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1.  Management of Persistent Cerebrospinal Fluid Leakage Following Thoraco-lumbar Surgery 
Asian Spine Journal  2012;6(3):157-162.
Study Design
This was a retrospective study of patients who had developed a dural tear after thoracic and lumbar spine surgery that was not recognized during the surgery, and was treated either by lumbar drainage or over-sewing of the wounds.
To revisit the treatment strategies in postoperative dural leaks and present our experience with over-sewing of the wound and lumbar drainage.
Overview of Literature
Unintended durotomy is a frequent complication of spinal surgery. Management of subsequent cerebrospinal fluid leakage remains controversial. There is no distinct treatment guideline according to the etiology in the current literature.
The records of 368 consecutive patients who underwent thoracic and/or lumbar spine surgery from 2006 throug h 2010 were retrospectively reviewed. Seven cerebrospinal fluid fistulas and five pseudomeningoceles were noted in 12 (3.2%) procedures. Cerebrospinal fluid diversion by lumbar drainage in five pseudomeningoceles and over-sewing of wounds in seven cerebrospinal fluid fistulas employed in 12 patients. Clinical grading was evaluated by Wang.
Of the 12 patients who had a dural tear, 5 were managed successfully with lumbar drainage, and 7 with oversewing of the wound. The clinical outcomes were excellent in 9 patients, good in 2, and poor in 1. Complications such as neurological deficits, or superficial or deep wound infections did not develop. A recurrence of the fistula or pseudomeningocele after the treatment was not seen in any of our patients.
Pseudomeningoceles respond well to lumbar drainage, whereas over-sewing of the wound is an alternative treatment option in cerebrospinal fluid fistulas without neurological compromise.
PMCID: PMC3429605  PMID: 22977694
Cerebrospinal; Drainage; Spinal; Primary repair; Wound Healing
2.  Isolated avulsion fracture of lesser tuberosity of the humerus: Review of the literature and report of two cases 
Two cases of acute isolated avulsion fracture of the lesser tuberosity of the humerus and their short-term outcome are presented with a review of previously reported cases. Open reduction and internal fixation was performed. Outcomes were excellent, and the patients regained their normal pain-free shoulder function 3 months after the operation. This was a Level IV study.
PMCID: PMC3157099  PMID: 21897585
Fracture; shoulder; tuberculum; tuberosity
3.  Evaluation of thoracic pedicle screw placement in adolescent idiopathic scoliosis 
European Spine Journal  2009;18(12):1892-1897.
Pedicle screw fixation is a challenging procedure in thoracic spine, as inadvertently misplaced screws have high risk of complications. The accuracy of pedicle screws is typically defined as the screws axis being fully contained within the cortices of the pedicle. One hundred and eighty-five thoracic pedicle screws in 19 patients that were drawn from a total of 1.797 screws in 148 scoliosis patients being suspicious of medial and lateral malpositioning were investigated, retrospectively. Screw containment and the rate of misplacement were determined by postoperative axial CT sections. Medial screw malposition was measured between medial pedicle wall and medial margin of the pedicle screw. The distance between lateral margin of the pedicle screw and lateral vertebral corpus was measured in lateral malpositions. A screw that violated medially greater than 2 mm, while lateral violation greater than 6 mm was rated as an “unacceptable screw”. The malpositions were medial in 20 (10.8%) and lateral in 34 (18.3%) screws. Medially, nine screws were rated as acceptable. Of the 29 acceptable lateral misplacement, 13 showed significant risk; five to aorta, six to pleura, one to azygos vein and one to trachea. The acceptability of medial pedicle breach may change in each level with different canal width and a different amount of cord shift. In lateral acceptable malpositions, the aorta is always at a risk by concave-sided screws. This CT-based study demonstrated that T4–T9 concave segments have a smaller safe zone with respect to both cord-aorta injury in medial and lateral malpositions. In these segments, screws should be accurate and screw malposition is to be unacceptable.
PMCID: PMC2899438  PMID: 19526376
Pedicle screws; Thoracic spine; Malposition; Adolescent idiopathic scoliosis
4.  Placement of pedicle screws in thoracic idiopathic scoliosis: a magnetic resonance imaging analysis of screw placement relative to structures at risk 
European Spine Journal  2008;17(5):657-662.
