Biomedical subjects
Publications and source records attributed to R Savini.
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A total of 187 random cases of untreated idiopathic scoliosis, seen from a minimum of 15 to a maximum of 47 years after the end of growth, were reviewed. All curves increased after skeletal maturity (average progression: 0.4 degrees per year). Thoracic curves tend to progress more than lumbar, lumbar more than thoracolumbar, and thoracolumbar more than double major curves. Pain was present in 114 cases (61%) and appeared more frequently in women, after pregnancies, and with fatigue. Cardiopulmonary symptoms were present in 42 patients (22%), especially those with thoracic and thoracolumbar curves greater than 40 degrees. Psychologic disturbances were found in 35 cases (19%), mostly female patients with thoracic curves greater than 40 degrees. The cosmetic appearance of these patients at long-term follow-up was better compared with that at the end of growth, even though the curves progressed. Patients with decompensation of the trunk at the end of growth seemed to improve with time. In an unselected group of patients with severe curves a mortality rate of 17% was found, twice as much as in the Italian general population.
Posterolateral lumbar and lumbosacral arthrodesis has been used during the last 50 years as a method of posterior arthrodesis in patients who have undergone previous laminectomies or after previous unsuccessful attempts at posterior fusion. The higher percentages of successful fusion has extended the use of this technique to other conditions such as spondylolisthesis and lumbar pain due to segmental instability. The present study is a clinical and radiographic evaluation of the results obtained in a series of 84 patients affected by lumbar or lumbosciatic pain arising from different causes - spondylolisthesis, degenerative lumbar disc disease or failed operations for lumbar disc prolapse. The follow-up was 2-6 years.
We reviewed the cases of nine patients with a giant-cell tumor of the vertebrae. All segments of the spine can be affected by the tumor, but there was a predilection for the lumbar segments in our series. Pain was present in all patients. The maximum duration before the diagnosis was made was three years and the minimum, forty-five days (average, 12.2 months). In six patients a neural deficit was also present. One patient was treated many years ago by radiation therapy alone; three patients were treated by decompressive laminectomy; two, by excision of the lesion and postoperative radiation therapy; and three patients underwent lesional but extensive excision as well as arthrodesis without any preoperative or postoperative radiation therapy. We have obtained good results with the latter treatment; after follow-ups of sixty, twenty-six, and twenty-four months in three patients the pain and the neural symptoms subsided, while roentgenographic examination showed no evidence of local recurrence. In all patients the autogenous bone grafts appeared to be incorporated, without any secondary deformity. We concluded that, due to the development of better surgical techniques, the surgical approach is probably the best modern treatment for a giant-cell tumor located in the spine.
Vertebral deformity in neurofibromatosis can present in two basic forms which determine the prognosis and treatment. In the first form, which is rare, there are no gross dystrophic changes, while in the second, which is the more common, such changes are widespread. Neurofibromatosic scoliosis where there are no signs of bone dystrophy poses no particular therapeutic problems. However, the surgical treatment of the dystrophic form is much more complex and the results far more uncertain. There is a high incidence of pseudarthrosis following posterior arthrodesis and fixation with Harrington rods, and this has shown the need for combined posterior and anterior arthrodesis in all cases of neurofibromatosic kyphoscoliosis. Furthermore, posterior arthrodesis alone does not provide protection against future relapse even when kyphosis is initially absent. Delayed kyphosis, due to subsidence of the vertebral bodies, frequently appears after six months and necessitates a second operation to reinforce the posterior arthrodesis. However, a greater guarantee of stability can be achieved simply by performing combined anterior and posterior arthrodesis at the outset.
Ossification of the posterior longitudinal ligament in the cervical spine may be a cause of cervical myelopathy. This ossification has often been encountered in Japan, but only sporadically among the Caucasian races. It is therefore probable that racial factors are relevant to the pathology. During the past four years, due to the routine use of computerised axial tomography (CAT) in the pre-operative study of cervical myelopathy, we were able to show that in 13 cases stenosis of the vertebral canal was due to ossification of the posterior longitudinal ligament. This was visible in the standard radiographs in only two out of these 13 cases. The clinical data, diagnostic criteria and results of treatment are reported. This is the largest series yet reported outside Japan.
