Background: Few studies addressed the immediate post operative complications after pediatric scoliosis surgery.

Objectives: The objective of this study was to evaluate the influence of pre, intra and post-operative parameters on immediate post-operative course.

Methods: A retrospective review of 109 pediatric patients’ records who underwent spinal fusion & instrumentation for scoliosis in one medical center between 1998–2005. The following data were collected: age and gender; curve type, etiology and degree; pulmonary function tests; surgical approach and the addition of thoracoplasty, operation time; blood products and morphine administration; blood test results at arrival to the intensive care unit (ICU). We evaluated the latter data influence on: 1. Prolonged post-operative ventilatory support. 2. Prolonged duration of ICU hospitalization 3. Presence of serious and non-serious post operative complications. Statistical analysis was done with T-test, Chi-square and Pearson correlations.

Results: Statistically significant correlations were found between neuromuscular etiology and prolonged ICU hospitalization, need for prolonged ventilatory support and the presence of major complications (P< 0.006). Anterior and combined anterior & posterior approaches were found to correlate with higher rate of pulmonary complications(P=0.015). All other parameters were not found to significantly and independently influence the post-operative course.

Conclusions: Anterior and combined approaches as well as neuromuscular etiology were found as risk factors for less favorable early post operative course while the addition of thoracoplasty and use of blood products were not.

Aim: To evaluate the long term effect of Distal transfer of the greater trochanter in Perthes’ disease.

Patients and methods: Twelve patients (thirteen hip joints, 10 males and 2 females) who suffered from Perthes’ Disease were treated by distal transfer of the greater trochanter (DTT). The operation was performed because of progressive shortening of the articulo-trochanteric distance accompanied by signs of insufficiency of the hip abductors. Total or near total femoral head involvement was found in all the patients except for one of them. Follow up period was 28 years (21–35). Mean age at diagnosis of Perthes’ was 7 years (4–11). Patient were studied in 1992 and reviewed again 13 years later, using the Harris hip score, short form 36 (SF36), physical examination and A-P X-rays.

Results: Not one of the patients underwent a total hip arthroplasty. Mean Harris hip score is 80 (range 54–100, 4 patients under 70 score). Mean SF36 score was 71 (range 30–94) and was correlated to the Harris score. Three of the patients were working in a physically demanding profession. The rest were office workers. Two of them chose non strenuous type of work due to the hip condition. Limb length discrepancy was 1.7 cm short on the operated side (range 0–3) and correlated with Trendelenburg sign (4 patients with positive sign). Femoral head sphericity according to Stulberg classification was good in 5 patients (grades 1–2), fair in 3 patients (grade 3) and poor in 4 patients (grade 4–5). Head sphericity was not correlated to age at diagnosis, Harris score, SF36 score or level of hip pain.

Conclusions: Long term outcome are surprisingly good in those patients, considering the degree of head involvement, advanced age at diagnosis and severity of disease which necessitated high degree of varus osteotomy and hence trochanter transfer.

Objective: To evaluate viscosupplementation by intraarticular injection of Orthovisc® Vs. Synvisc® (Molecular Weight 1.55 and 6 Million Daltons, respectively) in the treatment of knee osteoarthritis in clinical practice in Israel.

Methods: We performed a prospective evaluation of all patients treated with either Orthovisc® or Synvisc® by the senior author during a 2 year period. All patients suitable for hyaluronic acid injections were included in the study. Patients bought either product at their own expense and preference.

A total of 1566 injections were performed involving 522 knees. Patients were divided into two groups; one consisting of 277 patients who purchased Orthovisc® and a second consisting of 245 patients who purchased Synvisc®.

A Visual Analog Scale (VAS) assessed pain. The senior author performed all injections and sterile injection protocol was strictly adhered to.

Knees were injected at weekly intervals for 3 weeks. Patients were assessed at baseline, 1, 2, 3 & 4 weeks and 3, 6 & 12 months following initial visit.

Results: Both products were found to be of clinical benefit and have an acceptable safety profile. No difference in VAS values was found between the two groups. The calculated Power of Study for detection of a one-pain unit difference was 99.9% (α=0.05). This power was maintained through the first three visits and later declined.

Conclusion Our findings question the impact of hyaluronic acid molecular weight in alleviating osteoarthritic knee pain.

Study Design: Thirty-four patients who were operated for spinal deformities with the Spine System Evolution (SSE) were retrospectively reviewed.

