Medical Journal Of the Islamic Republic of Iran
Volume:25 Issue: 3, Autumn 2011

Correction of severe kyphosis is a challenging operation in spinal surgery. A two stage operation has been commonly used: anterior release and decompression followed by posterior correction and fusion. We describe the posterior vertebral osteotomy technique for correction of severe and rigid kyphosis through posterior-only approach. Twelve patients (six male and six female) with severe and rigid kyphotic deformity of the thoracic spine were treated by posterior vertebral column resection using a single posterior approach. The apex level of kyphosis was at the upper thoracic in five patients, the lower thoracic in four patients and mid thoracic in three patients. There was old fracture in one patient, congenital deformity in six, tumor in three and neurofibromatosis in two patients. After posterior vertebral column resection, segmental posterior instrumentation was used for correction of the kyphotic deformity. Complications and radiographic findings were analyzed to evaluate clinical outcomes and radiologic changes of posterior vertebral column resection in patients with angulated kyphotic deformity. The major curve correction was averaged 31.66 ° (SD=15.69) (45%). The resection was performed at the involve level in every patient. Posterior segmental fusion was achieved in average 8.9 (SD=1.7) segments. Anterior reconstruction was with titanium mesh cage in two and with cancellous chip packing in other patients. There were no neurologic complications after six month. Bony fusion achieved in all patients, and there was no correction loss. Satisfactory correction is safely performed by posterior vertebral column resection with a direct visualization of the circumferentially decompressed spinal cord. Although the performance is technically laborious, it offers good correction without jeopardizing the integrity of the spinal cord.

The Gamma Knife Radiosurgery (GKR) is an established management option for Cerebral Ar-teriovenous Malformations (AVMS). Therapeutic benefits of radiosurgery for arteriovenous malformations are complete obliteration of nidus with minimal neurological deficit. Radiosurgery was performed between February 2003 and April 2010 at Kamraniye day clinic, Teh-ran, Iran, using the Leksell gamma knife model B (Elektra Instruments AB, Stockholm, Sweden) on 82 consecu-tive patients with AVMs. The male-to-female ratio was 1.4:1(48M, 34F). The age of the patients ranged from 9 to 70 years (mean, 28.5±12 years). The marginal dose to the AVM nidus was 45 to 85% (median, 60%) isodose and ranged from 14 to 30 Gy (mean, 20.57±13Gy).The maximum dose ranged between 20 to 60 Gy (mean, 37.5 Gy ± 10.17Gy). Follow up of patients for complete AVM obliteration and in the case of complications MRI were performed. Complete obliteration of AVM was achieved in 56 cases (68.29%). It was marked in average 3.62 [SD=3.19] years (from 1 to 5 years) after GKR. Partial obliteration (≥50% reduction of the nidus volume) was marked in 24 cases(31%), and less than 50% reduction of the nidus volume was marked in 2 cases(2.4%) with a follow-up of 5 years. Complete obliteration of AVM had statistically significant associations with smaller score of Spetzler-Martin arteriovenous malformation grading system for AVMs. (p< 0.05) The Gamma Knife Radiosurgery can offer total and partial obliteration to acceptable percent of treated AVM with a low risk of morbidity. Higher success observed in patients with Spetzler-Martin Grade I and II AVMs, which was attributed to smaller volume of AVMs in this group.

Enchondroma, is the most frequent bone tumor of the hand, but chondrosarcoma is rare at this location. There is a high possibility of correct diagnosis of enchondroma and differentiating from its malignant counterpart by precise clinical and radiologic assessment without biopsy, a subject of debate in the literature. At the present study we substantially investigate this problem, in our patients. Case records, radiographs, and histology of 52 solitary enchondroma patients who underwent operation in our hospital between 1998 and 2010, were reviewed. Special attention paid to pre and post –op diagnoses, and compared with each other. Eighty-six percent of our patients were between the second to fourth decades of life, with a slight female predominance. In all, the primary diagnosis of enchondroma according to clinical presentation and radiographic appearance, supported by intraoperative gross appearance of tumor, and confirmed histologically by permanent section analysis. There was no mismatch between radiologic and histologic diagnosis. we concluded that correct diagnosis of enchondroma is almost always possible by precise clinical and radiographic assessment with no need for histologic confirmation before definitive treatment.