The Authors describe the technique of lateral laminectomy devised by Gui in 1965 for the treatment of cervical myelopathy secondary to cervical spondylosis. Spinal cord decompression is obtained by a lateral laminectomy with the maximum saving of bone, ligaments and muscles of the cervical spine. CAT scan demonstrated very well the effective decompression of the spinal cord achieved with this technique. The results of 87 cases treated in this way between 1968 and 1980 are reported. The average follow-up was 2.5 years. There was an improvement in the neurological symptoms in 82% of the cases.
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The clinical features and the treatment results of 15 patients with solitary plasmacytoma of the spine observed in a 28-year period (1950-1977) are reported. The signs at presentation were back pain in 4 cases and spinal cord compression in 11 cases. Three of these patients had paraplegia. Radiologically, the alteration encountered was an osteolytic lesion in all cases. The local treatment was radiotherapy in 11 cases and surgery plus radiotherapy in 4 cases. In 3 patients systemic chemotherapy was also employed. Seven patients are alive without signs of disease 3 to 9 years (mean 6 years) after diagnosis. Eight patients developed multiple myeloma in a period ranging from 1 to 8 years (mean 3.5 years). The relationship between multiple myeloma and solitary plasmacytoma of the spine, as well as the best treatment for the latter, are discussed.
Instability of the cervical spine gives rise to vertebral and neurological symptoms which may be progressive. The principal causes of instability are: trauma, sequelae of laminectomy, malformations, vertebral infections, rheumatoid arthritis, primary tumours (benign and malignant), metastases, and chronic degenerative disease of the discs. Each of these forms of instability must be identified and, depending on the symptoms and pathogenesis, is capable of responding to the appropriate treatment.
The Freeman-Sheldon syndrome is a rare hereditary disorder that was described by these authors in 1938 under the name of "cranio-carpotarsal dystrophia". It is characterised by a combination of congenital malformations of which the principal are: deformities of the face and skull, flexion and ulnar deviation of the fingers and talipes. The appearance of the face is the most striking feature, the small dimension of the oral fissure giving rise to the term "whistling face" proposed by Burian (1963). Spinal curvature is often present, and can show marked progression, as in one of our cases. The congenital hip dislocation present in both our cases has not been observed in previously described cases. As far as we know, the two cases described here are the first in Italy to be added to the other twenty-eight already reported in literature.
Marfan's syndrome is an hereditary disorder of the connective tissue which in its most classic form includes cardiovascular, ocular and skeletal manifestaions. Scoliosis is frequently present (40-75 per cent); the type of curve is similar to that seen in idiopathic scoliosis, but progression is often much more severe. One of our patients, a woman aged thirty-two who had never been treated, had two 180 degree curves. There is a high incidence (50 per cent) of double curves (right thoracic and left lumbar) and a 23 per cent incidence of triple curves. Vertebral inversion (thoracic lordoscoliosis) is very common and often accompanied by severe respiratory insufficiency, particularly if it is associated with funnel chest. Conservative treatment is almost invariably ineffective and should be reserved only for very slight curves. All curves of 50 degrees or more should be surgically corrected. A 40-50 per cent correction can be achieved without risk. In view of the high incidence of pseudarthrosis, systematic review and, if necessary, revision of the arthrodesis is to be recommended. In the more severe cases of kyphosis it is advisable also to perform an anterior arthrodesis. Surgery is contraindicated in the presence of severe mitral or aortic insufficiency or aortic aneurysm.
The authors review twenty-four cases of fracture and fracture dislocation of the thoracic and lumbar spine treated by open reduction and stabilisation with Harrington's rods. In twenty-one cases posterior arthrodesis was also performed. Distraction rods were used in eighteen patients, compression rods in three and both types in three. In twenty-two cases it was possible to carry out a long term review. Stabilisation was achieved in all but one case. There was an average loss of correction of the kyphosis amounting to 10.5 per cent. Marked improvement was noted in nine patients who had incomplete neurological lesions. In thirteen patients with complete neurological lesions, no improvement was noted. In all the cases the treatment made post-operative nursing easier and the patient was more quickly mobilised.
