OUTCOMES OF PALLIATIVE ORTHOPEDIC SURGERY FOR HIP DISLOCATION IN PATIENTS WITH CEREBRAL PALSY

Introduction. Hip dislocation is the key problem in patients with severe cerebral palsy (GMFCS IV, V) older than 10 years that affects life quality and limits functional capabilities. In the present study the authors evaluated the efficiency of the proximal femoral resection arthroplasty (pfra) and valgus proximal osteotomy of the femur (VPOF) associated with femoral head resection for pain control, improvement of postural management, hygiene and verticalization with total weight-bearing and correction of accompanying orthopaedic deformities. Material and мethods. A retrospective study compared two groups of patients where PFRA (7 cases, 13 hips) or VPOF (14 patients, 23 hips) were performed. Level V of GMFCS was reported in 10 patients, and level IV of GMFCS – in 11 patients. The mean age at time of surgery was 15.3±3.9 y.o. PFRA was performed in 7 cases (13 joints) and VPOF – in 14 patients (23 joints). Results. The authors did not observe any difference between the methods in respect of pain control, postural management, comfortable sitting position and hygiene. The verticalization with total weight-bearing and life quality improvement was achieved only after PVOF with femoral head resection associated with simultaneous knee and foot deformity correction performed according to the principles of Single-Event Multilevel Orthopedic Surgery. Conclusion. Both palliative methods allow to control pain syndrome, to achieve satisfactory postural management, comfortable sitting position and hygiene. But only VPOF with simultaneous knee and foot deformity correction provides possibility to verticalize the patient with weight-bearing using different orthopedic devices

Syndromic Assessment of Degenerative Disorders of the Lumbar Spine in Elderly Patients

Background. The choice of the method and options for surgical treatment of degenerative pathology of the lumbar spine is difficult due to the lack of clear clinical and radiological criteria for diagnosis and a direct correlation between the severity of the radiological manifestations of the disease and clinical symptoms. The aim of this study was to analyze the clinical and neurological characteristics of elderly patients with degenerative disorders of the lumbar spine and to identify the dominant clinical and radiologic syndromes. Methods. Сohort of 1013 patients were operated using MIS technologies (decompression alone, TLIF, LLIF, ALIF) in the period 2013–2017 (367 male/646 female). The age range is 60-89 years (mean 66 years). The criteria for identifying the leading syndromes: leg pain/back pain with a threshold value of 5 points according to VAS, X-ray criteria for clinical instability by A.A. White and M.M. Panjabi (value 5 points), Cobb angle 10°, markers of sagittal imbalance: Index Barrey (II and III), PT increase above target values, L4-S1 and LL deficiency. Results. Symptoms of compression were identified in 97% of patients. Radiculopathy syndrome was detected in 665 (66%) patients with mean leg pain 7 points, neurogenic intermittent claudication — in 319 (31%) patients. Degenerative spondylolisthesis according to radiological criteria was detected in 428 (42%) patients. Degenerative scoliotic deformity had 91 (9%) patients. In accordance with the proposed criteria, the dominant compression syndrome was determined in 624 patients (62%), clinical instability syndrome — in 338 (33%), deformity syndrome with sagittal imbalance — in 51 (5%). Conclusion. Syndromic assessment of clinical, neurological and radiological manifestations of degenerative disorders provides the possibility of identifying the dominant syndrome requiring operative surgical treatment and a differentiated approach to choosing the optimal surgical option

The use of LLIF technology in adult patients with degenerative scoliosis: retrospective cohort analysis and literature review

