Stuburo juosmeninės dalies kanalo stenozė: gydymas (II dalis)

Valentinas Uvarovas, Giedrius Kvederas, Igoris ŠatkauskasVilniaus universiteto Ortopedijos, traumatologijos ir plastinės chirurgijos klinikaVilniaus greitosios pagalbos universitetinė ligoninė,Šiltnamių g. 29, LT-2043 VilniusEl paštas: [email protected] Nors daugelis literatūros šaltinių pateikia gana prastus vėlyvuosius neoperacinio gydymo rezultatus, tačiau visi autoriai sutinka, jog beveik visada stuburo kanalo stenozę reikia pradėti gydyti konservatyviai. Nėra vienodų konservatyvaus gydymo schemų, tačiau geriausių rezultatų pasiekiama naudojant agresyvią gydymo taktiką. Studijose, apžvelgiančiose vėlyvuosius 1–5 metų konservatyvaus gydymo rezultatus, teigiama, kad gerų rezultatų pasiekiama nuo 15 iki 43% ligonių. Chirurginis gydymas siūlomas, jei konservatyvus buvo neveiksmingas. Literatūros duomenimis, geri ir puikūs rezultatai būdingi nuo 26% iki 100% operuotų ligonių. Chirurginė intervencija yra grindžiama blogėjančia gyvenimo kokybe, neurologinių simptomų progresavimu, o neurologinė simptomatika ir CT bei BMR duomenys yra tik papildomi argumentai. Vis dėlto neurologinius pažeidimus ne visada pavyksta panaikinti operaciniu būdu. Prasminiai žodžiai: stuburo kanalo stenozė, nervų šaknelės, neoperacinis gydymas, operacinis gydymas. Lumbar spinal stenosis: treatment Valentinas Uvarovas, Giedrius Kvederas, Igoris Šatkauskas The initial treatment for spinal stenosis should be conservative. An aggressive nonoperative treatment consisting of therapeutic exercise, analgesics, and epidural steroid injections is proposed. The natural long-term outcome of conservative treatment, however, is often unsatisfactory. Several studies on nonoperactive treatment of patients with 1 to 5 years of follow-up suggest that 15% to 43% of patients will have continued improvement after nonoperative treatment. Surgery is required after the failure of conservative care. The literature presents good and excellent results in 26% to 100% of patients after the surgical treatment of spinal stenosis. The decision to operate on a patient who has this condition should be based on a decrease in the patient's quality of life and an increase in the symptoms rather than on relatively subtle neurological findings and a positive magnetic resonance imaging scan. Additionally, it is reasonable to recommend operative treatment in an effort to decrease the neurological signs and to improve the quality of life. Operative intervention, however, cannot routinely be expected to reverse neurological deficits in every patient. Keywords: lumbar spinal stenosis, spinal nerve root, nonoperative treatment, operative treatmen

Kristaloidai ir koloidai perioperacinei skysčių terapijai: savybės ir dozavimo ypatumai

Straipsnio tikslas yra apžvelgti kristaloidų ir koloidų savybes, šių preparatų pranašumus ir trūkumus bei derinimo ypatumus perioperacinėje skysčių terapijoje. Racionali skysčių terapija gerina gydymo baigtį po didelių chirurginių intervencijų. Perioperacinei skysčių terapijai yra vartojami kristaloidų ir koloidų tirpalai bei jų deriniai. Nė viena iš tirpalų rūšių nėra pranašesnė už kitą, o nepageidaujamas poveikis labai priklauso nuo dozės. Trumpoje apžvalgoje aprašomos išskirtinės tirpalų savybės ir atsižvelgiant į naujausius mokslinius tyrimus apibūdinamos racionalaus jų dozavimo bei derinimo galimybės. Ypatingas dėmesys skiriamas naujų individualaus skysčių skyrimo metodų ir pusiau uždaros grandinės infuzinių sistemų naudojimo perspektyvoms. Reikšminiai žodžiai: skysčių terapija, kristaloidai, koloidai, perioperacinis laikotarpis, gydymo baigtis Crystalloids and colloids: aspects of their co-administration in perioperative fluid therap

Comparison of three tourniquet application methods in primary total knee arthroplasty surgery

The optimal timing of pneumatic lower limb tourniquet application during primary elective total knee arthroplasty surgery (TKA) is a matter of debate. 132 patients who undergo TKA were prospectively randomized into one of the 4 groups, and 120 of these patients completed the study. The tourniquet was inflated just before incision and deflated after the hardening of the cement for 30 patients (Group 1), it was inflated just before cement application and deflated after its hardening for another 30 patients (Group 2), and it was inflated before incision and deflated after the last suture of the skin for a further 30 patients (Group 3). The Group 4 received fluids at the discretion of an attending physician (standard of care). Group 1, 2 and 3 were given the same regimen but it was supplemented by a revGDT (revised Goal directed therapy) algorithm before the TKA and 24 h later. Fit-to-discharge criteria and six methods for calculating estimated blood loss were used. The estimated blood loss in Group 2 was higher than in Group 1 and 3. Group 1 was better fit to discharge than Group 3 and Group 4. Inflation of an automatic pneumatic lower limb tourniquet before skin incision and its deflation after hardening of cement tends to give better outcomes in TKA patients during six postoperative days. The estimated blood loss was highest when the tourniquet was inflated just before cement application and deflated after its hardening. Perioperative revGDT enhanced recovery after TKA

