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Sostituzione protesica del disco cervicale
No full textLa discectomia ed artrodesi cervicale per via anteriore (anterior cervical discectomy and fusion,
ACDF) rappresenta la procedura di scelta per il trattamento delle radicolopatie e mielopatie da ernia
del disco cervicale. Sebbene si tratti di una procedura efficace e con tassi di complicanze modesti
(2-4%), studi clinici e biomeccanici recenti hanno evidenziato come la tecnica di artrodesi cervicale
anteriore alteri irrimediabilmente la biomeccanica del rachide cervicale. L’artrodesi del livello trattato
determina una redistribuzione dei carichi meccanici sui livelli adiacenti con accelerazione del pro-
cesso di degenerazione discale. Stime attuali suggeriscono che circa il 25% dei pazienti sottoposti
ad ACDF svilupperà una discopatia del livello adiacente a 10 anni (3% all’anno) e la metà di questi
richiederà un nuovo intervento chirurgico. La sostituzione protesica del disco cervicale si propone
come procedura alternativa all’artrodesi anteriore (ma non alla decompressione!) per la prevenzione
della degenerazione dei segmenti adiacenti. I primi trials prospettici e randomizzati su ACDF e pro-
tesi discale hanno avuto inizio negli anni 2000 ed hanno dimostrato percentuali di successo simili o
a volte superiori per le protesi discali rispetto all’ACDF ed una sostanziale sovrapposizione in termini
di sicurezza tra le due metodiche. L’esito di questi trials ha portato all’immissione in commercio di
numerosi dispositivi per la sostituzione protesica discale cervicale. Il candidato ideale resta tuttora
il giovane adulto con radicolopatia sintomatica e con articolazioni posteriori intatte. L’obiettivo di
questo articolo è di revisionare criticamente la Letteratura a supporto dell’utilizzo delle protesi discali
cervicali tracciandone brevemente le linee di sviluppo future. La sostituzione protesica discale cer-
vicale è oramai una tecnica matura e riconosciuta a livello internazionale; i dati di medio follow-up
ad oggi disponibli sono incoraggianti, ma soltanto dati a più lungo termine potranno confermare la
promessa di una riduzione della degenerazione dei segmenti adiacenti.Anterior cervical discectomy and fusion (ACDF) is a common surgical procedure for the treatment
of cervical radiculopathy and myelopathy due to cervical disc disease. Although it is a generally
successful and safe procedure (complication rate between 2 and 4%), more recent studies have
raised concerns regarding alterations of cervical spine biomechanics following a fusion. The fusion
of a cervical segment leads to increased stress and loading on the adjacent segments which in turn
can accelerate the degeneration process. Current estimates suggest that 25% of patients treated
with ACDF will develop adjacent segment degeneration at 10 years (3% per year) and half of these
patients will require new surgical intervention. Cervical disc arthroplasty (CDA) was developed as an
alternative procedure to preserve motion both at the affected and adjacent levels and theoretically
lower rates of adjacent segment degeneration. Prospective randomized trials comparing ACDF with
CDA were initiated in 2000 and have demonstrated significant differences in some clinical outcome
measures favouring CDA and comparable safety profiles between the two techniques. Following
these trials many different devices have been licensed and are currently available on the market. The
typical candidate patient for CDA is the young active adult patient with single level symptomatic disc
disease and with intact posterior facet joints. The aim of this article is to critically review available
literature supporting clinical use of CDA. Cervical disc replacement is nowadays an accepted
technique with established short and medium-term follow-up data, however only long-term data will be able to confirm the promise of decreased adjacent segment disease
and fewer reoperations
Single-stage posterior reduction and instrumented fusion of high-grade L5–S1 spondylolisthesis
No full textIntratechal baclofen pumps do not accelerate progression of scoliosis in quadriplegic spastic cerebral palsy
No full textPURPOSE:
To compare scoliosis progression in quadriplegic spastic cerebral palsy with and without intrathecal baclofen (ITB) pumps.
METHODS:
A retrospective matched cohort study was conducted. Patients with quadriplegic spastic cerebral palsy, GMFCS level 5, treated with ITB pumps with follow-up >1 year were matched to comparable cases by age and baseline Cobb angle without ITB pumps. Annual and peak coronal curve progression, pelvic obliquity progression and need for spinal fusion were compared.