Objectives: To evaluate the efficiency of SSE to correct spinal deformities.

Summary of Background Data: Since the end of the Harrington rods era, several instrumentation were introduced for correction of spinal deformities. Most of these instrumentations are evolution of he CD instrumentation and are based on combination of translation, distraction/compression and possible some rotation forces. Cord injuries were informed to be more frequent with the new instruments and are related both to ischemic injuries and to mechanical insults to the cord by the supralaminar and the infralaminar hooks. Correction by the SSE is based on pedicle screws and pedicular-transverse locks. No hook is inserted into the spinal canal.

Methods: All charts, radiographs, and images of the patients operated for spinal deformities with the SSE were reviewed. Thirty-four patients were found. For the purpose of this study they were evaluated for the amount of correction achieved, balance of the spine, subjective satisfaction of the cosmetic appearance and the surgical complications.

Results: The mean age of the operated patients was 19.5 years. Twenty-one were operated for idiopathic scoliosis and were found to have 61% correction of the major curves. Five patients were operated for neuromuscular scoliosis with 69% of correction in average, four were operated for thoracic hyperkyphosis with reduction of the curves to physiologic range in all of them and four were operated for adult scoliosis with 38% of correction. Twenty-eight patients were satisfied from the results and the same number of patients were found to be balanced in the range of up to one-centimeter shift from the mid-line. No patient was found to have any major neurologic complication and no deep wound infections was registered. One patient had postoperative bronchopneumonia, another one had pneumothorax, one had superficial wound infection and another girl was troubled with her body image.

Conclusions: SSE instrumentation was found friendly to use and relatively safe for correction of spinal deformities.

Study design: An experimental human study of retrieval material.

Objectives: Assessment and evaluation of the involvement of TNFα and Nitric oxide in sciatic pain.

Summary and background data: It appears that the inflammation produced by the herniated fragment is at least partially related to the sciatic pain. TNFα was found to be expressed by herniated nucleus polposus of rats and exogenous TNFα applied in vivo to rat nerve root produced neuropathologic changes and behavior deficit that mimicked experimental studies with herniated nucleus polposus (HNP) applied to nerve roots. Nitric oxide was shown to be involved in the mechanism that produce mechanical and thermal hyperalgesia in rats. Nitric oxide synthesis can be induced by different cytokines among them TNFα and is mediated by the enzyme Nitric oxide synthase. The current study was performed in order to evaluate the possible mechanism of action of TNFα in human herniated discs and define the relationship between nitric oxide and TNFα production by human discs.

Methods: Six herniated fragments of lumbar discs were compared to a similar number of normal intervertebral discs removed during spinal fusion procedures of the lumbar and thoracic spine for the presence of TNFα and the expression of Nitric oxide synthase.

Results: TNFα was expressed by chondrocytes of the herniated fragments but not by the same cells in normal discs. Similar expression pattern was noted for nitric oxide synthase. Both materials were not expressed in the healthy discs.

Conclusions: TNFα appears to be related to pain mechanism of disc herniation. It’s effect is mediated through Nitric oxide. It is well known that NSAIDs are relatively inefficient in modulating TNF-related pain. This might explain the lack of efficacy of currently used medications.

Vertebral fracture due to a metabolic bone disease or a neoplastic disease is a common and debilitating condition. It most often is associated with either osteoporosis or metastatic bone disease. Some of the patients suffering from such fractures continue to complain of back pain and deformity despite optimal medical therapy, including radiotherapy and biphosphonates.

Vertebroplasty, i.e. transcutaneous injection of bone cement into the vertebral body can serve as an internal fixation device and allows restoration of mechanical strength and partial restoration of the vertebral height.

During the year 2000, 17 vertebrae in 12 patients were injected. These were either lumbar or thoracic vertebrae. All patients reported decrease in pain and improved ambulation capacity.

Two minor complications were encountered including headache lasting for 72 hours prior to spontaneously resolving. This possibly indicates a transarachnoidal approach, the other complication has been cement leak below the posterior longitudinal ligament. The patient reported pain amelioration. No emergency surgical interventions were necessary to date.

Treatment of metastatic bone disease should be staged, with only a few vertebrae injected in each session, to prevent pulmonary embolization.

Vertebroplasty appears to allow excellent palliative treatment in patients suffering from unresectable primary tumors of the vertebrae, or more commonly, metastatic bone tumors as well as osteoporotic fractures.