Introduction Incidence of adult degenerative scoliosis (ADS) among individuals over 50 years old reaches 68%. Surgical interventions aimed at correcting the spinal deformity in patients of the older age group are accompanied by a high risk of complications. The use of LLIF is associated with lower complications as compared with open anterior or posterior fusion. Materials and methods Seventy-one patients with ADS (13 men, 58 women) were operated at the Federal Neurosurgical Center. Their average age was 60.4/60 (average/median) [55;64.5] (1: 3 quartile) years. The follow-up was from 12 to 18 months. X-ray study, SCT, MRI of the lumbar spine were used. Questionnaire surveys were conducted using the visual analog pain scale (VAS), Oswestry Disability Index (ODI) and the Short Form-36 (SF-36). Deformity correction was estimated in the frontal plane with Cobb’s method. Scoliosis was classified according to SRS-Schwab classification. Parameters of sagittal balance were estimated: PI (Pelvic incidence), SS (Sacral slope), PT (Pelvic tilt), LL (Lumbar lordosis). SVA, PT and PILL (PI minus LL) were defined adjusted for the age. Results Back pain according to VAS relieved from 6.1/6 [4;8] to 2.2/2 [2;3] points (p < 0.001) and was statistically significant at 12 months after the surgery. Leg pain according to VAS decreased from 5.4/5 [4;8] to 2.1/2 [1;3] points (p < 0.001) and was statistically significant at 12 months after the surgery. Functional adaptation according to ODI improved from 51.2/52.2 [38.6;64.1] to 31.8/33.3 [26.1;35.9] (p < 0.001). According to SF36, PH before the surgery was 25.7/24.3 [21.8;28.9] on average and at 12 months after the surgery - 38.7/38.7 [35.4;41.2] (p < 0.001). SF-36 MH before surgery was 27.1/26.3 [21.8;31.4] on average and 12 months later – 41.3/40.6 [36.5;43.7] (p < 0.001). PT before the surgery was 23.3/22° [17.5;28], 12 months later it was 17.9/17° [15;20] (p < 0.001). PI-LL was 11.5/10 ° [4;17.5], 12 months later – 8.4/8 ° [5.5;11.5] (p = 0.11). Transient paresis of femur flexors on the ipsilateral side was observed in five (7 %) cases; transient hyposthesia on the anterior thigh surface occurred in eight (11.2 %) cases. There were two cases of medial malposition (0.4 %) of pedicle screws (474 screws), pseudoarthrosis at two levels (1.2 %) (Grade 4 Bridwell) out of 166 levels performed, and seven (4.2 %) cases of damage to cortical endplates. Conclusion Restoration of local sagittal balance in ADS patients by short-segment fixation using LLIF technology leads to a statistically significant improvement in the quality of life and increases functional adaptation. Few early and late postoperative complications, less intraoperative blood loss and shorter hospital stay make LLIF in combination with MIS transpedicular fixation a method of choice in determining the surgical tactics for ADS in elderly and old age patients

Особенности состояния мягких тканей на вершине деформации у больных кифосколиозом на фоне нейрофиброматоза 1-го типа

Objective. Evaluation of skin sensitivity and analysis of morphological changes in paravertebral muscles and back skin in kyphoscoliotic deformity projection in patients with type 1 neurofibromatosis (NF-1).Materials and methods. Ten NF-1 patients who underwent surgery to treat kyphoscoliosis were examined. Using an electrical esthesiometer thermal pain sensitivity before the surgery was studied in dermatomes corresponding to the apex of the deformity. Skin and muscle biopsy samples were collected intraoperatively in the projection of the apex of the deformity curve and were subsequently analyzed by light and scanning electron microscopy.Results. Patients with kyphoscoliosis with underlying NF-1 were characterized by abnormal thermal pain sensitivity, pathological structural changes in skin and muscles accompanied by disrupted innervation and blood supply.Discussion. The observed changes may be responsible for lowered postoperative reparative potential of tissues and they must be considered in prevention and prognosis of treatment and rehabilitation efficacy.Цель работы. Оценка кожной чувствительности и анализ морфологических изменений паравертебральных мышц и кожи спины в проекции вершины кифосколиотической деформации у пациентов с нейрофиброматозом 1-го типа (НФ-1).Материалы и методы. Обследованы 10 больных НФ-1, которым проводилось хирургическое лечение по поводу кифосколиоза. Температурно-болевую чувствительность до операции исследовали с использованием электрического эстезиометра в дерматомах, соответствующих вершине деформации. Биоптаты кожи и мышцы забирали интраоперационно в проекции вершины дуги деформации позвоночника с последующим гистологическим анализом с помощью световой и сканирующей электронной микроскопии.Результаты. У больных кифосколиозом на фоне НФ-1 были выявлены нарушения температурно-болевой чувствительности, патологические структурные изменения кожи и мышц, нарушения их полноценной иннервации и кровоснабжения.Обсуждение. Обнаруженные изменения могут обусловливать снижение репаративного постоперационного потенциала тканей, что необходимо учитывать в профилактике и прогнозе эффективности лечения и реабилитации

Многоуровневые инъекции ботулинического токсина типа А (Абоботулотоксина) при лечении спастических форм детского церебрального паралича: ретроспективное исследование опыта 8 российских центров