Trijų kraujotakos sumažinimo metodų palyginimas atliekant planinį cementinį kelio sąnario endoprotezavimą

The optimal timing of pneumatic lower limb tourniquet application during primary elective total knee arthroplasty surgery (TKA) is a matter of debate. 132 patients who undergo TKA were prospectively randomized into one of the 4 groups, and 120 of these patients completed the study. The tourniquet was inflated just before incision and deflated after the hardening of the cement for 30 patients (Group 1), it was inflated just before cement application and deflated after its hardening for another 30 patients (Group 2), and it was inflated before incision and deflated after the last suture of the skin for a further 30 patients (Group 3). The Group 4 received fluids at the discretion of an attending physician (standard of care). Group 1, 2 and 3 were given the same regimen but it was supplemented by a revGDT (revised Goal directed therapy) algorithm before the TKA and 24 h later. Fit-to-discharge criteria and six methods for calculating estimated blood loss were used. The estimated blood loss in Group 2 was higher than in Group 1 and 3. Group 1 was better fit to discharge than Group 3 and Group 4. Inflation of an automatic pneumatic lower limb tourniquet before skin incision and its deflation after hardening of cement tends to give better outcomes in TKA patients during six postoperative days. The estimated blood loss was highest when the tourniquet was inflated just before cement application and deflated after its hardening. Perioperative revGDT enhanced recovery after TKA

Stuburo juosmeninės dalies kanalo stenozė: klinikinė anatomija, diagnostika (I dalis)

Valentinas Uvarovas, Giedrius Kvederas, Igoris ŠatkauskasVilniaus universiteto Ortopedijos, traumatologijos ir plastinės chirurgijos klinikaVilniaus greitosios pagalbos universitetinė ligoninėŠiltnamių g. 29, LT-2043 VilniusEl paštas: [email protected] Pasaulyje ženkliai auga pagyvenusių žmonių populiacija, kartu daugėja ligų, kuriomis dažniausiai sergama perkopus į antrą gyvenimo pusę. Viena iš tokių ligų yra stuburo kanalo stenozė, t. y. susiaurėjimas. Dažniausia stuburo kanalo stenozės priežastis yra su amžiumi progresuojantys stuburo degeneraciniai pokyčiai. Ne visada arklio uodegos ar nervų šaknelių spaudimas sukelia dirginimo simptomus, tačiau progresuojant patologiniams anatominiams ir fiziologiniams pokyčiams gali išryškėti klinika. Kartais rentgenologiniai duomenys neatspindi klinikos, todėl labai svarbu tiksliai įvertinti ligos simptomus, jų eigą bei rentgenologinius duomenis, kad būtų pasirinkta tinkama gydymo taktika. Prasminai žodžiai: stuburo kanalo stenozė, neurogeninė klaudikacija, nervinės šaknelės, arklio uodega Lumbar spinal stenosis: clinical anatomy, diagnostics Valentinas Uvarovas, Giedrius Kvederas, Igoris Šatkauskas Lumbar spinal stenosis remains one of the most frequently encountered clinical important degenerative spinal disorders in the ageing population. Spinal stenosis is a narrowing or stricture of the spinal canal. Cauda equina and nerve root compression are noted in many asymptomatic individuals. The spinal degenerative process associated with ageing leads to pathoanatomical and pathophysiological changes with occasional clinical consequences. With progressive degenerative changes and compression, spinal stenosis may become symptomatic, although the severity of the symptoms is not necessarily associated with the magnitude of the compression seen on imaging studies. A thorough understanding of the etiology, pathologic features and a correlation between the symptoms and the precise location of the thecal sac and nerve root are very important in evaluating the imaging studies and planning appropriate treatment. Keywords: lumbar spinal stenosis, neurogenic claudication, spinal nerve root, cauda equin

Comparison of One-Year Functional Outcomes and Quality of Life between Posterior Pelvic Ring Fixation and Combined Anterior-Posterior Pelvic Ring Fixation after Lateral Compression (B2 Type) Pelvic Fracture