CuT380A intra uterine device Intra Uterine Device (IUD) is used in the health system of Iran. The most important and frequent side effects of the IUDs are hypermenorrhea and polymenorrhea. In Iran, iron supplement are not prescribed for the IUD users and there are no documents indicating their iron reservation status. This study was performed to determine the iron status in Gorganian IUD users. This historical cohort study was performed on 100 IUD users (exposed group) and 100 non-IUD users (non-exposed group) in the Golestan province in north east of Iran in 2008. To evaluate the iron status hemoglobin and ferritin levels were measured. Data was analyzed by SPSS 13 by using Chi square and Independent T-test. A p-value less than 0.05 were considered as statistically significant. Hgb less than 10.5 was seen in 5% and 6% of IUD users and non-IUD users respectively which was not statistically significant (OR: 1.43, 95% CI: 0.39-5.25). Low Ferretin Level (less than 15) was seen in 53% of IUD users and in 35% of non-IUD users which was statistically significant (OR: 2.35, 95% CI: 1.28-4.29) Duration of menstrual period in the two groups was statistically significant (7.5±2.4 vs. 6.4±1.8, p= 0.005) but interval of menstruation (days) was not statistically significant (26.7±4.7 vs. 28±11.2, p> 0.05). On the basis of the results obtained we suggest either routine iron supplementation following application of IUD, or use of the hormone releasing IUD as an alternative for copper IUDs.

Primary hyperparathyroidism is autonomous production of parathyroid hormone. After removal of adenoma, one of the surgeons concern is postoperative hypocalcaemia. There is no precise method to determine if patients have hypocalcaemia postoperatively. The purpose of this study was to determine the relation between parathyroid adenoma weights, postoperative serum calcium and serum biochemical parameters in patients with primary hyperparathyroidism. In a prospective study, eighty patients with single parathyroid adenoma were enrolled. Preoperative serum levels of calcium, phosphate, PTH, as well as Postoperative serum calcium and weight of adenomas were recorded. The level of significance was set to be p < 0.05. There was no significant correlation between postoperative serum calcium, parathyroid adenoma weight (r= -0.17, p= 0.1), and parathyroid hormone level (r = -0.11, p = 0.3). However, a weak correlation between postoperative and preoperative serum calcium levels (r = 0.23, p = 0.03) was observed. Moreover, Serum calcium decline after adenoma resection was statistically correlated with adenoma weight (r = 0.36, p= 0.001), preoperative serum calcium (r = 0.92, p= 0.0007), PTH (r= 0.54, p= 0.0005) and ALP levels (r = 0.3, p= 0.006). Although preoperative serum markers and adenoma weight are unreliable in predicting postoperative serum calcium level, it is possible to estimate postoperative calcium decline by considering adenoma weight and preoperative serum biochemical parameters.

Subacromial impingement is a common cause of shoulder pain and many patients with this condition recover with conservative management. The most commonly used modalities of nonoperative treatment include activity modification, anti-inflammatory medication and subacromial injection of steroid and ultrasound and physical therapy programs. This study assessed the value of physiotherapy versus subacromial corticosteroid injection in patients with shoulder impingement syndrome (SIS). Seventy three patients with SIS enrolled in the study and treated through physiotherapy (n=37) and subacromial corticosteroid injection (n=36). Two follow-up sessions accomplished at the end of 4th week and 3rd month of treatment respectively. Corticosteroid injection caused dramatic improvement in the painful state (p<0.0001) and sleep dysfunction score (p=0.039) in the first follow-up. However, physiotherapy showed significantly better results regarding patients’ pain score (p=0.016) and their shoulder join range of motions (p=0.017 and p=0.029 for the abduction and extension, respectively) in their second follow-up. Our study results showed that subacromial corticosteroid injection primarily resulted in more improvement in the impingement symptoms. However, with the long-term follow-up the results were better for the physiotherapy. These results suggest that patients should not undergo surgery before having conservative treatment.