Background: The contemporary application of Botulinum toxin A (BTA) in cerebral palsy (CP) implies multilevel injections both in on-label and off-label muscles. However, there is no single international opinion on the effective and safe dosages, target muscles, and intervals between the injections.Objective: Our aim was to analyze the Russian multicenter independent experience of single and repeated multilevel injections of Abobotulinum toxin А in patients with spastic forms of CP.Methods: 8 independent referral CP-centers (10 hospitals) in different regions of Russia. Authors evaluated intervals between the injections, dosages of the BTA for the whole procedure, for the body mass, for the each muscle, and functional segment of the extremities.Results: 1872 protocols of effective BTA injections (1–14 repeated injections) for 724 patients with spastic CP were included. The age of the patients was between 8 months to 17 years 4 months at the beginning of the treatment (with a mean of 3 years 10 months). Multilevel BTA injections were indicated for the majority (n = 634, 87.6%) of the patients in all the centers. The medians of the dosages for the first BTA injection were between 30–31 U/kg (500 U), the repeated injections doses up to 45 U/kg (1000 U) (in most centers). The median intervals between the repeated injections were 180–200 days in 484 (66.9%) patients and 140–180 days in 157 (24.7%) patients. In 2 centers, children with GMFCS IV–V were injected more often than others.Conclusion: Multilevel BTA injections were indicated for the most patients. The initial dose of Abobotulinum toxin A was 30–31 U/kg. The repeated injections dose could increase up to 40 U/kg. The repeated injections were done in 140–200 days after the previous injection.Современная концепция ботулинотерапии при детском церебральном параличе (ДЦП) предлагает использование многоуровневых инъекций в расширенное число мышц. Однако по-прежнему отсутствует консенсус относительно выбора оптимальных доз, мышц и интервалов между инъекциями.Цель исследования: изучить российский опыт применения однократных и повторных многоуровневых инъекций абоботулотоксина при лечении спастичности у пациентов с ДЦП.Методы: в ретроспективном исследовании проанализирован опыт ботулинотерапии при ДЦПв 8 специализированных центрах России. Изучали протоколы клинически эффективных инъекций. Оценивали общие дозы препарата БТА, дозы на единицу массы тела пациентов, на всю инъекционную сессию и отдельные мышцы, а также интервалы между инъекциями.Результаты: изучено 1872 протокола клинически эффективных инъекций, всего от 1 до 14 повторных инъекций, сделанных 724 пациентам в возрасте от 8 мес до 17 лет 4 мес (медиана возраста на момент первой инъекции БТА — 3 года 10 мес) на момент начала ботулинотерапии. Большинство пациентов (n = 634; 87,6% инъекций) получили многоуровневую ботулинотерапию. Во всех центрах при первичных инъекциях БТА медиана доз находилась в пределах 30–31 Ед/кг массы тела (общая — 500 Ед). При повторных инъекциях в большинстве учреждений максимальные дозы превышали 45 Ед/кг (1000 Ед). Средние интервалы между повторными инъекциями колебались в пределах 140–180 сут для 157 (24,7%) и 180–200 сут для 484 (66,9%) пациентов. В 2 из 8 центров пациенты с наиболее выраженными двигательными нарушениями (GMFCS IV–V) требовали более частых повторных инъекций БТА.Заключение: в специализированных центрах большинству пациентов с ДЦП ботулинотерапию проводили по многоуровневой схеме. Общая доза абоботулотоксина при первичных инъекциях составляла 30–31 Ед/кг; при повторных инъекциях она могла быть увеличена до 40 Ед/кг и более. Вопрос о повторном проведении инъекции БТА рассматривался в интервале 140–200 сут после предшествующей инъекции

Deformities of the spine and limbs in patients with Duchenne myodystrophy: Clinical features, diagnosis and treatment. Interstate consensus protocol

Objective. To develop an algorithm for the diagnosis and treatment of orthopedic syndrome in patients with Duchenne muscular dystrophy (DMD) based on an assessment of the evidence level of published data. Material and Methods. Consensus is a version of the main foreign protocols adapted for use in post-Soviet countries (the basis of consensus is the TREAT NMD protocol: treatnmd.ncl.ac.uk/care/dmd/diagnosis-management-DMD), as well as of works systematized on the basis on evidence level and reflecting modern approaches to the diagnosis and rehabilitation (including surgical) of spinal and limb deformities in patients with Duchenne myodystrophy. The recommendations are based on literature data and the authors' own experience. Search in electronic databases was performed on the Medline, Embase, Web of Science and Cochrane Library platforms. Preference was given to studies that could be classified as evidence level 2+ and higher according to the ASMOK system. References are given in the order of their mention in the text. The search depth was 5 years. Methods used to assess the quality and strength of the evidence were expert consensus and assessment of significance in accordance with the rating scheme. Methods used to analyze evidence were reviews of published meta-analyzes and systematic reviews with evidence tables. Results. The consensus reflects aspects of clinical examination, respiratory support and postural control depending on the functional level, conservative and surgical treatment of spinal and limb deformities, anesthesia-related risk assessment, and preoperative, intraoperative and postoperative management of patients with DMD. Conclusion. Deformities of the spine and lower extremities in DMD are frequent manifestation of the natural history of the underlying disease with the development of secondary orthopedic pathology, causing not only a severe violation of the function of movement and support, but also a violation of the function of internal organs. This requires a detailed assessment of the general somatic and neurological status in general, and the characteristics of the damage to the axial skeleton and extremities in particular. This is achieved by a detailed preoperative multidisciplinary examination to thoroughly assess the risks of complications and to skillfully follow-up a patient depending on functional status and regardless of age. The use of surgical treatment techniques for orthopedic pathology in DMD with proven effectiveness significantly improves self-care, the quality of life of patients and their closest persons, improves the balance of the body, and helps to maintain the function of external respiration and the possibility of verticalization

