Giant cell tumour of the sacrum: a suggested algorithm for treatment

To investigate the outcome of our management of patients with giant cell tumour of the sacrum and draw lessons from this. A retrospective review of medical records and scans for all patients treated at our unit over the past 20 years with a giant cell tumour of the sacrum. Of the 517 patients treated at our unit for giant cell tumour over the past 20 years, only 9 (1.7%) had a giant cell tumour in the sacrum. Six were female, three male with a mean age of 34 (range 15-52). All, but two tumours involved the entire sacrum and there was only one purely distal to S3. The mean size was 10 cm and the most common symptom was back or buttock pain. Five had abnormal neurology at diagnosis, but only one presented with cauda equina syndrome. The first four patients were treated by curettage alone, but two patients had intraoperative cardiac arrests and although both survived all subsequent curettages were preceded by embolisation of the feeding vessels. Of the seven patients who had curettage, three developed local recurrence, but all were controlled with a combination of further embolisation, surgery or radiotherapy. One patient elected for treatment with radiotherapy and another had excision of the tumour distal to S3. All the patients are alive and only two patients have worse neurology than at presentation, one being impotent and one with stress incontinence. Three patients required spinopelvic fusion for sacral collapse. All patients are mobile and active at a follow-up between 2 and 21 years. Giant cell tumour of the sacrum can be controlled with conservative surgery rather than subtotal sacrectomy. The excision of small distal tumours is the preferred option, but for larger and more extensive tumours conservative management may well avoid morbidity whilst still controlling the tumour. Embolisation and curettage are the preferred first option with radiotherapy as a possible adjunct. Spinopelvic fusion may be needed when the sacrum collapses.

A simplified Galveston technique for the stabilisation of pathological fractures of the sacrum

Mechanical stabilisation of pathological fractures of the sacrum is technically challenging. There is often inadequate purchase in the sacrum, and stabilisation has to be achieved between the lumbar vertebrae and ilium. We present a simplification of the Galveston technique. We treated a total of six patients with this technique, four for metastatic disease and two for primary tumours. Our technique consists of the formation of a proximal stable construct using ISOLA pedicle screws linked distally using a modular system of connectors to threaded iliac bolts with cross linkages. Neurological decompression and fusion was performed as appropriate. The benefits of this method are: ease of access to the ilium, a solid purchase to the ilium, less rod contouring and shorter operating time. We have had no operative complications from this procedure. All patients were discharged home mobile, with a reduced opiate requirement.

A high risk group for thoracolumbar fractures

Unconscious patients with multiple injuries present a major diagnostic and therapeutic problem. The incidence of neurological deficit increases if diagnosis of a spinal injury is delayed or missed. Thoracolumbar fractures are commonly the result of high energy injuries and in an unconscious patient the risk of missing such fractures is increased considerably. There is little consensus on which blunt trauma patients warrant thoracolumbar spine films when no pain, tenderness, neurological deficit or cervical spine injuries are identified. We present a retrospective analysis of all patients who were admitted to the Major Injuries Unit at the Birmingham General Hospital and underwent radiological survey of the thoracolumbar spine. Of the 110 patients, all spinal fractures were detected in 94 patients with a Glasgow Coma Scale (GCS) > or = 11. Of the 16 with a GCS < or = 10, 9 patients had sustained injuries of their thoracolumbar spine 4 of which were not detected initially due to a decreased level of consciousness. The common features amongst the 4 patients with missed injuries were: (1) High velocity injury. (2) Decreased level of consciousness on admission. (3) Associated head injury. (4) Pelvis/lower extremity injury. We describe the four cases and identify a group of high risk patients for thoracolumbar fractures. Radiological examination of the thoracolumbar spine is essential in this group.

Late-onset idiopathic scoliosis in children six to fourteen years old. A cross-sectional prevalence study

We performed a point-prevalence survey of 15,799 children, six to fourteen years old, who formed part of a prospective longitudinal study. Our purpose was to detect the prevalence of scoliosis and to investigate associated factors. On the basis of the initial screening, 934 children (5.9 per cent) were referred for additional clinical and radiographic examinations; 896 children returned for this second evaluation. A lateral spinal curve with a Cobb angle of more than 5 degrees was seen in 431 children (2.7 per cent of the 15,799 children). Only seventy-six children (0.5 per cent) had a curve that met our definition of idiopathic scoliosis (a curve of more than 10 degrees with concordant apical rotation). The point-prevalence rate was higher in girls, and it increased with age. The rate was 0.1 per cent (four of 5246) in the age-group of six to eight years, 0.3 per cent (sixteen of 5831) in the age-group of nine to eleven years, and 1.2 per cent (fifty-six of 4722) in the age-group of twelve to fourteen years old. With allowance for the fact that different definitions of idiopathic scoliosis have been used in earlier studies, our results suggest that the natural history of idiopathic scoliosis may be becoming more benign spontaneously.

Thoracic spinal cord compression caused by hypophosphataemic rickets: a case report and review of the world literature

Vitamin D resistant hypophosphataemic rickets is a rare cause of spinal cord compression. The compression is caused by a combination of thickening of the laminae and calcification of the ligamentum flavum. Modern imaging techniques including CT and MRI provide excellent detail of both the level and degree of compression. MRI is particularly useful for examining the rest of the spinal cord for areas of impending compression and for postoperative follow-up. With careful surgical decompression a full neurological recovery can be achieved.

Computerised axial tomography for tibial plateau fractures

Sixteen consecutive patients with tibial plateau fractures were investigated by standard radiography, biplanar tomography and computerised axial tomograms (CT scans). It was found that CT scanning proved most helpful for classifying the type of fracture, for evaluating the degree of comminution, and for measuring displacement. Moreover, because a single position was maintained throughout the investigation, the patients felt less discomfort than during other assessment procedures. For these reasons CT scanning is recommended for evaluating this type of fracture.

Intracompartmental pressure monitoring of leg injuries. An aid to management

Acute compartment syndromes often develop insidiously and are often recognised too late to prevent permanent disability. Management is difficult as the compartment involved is seldom clinically apparent. By continuously monitoring the intracompartmental pressure these problems can be avoided: transient compartment syndromes can be differentiated from established ones and the correct compartment can be surgically decompressed. Pressure monitoring techniques were used in 28 patients; three developed a compartment syndrome requiring surgical intervention, seven had a temporary increase of pressure and in 18 the pressure remained unaltered. Of the three with compartment syndromes, one was unusual in that it affected the thigh and another, unique in our experience, affected both the thigh and the calf. Intracompartmental pressure monitoring significantly altered the management of two cases giving successful results with minimal intervention.

Rheumatoid stricture of oesophagus

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