In posterior pedicle screw instrumentation of thoracic idiopathic scoliosis, screw malposition might cause significant morbidity in tems of possible pleural, spinal cord, and aorta injury. Preoperative axial magnetic resonace images (MRI) in 12 consecutive patients with right thoracic adolescent scoliosis, all with King type 3 curves, were analyzed in order to evaluate the relationship between the inserted pedicle screw position to pleura, spinal cord, aorta. Axial vertebral images for each thoracic level were scanned and the simulation of pedicle screw insertion was performed using a digital measurement programme. The angular contact value for each parameter regarding the pleura and spinal cord was measured on both sides of the curve. The aorta-vertebral distance was also measured. Aorta-vertebral distance was found to be decreasing gradually from the cephalad to the caudad with the shortest distance being measured at T12 with a mean of 1.2 mm. Concave-sided screws on T5–T9 and convex-sided screws on T2–T3 had the greatest risk to spinal cord injury. Pleural injury is most likely on T4–T9 segments by the convex side screws. T4–T8 screws on the concave side and T11–T12 screws on the convex side may pose risk to the aorta. This MRI-based study demonstrated that in pedicle instrumentation of thoracic levels, every segment deserves special consideration, where computer scanning might be mandatory in immature spine and in patients with severe deformity.
PMCID: PMC2367414  PMID: 18301931
Pedicle screw; Thoracic spine; Pleura; Spinal cord; Aorta
5.  Juvenile idiopathic scoliosis treated with posterior arthrodesis and segmental pedicle screw instrumentation before the age of 9 years: a 5-year follow-up 
Scoliosis  2009;4:1.
Study design
Retrospective study.
To evaluate the radiological results of fusion with segmental pedicle screw fixation in juvenile idiopathic scoliosis with a minimum 5-year follow-up.
Summary of background data
Progression of spinal deformity after posterior instrumentation and fusion in immature patients has been reported by several authors. Segmental pedicle screw fixation has been shown to be effective in controlling both coronal and sagittal plane deformities. However, there is no long term study of fusion with segmental pedicle screw fixation in these group of patients.
Seven patients with juvenile idiopathic scoliosis treated by segmental pedicle screw fixation and fusion were analyzed. The average age of the patients was 7.4 years (range 5–9 years) at the time of the operation. All the patients were followed up 5 years or more (range 5–8 years) and were all Risser V at the most recent follow up. Three dimensional reconstruction of the radiographs was obtained and 3DStudio Max software was used for combining, evaluating and modifying the technical data derived from both 2d and 3d scan data.
The preoperative thoracic curve of 56 ± 15° was corrected to 24 ± 17° (57% correction) at the latest follow-up. The lumbar curve of 43 ± 14° was corrected to 23 ± 6° (46% correction) at the latest follow-up. The preoperative thoracic kyphosis of 37 ± 13° and the lumbar lordosis of 33 ± 13° were changed to 27 ± 13° and 42 ± 21°, respectively at the latest follow-up. None of the patients showed coronal decompensation at the latest follow-up. Four patients had no evidence of crankshaft phenomenon. In two patients slight increase in Cobb angle at the instrumented segments with a significant increase in AVR suggesting crankshaft phenomenon was seen. One patient had a curve increase in both instrumented and non instrumented segments due to incorrect strategy.
In juvenile idiopathic curves of Risser 0 patients with open triradiate cartilages, routine combined anterior fusion to prevent crankshaft may not be warranted by posterior segmental pedicle screw instrumentation.
PMCID: PMC2633314  PMID: 19123957
6.  The use of combined lateral and medial releases in the treatment of post-traumatic contracture of the elbow 
International Orthopaedics  2006;31(5):635-638.
Elbow stiffness is a common disorder, which restricts daily activities. Between 30° and 130° of elbow movement is usually enough to perform most daily activities. However, a 10° to 15° loss of elbow extension may be a problem when the patient is an athlete. From 1996 to 2004, 20 elbows of 20 patients (who were available for follow-up examination) were treated by lateral and medial release at Kocaeli University, for post-traumatic elbow contracture. Preoperative and the postoperative 12-month follow-up measurements were performed. The mean preoperative arc of motion was 35° and this value improved to 86.2°. The maximum improvement at the arc of motion was 105°. In an effort to understand the pathophysiology of the condition, surgical approaches may be used safely. The purpose of this study was to assess the functional outcome of the elbow joint after using a combination of lateral and medial approaches to treat elbow stiffness.
PMCID: PMC2266642  PMID: 17036222

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