The children with middle ear effusion need repeated re-tympanostomies. Adenoidectomy is an effective surgical intervention in the management of chronic otitis media with effusion in conjunction with in-sertion of tympanostomy tubes (TTs). To find out whether TTs in different positions decrease the rate of re-tympanostomies study was done. The present study retrospectively evaluated the effectiveness of adenoidectomy on retention of Shepard TTs in antero-inferior quadrant (AIQ) and postero-inferior quadrant (PIQ) with chronic, persistent or recurrent otitis media. Eighty-five children (one-hundred and seventy ears) underwent bilateral myringotomy and TTs placement with and without adenoidectomy with informed consent. According to the TTs retention duration rate, there was a significant difference between adenoidec-tomy and non-adenoidectomy groups in AIQ. It was concluded that TTs placement in the AIQ in conjunction with adenoidectomy showed better improvement and prolonged ventilation. This study suggests that adenoidectomy is an effective surgical intervention in the management of otitis media especially when it is performed in conjunction with insertion of TTs. This significantly decreases tube extrusion rate especially in an AIQ, which might be due to improving eustachian tube function that consequently reduces repeated otitis media.

A 26 -year- old woman presented with rhabdomyolysis secondary to severe hypokalemia. Hypertension and metabolic alkalosis could lead to the suspicion of primary aldosteronism, which was confirmed by a decreased plasma rennin, elevated plasma aldosterone levels and high aldosterone/rennin ratio additionally. Additionally adrenal computed tomography showed an adrenal tumour. Blood pressure and hypokalemia returned to the normal level after adrenalectomy was performed. This case report highlights the need to be alert to the possibility of primary aldosteronism incidence in a patient presenting with rhabdomyolysis and hypertension caused by severe hypokalemia.

A 2.5 year old girl is presented with both hands constriction bands leading to distal amputations and the rare deformity of shoulder duplication in the right side accompanying constriction skin marking over the affected shoulder. The cephalomedial scapula articulated with the clavicle and the caudolateral scapula articulated with humeral head. The most important physical finding which could explain the pathophysiology of this rare anomaly, was constriction band marking over the right shoulder. Shoulder range of motion was limited but still functional and no surgical intervention was required for the scapular duplication.

Carcinoid tumors are well differentiated neuroendocrine tumors with secretory components. These tumors are uncommon but the most common primary tumors of the distal small intestine. We present a rare terminal ileum carcinoid tumor presenting with a small bowel obstruction. A 65 years old man presented with intermittent, gen-eralized, dull and colicky abdominal pain accompanied with intermittent nausea, fever and chills for 1 year and post prandial generalized colicky abdominal pain from 5 days prior to admission. He also complained of weight loss and frequent constipations during recent year. His abdomen was soft with mild tenderness in periumbilical, right lower quadrant and left lower quadrant without guarding, rebound tenderness and palpable mass. Laborato-ry findings indicated anemia, and barium enema showed right lower quadrant mass effect in small intestine. Narrowing of terminal ileum was noted in colonoscopy. Free fluid in lower abdomen and pelvis with 37*28*25 paravertebral hypoechoic pelvic mass, without peristalsis was seen in abdomen and pelvic sonography. After mass localization in abdominal CT scan, laparotomy and excisional biopsy was performed. The diagnosis of carcinoid tumor was confirmed by pathologic report. Carcinoid tumors are rare tumors of the Gastro intestinal tract, however, they are the most common primary tumors of the small intestines. Most of these tumors have a very indolent course and may present with non specific symptoms. In view of the poor prognosis associated with the late diagnosis, it is imperative to think of this differential diagnosis in patients presenting with non specific symptoms and in intermittent partial bowel obstruction.