Background and Objectives: The treatment algorithm of lateral compression B2 type pelvic fractures are still under debate. Some authors advocate conservative treatment, while others recommend surgical approach. The clear indications for isolated anterior or posterior ring fixation or combined anterior-posterior pelvic ring fixation of B2 type fractures remain unclear. The aim of this study was to compare the functional outcomes and quality of life after isolated posterior pelvic ring fixation and combined anterior-posterior pelvic ring fixation for the treatment of B2 pelvic fractures. Materials and Methods: Patients aged 18 to 65 years with B2 type pelvic fracture hospitalized in a single trauma centre over a period of 3 years were included in the research. Based on the attending surgeon’s preference, patients were treated with isolated posterior or combined anterior-posterior pelvic fixation. The quality of life and pelvic function were assessed using SF-36 and Majeed questionnaires, respectively. Patients filled in the questionnaires twice: during the first hospitalization (concerning their pre-trauma state—timepoint I) and one-year after the injury (timepoint II). Results: A cohort of 32 patients with B2 type pelvic fracture was enrolled in the analysis: 23 (72%) were female and 9 (28%) were male. The mean age was 35.3 ± 11.9 years. In this cohort 13 (41%) patients underwent isolated posterior pelvic ring fixation (group I) and 19 (59%) patients underwent combined anterior-posterior pelvic ring fixation (group II). No statistically significant differences were observed between the groups in both timepoints concerning Majeed, SF-36 PCS and MCS scores. However, in both groups Majeed and SF-36 PCS scores were statistically significantly lower one year after pelvic fracture compared with pre-trauma state, while SF-36 MCS scores did not differ. Conclusions: No differences were found in quality of life and functional outcomes between isolated posterior pelvic ring fixation and combined anterior-posterior fixation for the treatment of B2 type pelvic fractures

Revision Rates After Surgical Treatment for Femoral Neck Fractures: Results of 2-Year Follow-up

Background and Objective. Intracapsular fractures of the femoral neck account for a major share of fractures in the elderly. Open reduction and internal fixation has been shown to have a higher rate of revision surgery than arthroplasty. The aim of this study was to assess and compare the rates of revision surgery performed after internal fixation and primary total hip arthroplasty. Material and Methods. Between 2004 and 2006, 681 intracapsular femoral neck fractures in 679 consecutive patients were treated with internal fixation or total hip arthroplasty at our institution. Revision surgery rates were evaluated at 1-, 3-, 6-, 12-, and 24-month follow-up. Results. There was no significant difference in the ratio of internal fixation to total hip arthroplasty during 2004–2006 (P=0.31). The mean rate of total hip arthroplasty was 19.1% with a lower rate being among patients younger than 60 years. Revision surgery rates at the 2-year followup were higher in the internal fixation group compared with total hip arthroplasty group (28.9% vs. 7.0%, P<0.001). Patients who underwent internal fixation were at a 4-fold greater risk of having revision surgery at the 2-year follow-up than those who underwent total hip arthroplasty (odds ratio, 4.11; 95% CI, 1.95–8.65; P<0.001). Age was a significant risk factor for revision surgery after total hip arthroplasty (hazard ratio, 0.93; 95% CI, 0.87–0.98; P=0.02), but not significant after the internal fixation (P=0.86). Conclusions. Higher revision surgery rates after internal fixation favors arthroplasty as a primary choice of treatment for the femoral neck fractures

Mortality After Femoral Neck Fractures: A Two-Year Follow-up

Background and Objective. To identify the survival and standardized mortality ratio with respect to gender, age, and treatment method of patients treated for femoral neck fractures. Material and Methods. A retrospective review of medical records of 736 patients treated for femoral neck fractures at Vilnius University Emergency Hospital during 2004–2006 was carried out. Results. The overall 1- and 2-year survival rates were 77.4% and 67.1%, respectively. Lower survival rates were observed in the internal fixation group than in the primary and secondary total hip arthroplasty groups (63.2% vs. 72.0% and 75.1%). Cox proportional hazards model analysis showed patient age to be a significant risk factor for survival (hazard ratio, 1.05; 95% CI, 1.04– 1.07; P<0.001). The overall standardized mortality ratio was 2.50. The standardized mortality ratios for men and women were 3.07 and 2.27, respectively, but the difference between these groups was not significant. Conclusions. Standardized mortality and survival rates decreased with increasing patients’ age. Significantly lower survival rates were documented in the internal fixation group as compared with primary and secondary total hip arthroplasty groups. There was a trend toward a higher standardized mortality ratio in men than women, but the difference was not significant

Functional outcomes and quality of life after surgical treatment of spinopelvic dissociation: a case series with one-year follow-up

Spinopelvic dissociation is a transverse sacral fracture in conjunction with a vertical fracture of the sacrum on both sides, which causes the dissociation of the upper sacrum and spine from the pelvis. The most common causes of these fractures are high energy injuries such as falls from height or motor vehicle accidents. Spinopelvic dissociation is rare and heterogenous with severe associated injuries. The aim of this study was to assess the injury characteristics, changes in the quality of life and functional outcomes in the 1-year period after spinopelvic dissociation