patients were mobilized with a soft collar following operation. All grafted areas united and there were no malunions. No patient deteriorated neurologically.
We report on two children with tuberculosis of the craniocervical junction. Atlantoaxial instability was evident in both patients due to the destruction of the dens and the atlantoaxial ligaments. In addition, one child had tuberculosis involving the anterior arch of the atlas and the anterior rim of the foramen magnum. Despite anti-tuberculosis treatment and immobilization, atlantoaxial instability was evident on flexion/extension views. Successful fusion of C1 and C2 was performed in both patients.
The authors treated 31 patients with septic arthritis of the sacroiliac joint (14 patients with tuberculosis, 7 acute staphylococcal, 6 gonococcal, and 4 typhoid). The clinical presentation was vague and nonspecific, but most patients reported buttock pain, low back pain and difficulty walking. In 28 patients, the diagnosis was established after clinical examination, bone scans, hematologic investigations, and blood cultures. The diagnosis was established through arthrocentesis of the sacroiliac joint in 9 patients. In 3 patients, there was a delay in diagnosis. Twenty-nine patients improved on a conservative regimen of bed rest and antibiotics. Two patients required open drainage because of a large buttock abscess that was secondary to tuberculosis sarcoiliitis.
We treated 13 children with histologically confirmed cystic tuberculosis of bone. Ten had solitary cystic lesions and three had the multicystic form. Signs and symptoms were related mainly to the joint adjacent to the cyst. Most lesions were in the metaphyses of long bones. They were radiolucent, round or oval, and resembled pyogenic infections, aneurysmal and simple bone cysts, cartilaginous tumours or osteoid osteoma. Only two of the children had pulmonary tuberculosis. The Mantoux skin test was negative in four children and the ESR was normal in five. Curettage followed by anti-tuberculosis therapy for one year resulted in good healing, but two children had residual joint contractures. Biopsy should be taken from the cystic area rather than from the synovium when a joint is involved.
In an effort to define better diagnostic and treatment criteria, we reviewed the cases of 50 patients with injuries of the upper dorsal spine from T2-T9, seen between January 1983 and July 1988. The majority of injuries were caused by road traffic accidents, followed by falls from a height, and train accidents. More than 50 per cent had associated injuries, of which four were missed; 50 per cent had neurological deficits, and the majority of these cases had burst fractures and fracture-dislocations. Treatment was non-operative in the majority of cases, with only four cases undergoing anterior spinal decompression and fusion, and one had posterior instrumentation and fusion. At follow-up (1-3 years), only one patient, a child, had significant deformity. All patients with partial neurological deficit improved, whereas none of those with complete neurological lesions recovered. Five patients had significant back pain requiring analgesics but not significant enough to interfere with their activities. We concluded that most of these injuries are stable and should be treated non-operatively. Surgery is only indicated in cases with partial neurological deficit and significant spinal canal compromise or significant instability. Children should be followed up until maturity to look for late deformity.
We reviewed 37 patients following a posterior spinal fusion for traumatic ligamentous instability of the atlanto-axial joint. All patients were neurologically intact and the atlanto-dental interval ranged from 5 to 9 mm. A Gallie fusion was performed in 19 patients, a Brooks fusion in 16 patients and an occipitocervical fusion in two patients. A SOMI brace was used postoperatively for 12 weeks. Bony fusion was obtained in 32 patients. Displacement occurred in 11 patients, five of whom developed non-union.
Haemangiopericytoma of the floor of the mouth with metastases to the lumbar spine in a 23-year-old black woman is described. She represents the 36th patient with oral cavity haemangiopericytoma and the 4th with a floor of mouth lesion. The aggressive behaviour of haemangiopericytoma and its resistance to all forms of recommended treatment was shown in this patient.
This study was undertaken to determine the incidence and clinical features of avascular necrosis of bone in 69 transplant recipients all of whom had a functioning allograft for at least 12 months. An attempt was also made to identify any potential predisposing factors. The patients were assessed by an orthopaedic surgeon. The diagnosis of avascular necrosis was made on the basis of radiographs and isotope bone scans. Fourteen patients (20.2%) developed avascular necrosis with a mean onset of 19 months post-transplantation. The hip joint was most commonly affected. The isotope bone scan was the most sensitive diagnostic tool; abnormalities were detected before the onset of symptoms in 4 patients. Avascular necrosis was more common in Indian transplant recipients and was also associated with: (i) cadaver transplants; (ii) more frequent bouts of acute rejection (P < 0.05); and (iii) a greater incidence of other steroid-associated side-effects (P < 0.05). Alcohol consumption and radiological evidence of osteoporosis were more prevalent in the avascular necrosis group (42.8% v. 29.0% and 28.5% v. 7.2% respectively). Avascular necrosis did not correlate with age, sex, renal function at 1 year or severe secondary hyperparathyroidism. This study suggests that corticosteroid therapy plays an important role in the pathogenesis of avascular necrosis. Excessive alcohol consumption and osteoporosis also appear to be risk factors.
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Eight patients with neurofibromatosis presented with symptoms of cervical spine involvement over a period of 17 years, five of them within the second decade of life. The symptoms included neurological deficit in five, a neck mass in four, and deformity in three; only two complained of pain. Osteolysis of vertebral bodies with kyphosis of more than 90 degrees was the most common radiological feature. Posterior fusion failed in the one patient in whom it was performed. Good results were achieved by anterior fusion, alone, or combined with posterior fusion. Surgical complications included one death in a patient with a malignant neurofibroma, and one case of transient neurological deterioration.
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A retrospective clinical and radiologic study was made of 16 children with foot deformities and associated occult spinal abnormalities in a 3-year period. Eleven children had bilateral foot deformities; the deformities were unilateral in five. Midline cutaneous lesions of the back were noted in 13 children; the most common dermal sign was a hairy patch. All children had radiologic features of spinal dysraphism on combined computed tomography (CT) scan and myelogram. Spinal dysraphism was not considered in the initial assessment of four children. Children with foot deformity should therefore have a careful assessment of the spine, including a neurologic evaluation.
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Aspergillosis involving either the vertebral body or the intervertebral disc is a rare cause of osteomyelitis of the spine. The following is a report of five cases of Aspergillus fumigatus infection of the spine treated successfully with amphotericin B and 5-flucytosine. In three patients, the diagnosis was established at closed-needle biopsy; two patients with paraplegia had an anterior decompression and fusion. The follow-up period ranged from 19 to 48 months.
Of 23 children with infections of the clavicle, 11 had pyogenic osteomyelitis, four had tuberculosis, and eight (infants) had congenital syphilis. Acute pyogenic infections were treated by drainage. Resection of the clavicle was performed in chronic cases. Curettage and antituberculosis drugs were effective for children with tuberculous infection of the clavicle. Procaine penicillin was used for the treatment of congenital syphilis. Biopsy is generally necessary to differentiate chronic infection from neoplasm.