RESULTS:
ITB group: 25 patients (9 female), mean age at pump insertion 9.4 and Risser 0.9. Initial Cobb angle 25.6° and pelvic tilt 3.2°. Follow-up 4.3 (1.0-7.8) years. Cobb angle at follow-up 76.1° and pelvic tilt 18.9°. Non-ITB group: 25 patients (14 female), mean age at baseline 9.2 and Risser 1.0. Initial Cobb angle 29.7° and pelvic tilt 7.1°. Follow-up 3.5 (1.0-7.5) years. Cobb angle at follow-up 69.1° and pelvic tilt 21.0°. The two groups were statistically similar for baseline age, Cobb angle and Risser grade. Mean curve progression was 13.6°/year for the ITB group vs 12.6°/year for the non-ITB group (p = 0.39). Peak curve progression was similar between the groups. Pelvic tilt progression was comparable; ITB group 4.5°/year vs non-ITB 4.6°/year (p = 0.97). During follow-up 5 patients in the ITB group and 9 in the non-ITB group required spinal fusion surgery for curve progression (p = 0.35).
CONCLUSIONS:
Patients with quadriplegic spastic cerebral palsy with and without ITB pumps showed significant curve progression over time. ITB pumps do not appear to alter the natural history of curve progression in this population
Trattamento delle lesioni del rachide nel polifratturato di eta' pediatrica
No full textSpine injuries involve 1 to 5% of children admitted to trauma centers and a high index of suspicion is warranted owing to the potential severe consequences of unstable lesions. Evaluation of cervical and lumbar trauma in children requires an understanding of developmental anatomy to differentiate trauma from age-appropriate findings. Generally speaking, young children more often have ligamentous injuries, whereas older children and adolescents have bone injuries as the spine takes on adult features. The aim of this review is to provide a concise overview of the major aspects involved in spine injuries detection and management in children. Epidemiology is discussed first, and then appropriate precautions and paediatric spine immobilization protocols are presented. Details of paediatric spine radiological anatomy are included and our institutional spine clearance protocol is discussed. Lastly, a short paragraph is devoted to analyze treatment of spinal cord injuries in children and halo immobilization
Congenital defects of C1 arches and odontoid process in a child with Down’s syndrome: a case presentation
No full textWe present the case of a 2-year-old child with Down's syndrome who presented to our unit with torticollis. Imaging studies revealed the rare occurrence of anterior and posterior C1 arch defects, absent odontoid process, and atlantoaxial subluxation. We managed her conservatively for 3 years without neurological deficits or worsening of atlantoaxial subluxation. We discuss the rare occurrences of anterior and posterior arch defects of the atlas, the radiological presentations of axis defects in patients, and the occurrence of atlantoaxial instability in patients with Down's syndrome. Management options with consideration to surgery in asymptomatic and symptomatic patients are also discussed
Clinical outcome and safety study of a newly developed instrumented French-door cervical laminoplasty technique
No full textBACKGROUND:
Standard laminectomy for treatment of cervical myelopathy is associated with secondary instability and kyphosis, while laminectomy combined with fusion puts adjacent segments at risk of degeneration. Single- and double-door laminoplasty techniques have been developed to overcome these limitations. More recently, complications related to bone graft dislodgment have fostered development of hardware-augmented laminoplasty techniques. The aim of this study is to review the clinical safety and effectiveness of a newly developed technique of instrumented French-door laminoplasty for treatment of cervical myelopathy.
MATERIALS AND METHODS:
A series of 25 consecutive myelopathic patients were treated with a novel instrumented cervical French-door laminoplasty technique, whereby the enlarged posterior arch was held open with maxillofacial plates and screws. Patients had pre- and postoperative assessments with the Neck Disability Index (NDI), Japanese Orthopaedic Association (JOA) Score, Visual Analogue Score and radiographs. Minimum follow-up was 40 months, with regular interval assessments.
RESULTS:
There were 18 males with a mean age of 45 years. The mean operative time was 145 min. The average hospital stay was 2.4 days and the mean follow-up was 56.5 months (40-72). All patients reported neurological improvements and there was a 35% improvement in NDI, and JOA score improved by 4.8 points. No postoperative hardware-related complications were noted and only one case of temporary C5 palsy, which completely resolved by the one-year follow-up.
CONCLUSIONS:
Our data and clinical experience demonstrate that this hardware-augmented laminoplasty technique is safe and effective. We observed no hardware-related complications in our series. The use of readily available maxillofacial titanium miniplates and ease of surgical procedure means that this technique can be easily adopted into clinical practice
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