A case is presented of cord compression due to vertebral echinococcosis which relapsed after a first laminectomy elsewhere. The authors carried out a second excision with decompression from the anterior approach, supplemented by grafting. After a period of recovery and well being, relapse occurred with renewal of the cord compression. A second decompressive laminectomy and excision of the relapsed cyst was carried out. The present case illustrates the limitations of surgery in this parasitology, because of the extreme liability to relapses.
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Between 1968 and 1973 forty nine patients suffering from poliomyelitic scoliosis were treated surgically at the Rizzoli Institute. They were due to asymmetrical paralysis and contracture in the muscles of the trunk and limbs. Associated pathological conditions were found, such as pelvic obliquity, and vascular and trophic changes due to ganglionic lesions. The differing incidence and combination of these factors gave rise to various clinical types of spinal deformity. The average severity of curve was 39 degrees, the localisation was predominantly central, the average extent was ten vertebrae, and there was a marked predominance of right convexity (twenty nine out of thirty six). The rate of progression was maximum during puberty and almost negligible after bony maturity. It was greater in males and was unfavourably affected by the severity and asymmetrical distribution of the paralysis, by the early appearance of the disease, by high localisation of the deformity, and by the erect posture in patients who were ambulant. The most frequent visceral complications were in the respiratory system (ten patients with a deficit over 50%), followed by cardiac changes. Surgical treatment was adopted in patients with progressive curves over 60 degrees, because of the inevitable deterioration in their general condition and the tendency of the deformity to become fixed. Pre-operative correction by Halo-traction results (52% correction) than Risser plasters (38%). Posterior arthrodesis by Harrington's method was carried out in all the more recent cases (forty four). Post-operative plaster was maintained for eight months and then replaced by an orthopaedic corset. At bony maturity there was an averaged improvement of 35% in the angle of curvature, and an average improvement of 6% in vital capacity. The best corrections were obtained in patients under fourteen (42%), in dorso-lumbar scoliosis (40%) and in patients with curves above 100 degrees (38%). There was an average increase in height of 9.1 cms and a reduction in the gibbus of 3.4 cms. The complications included one traumatic pneumothorax, eight pseudarthroses, and breakage of the distraction rod in two cases resulting in complete relapse of the deformity. In six cases the upper hooks became loos and there were two cases of postoperative staphylococcal infection. In the distally sited curves our present policy is towards combining posterior arthrodesis with Dwyer's anterior interbody fusion.
The authors carried out a study of respiratory function in seventy six patients suffering from severe scoliosis of different types; forty five idiopathic, sixteen poliemyelitic, ten congenital, and five neurofibromatosic. The age incidence was from a minimum of eleven years to a maximum of thirty three, with the average around fifteen years. The site of the deformity was predominantly dorsal (fifty cases), though there were also lumbar and dorso-lumbar types. The average angle of curvature (Cobb) before treatment was 110 degrees. Arthrodesis by the Harrington technique was carried out on all patients after correction with a Risser-type plaster in sixty nine cases, and Halo-traction in seven cases. The post operative period in plaster was about eight months. Spirometric tests were carried out before treatment, after preoperative correction, and two to three years after operation, always with the chest out of plaster. The results of these tests are expressed as percentage reductions in the maximum ventilation compared with the average normal values in the tables reported by Baldwin et al. (1948). The values obtained before commencing treatment showed that lumbar scoliosis even if very severe, never leads to severe respiratory deficits. There is no linear relationship between the severity of the curve and the respiratory deficit, though there is a general connection between them. Tests of respiratory function were carried out after corrective treatment, both before and after operation and at a two year follow up. There was an overall average improvement of 10% in the respiratory deficit, with a maximum of about 20% in a group of twenty two patients with the most severe deficit before commencing treatment. Follow-up three years after operation showed the improvement in respiratory fimction had been maintained. The authors conclude that arthrodesis by the Harrington technique does not diminish the respiratory gain achieved by pre-operative correction. On the contrary, it stabilises it and maintains it over the three year follow-up period of the present survey.