Treatment of congenital spinal deformities in children: Yesterday, today, tomorrow

The paper presents an unsystematized review of technologies, techniques and options for surgical treatment of congenital spinal deformities in children over the past 40 years. The main trends in the surgery of spinal deformities are highlighted: evolution of methods of visual diagnostic, treatment planning, and surgeon action control, introduction of adapted functional status scales and questionnaires for quality of life, hybridization of surgical techniques, evolution of spinal implants and instruments, and progress of anesthetic management. At the same time, new clinical and scientific problems are also discussed in the paper: questions of unifying terminology, planning the volume of treatment, the difficulty of comparing treatment methods and technologies, education, and integration

Spinal muscular atrophy: Clinical features and treatment of spinal and limb deformities. Interstate consensus protocol

Objective: To substantiate the protocol for the diagnosis and treatment of deformities of the spine and limbs in patients with spinal muscular atrophy basing on an assessment of the level of evidence of published data. Material and Methods: Data on foreign protocols and their adaptation for use in Russia and CIS countries were analyzed and summarized. The main platform was the evidence-based systematization of studies reflecting modern approaches to the diagnosis and treatment (including surgery) of spinal and limb deformities in patients with spinal muscular atrophy. The formulated recommendations are based on literature data and the authors' own experience. Literature was searched in online databases of Medline, Embase, Web of Science, and Cochrane Library information platforms. Preference was given to studies that could be classified as evidence level 2+ and higher according to the ASMOK system. References are given in the order of their mention in the text. Search depth was 5 years. Methods used to assess the quality and strength of evidence were expert consensus and significance assessment in accordance with the rating scheme. Methods used to analyze evidence were reviews of published meta-analyzes and systematic reviews with evidence tables. Results: Various aspects of clinical examination, respiratory support and postural control, conservative and surgical treatment of spinal and limb deformities, preoperative, intraoperative and postoperative management, and anesthetic risk assessment in patients with spinal muscular atrophy are highlighted. Conclusion: Secondary orthopedic pathology in patients with spinal muscular atrophy causes not only severe violation of the musculoskeletal system functions (support, movement, and verticalization), but also pathological changes in the vital functions of internal organs and systems (respiratory, digestive, cardiovascular). A thorough analysis of the patient's condition (assessment of general somatic, neurological, and orthopedic statuses) based on the data of preoperative multidisciplinary examination allows assessing the risks of complications and developing individual program of surgical rehabilitation of the patient. Surgical correction of orthopedic pathology in spinal muscular atrophy improves the functional status of the patient, improves the quality of life and the level of self-care, and optimizes the function of external respiration

Rating of intra-operative neuro-monitoring results in operative correction of the spinal deformities

Purpose of the work was filing the electrophysiological phenomena observed in the process of intra-operative neuromonitoring followed by development of the results’ scale of intra-operative neuro-physiological testing of the pyramidal tract. Materials and мethods. The selection for evaluation included data of 147 protocols of intra-operative neuromonitoring in 135 patients (53 males, 82 females), aged from 1 y. 5 m. to 52 years (14,1±0,7 years) with spinal deformities of different etiology who underwent instrumentation spinal correction followed by fixation of thoracic / thoracolumbar spine segments using various variants of internal systems of trans-pedicular fixation. Intra-operative neuro-monitoring was performed using system «ISIS IOM» (Inomed Medizintechnik GmbH, Germany). The changes of motor evoked potentials were evaluated according to this scale. Results. Five types of pyramidal system reaction to operative invasion were revealed. According to neurophysiological criteria three grades of the risk of neurological disorders development during operative spinal deformity correction and, correspondingly, three levels of anxiety for the surgeon were defined. Conclusion. Intra-operative neurophysiological monitoring is the effective highly technological instrument to prevent neurological disorders in the spinal deformity. Offered rating scale of the risk of neurological complications gives the possibility to highlight three levels of anxiety during operative invasion