Long-term outcome after surgical treatment of Scheuermann's Kyphosis (SK)

STUDY DESIGN

A retrospective observational cohort study with a minimum follow-up of 10 years of patients who underwent surgery for Scheurmann Kyphosis (SK).

OBJECTIVE

Evaluate the long-term clinical and radiological outcome of patients with SK who either underwent combined anterior-posterior surgery or posterior instrumented fusion alone. There is paucity of literature for long-term outcome studies on SK. The current trend is towards only posterior (PSF) surgical correction for SK. The combined strategy of anterior release, fusion and posterior spinal fusion (AF/PSF) for kyphosis correction has become historic relic. Long-term outcome studies comparing the two procedures are lacking in literature.

METHODS

51 patients (30 M: 21F) who underwent surgery for SK at a single centre were reviewed. Nineteen had posterior instrumentation alone (PSF) (Group 1) and 32 underwent combined anterior release, fusion with posterior instrumentation (AF/PSF) (Group 2). The clinical data included age at surgery, gender, flexibility of spine, instrumented spinal levels, use of cages and morcellised rib grafts (in cases where anterior release was done), posterior osteotomies and instrumentation, complications and indications for revision surgery. Preoperative flexibility was determined by hyperextension radiographs. The radiological indices were evaluated in the pre-operative, 2-year post-operative and final follow-up [Thoracic Kyphosis (TK), Lumbar lordosis (LL), Voustinas index (VI), Sacral inclination (SI) and Sagittal vertical axis (SVA)]. The loss of correction and incidence of JK (Junctional Kyphosis) and its relation to fusion levels were assessed. Complications and difference in outcome between the two groups were analyzed.

RESULTS

The mean age at surgery for 51 patients was 20.6 years who were followed up for a minimum of 10 years (mean: 14 years; range 10-16 years). The mean age was 18.5 ± 2.2 years and 21.9 ± 4.8 years in groups 1 and 2, respectively. The mean pre- and 2-year post-operative ODIs were 32.6 ± 12.8 and 8.4 ± 5.4, respectively, in group 1 (p < 0.0001) and 30.7 ± 11.7 and 6.4 ± 5.7, respectively, in group 2 (p < 0.0001). The final SRS-22 scores in group 1 and 2 were 4.1 ± 0.4 and 4.0 ± 0.35, respectively (p = 0.88). The preoperative flexibility index was 49.2 ± 4.2 and 43 ± 5.6 in groups 1 and 2, respectively (p < 0.0001). The mean TKs were 81.4° ± 3.8° and 86.1° ± 6.0° for groups 1 and 2, respectively, which corrected to 45.1° ± 2.6° and 47.3° ± 4.8°, respectively, at final follow-up (p < 0.0001). The mean pre-operative LL angle was 60.0° ± 5.0° and 62.4° ± 7.6° in groups 1 and 2, respectively, which at final follow-up was 45.1° ± 4.4° and 48.1° ± 4.8°, respectively (p < 0.0001). The mean pre-operative and final follow-up Voustinas index (VI) in group 1 were 22.9 ± 2.9 and 11.2 ± 1.2, respectively, and in group 2 was 25.9 ± 3.5 and 14.0 ± 2.3, respectively. The mean pre-operative and final follow-up SI angle were 43.6° ± 3.3° and 31.2° ± 2.5° in group 1, respectively, and 44.3° ± 3.5° and 32.1° ± 3.5° in group 2, respectively (p < 0.0001). The pre-operative and final follow-up SVA in group 1 were - 3.3 ± 1.0 cms and - 1.3 ± 0.5 cms, respectively, and in group 2 was - 4.0 ± 1.3cms and - 1.9 ± 1.1cms, respectively (p < 0.0001). Though the magnitude of curve correction in the groups 1 and 2 was significant 36° vs 39° (p = 0.05), there was no significant difference in correction between the two groups. Proximal JK was seen in seven and distal JK in five patients were observed in the whole cohort.

CONCLUSION

The long-term clinical outcomes for both PSF and AF/PSF are comparable with reproducible results. No difference was noted in loss of correction and outcome scores between the two groups. The correction of thoracic kyphosis (TK) had a good correlation with ODI. AF/PSF had much higher complications than PSF group. The objective of correcting the sagittal profile and balancing the whole spinal segment on the pelvis can be achieved through single posterior approach with fewer complications.

Enhanced recovery after surgery (ERAS) in adolescent idiopathic scoliosis (AIS): a meta-analysis and systematic review

STUDY DESIGN

A systematic review reporting on the efficacy of an ERAS protocol in patients undergoing spinal fusion for AIS.

OBJECTIVE

To systematically evaluate the relevant literature pertaining to the efficacy of ERAS protocols with respect to the length of stay, complication, and readmission rates in patients undergoing posterior spinal corrective surgery for AIS. ERAS is a multidisciplinary approach aimed at improving outcomes of surgery by a specific evidence-based protocol. The rationale of this rapid recovery regimen is to maintain homeostasis so as to reduce the postoperative stress response and pain. No thorough review of available information for its use in AIS has been published.

METHODS

A systematic review of the English language literature was undertaken using search criteria (postoperative recovery AND adolescent idiopathic scoliosis) using the PRISMA guidelines (Jan 1999-May 2020). Isolated case reports and case series with < 5 patients were excluded. Length of stay (LOS), complication and readmission rates were used as outcome measures. Statistical analysis was done using the random effects model.

RESULTS

Of a total of 24 articles, 10 studies met the inclusion criteria (9 were Level III and 1 of level IV evidence) and were analyzed. Overall, 1040 patients underwent an ERAS-type protocol following posterior correction of scoliosis and were compared to 959 patients following traditional protocols. There was a significant reduction in the length of stay in patients undergoing ERAS when compared to traditional protocols (p < 0.00001). There was no significant difference in the complication (p = 0.19) or readmission rates (p = 0.30). Each protocol employed a multidisciplinary approach focusing on optimal pain management, nursing care, and physiotherapy.

CONCLUSION

This systematic review demonstrates advantages with ERAS protocols by significantly reducing the length of stay without increasing the complications or readmission rates as compared to conventional protocols. However, current literature on ERAS in AIS is restricted largely to retrospective studies with non-randomized data, and initial cohort studies lacking formal control groups.

LEVEL OF EVIDENCE

3.

Schmorl Node-A Cause of Acute Thoracic Pain: A Case Report and Pathophysiological Mechanism

Purpose

We report a case of a patient with an acute symptomatic Schmorl node (SN) that spontaneously resolved with characteristic imaging findings. The extensive hematological investigations also allow some insight as to the likely pathophysiology of the painful lesion.

Methods

Case report of an acute symptomatic SN.

Results

A fit and athletic 44-year-old female participant in a competitive paddling event developed atypical thoracic pain and was admitted for further investigation. Normal blood results included complete blood cell count, clotting, and D-dimer. Creatine phosphokinase was 63 U/L (reference < 167 U/L) and troponin I levels were not raised. Her only hematological abnormality was an elevated C-reactive protein (CRP) at 60.2 mg/L (reference < 5 mg/L). Magnetic resonance imaging (MRI) scan showed signal hyperintensity involving T7 vertebral body, surrounding an enlarged SN. Patient was given oral nonsteroidal anti-inflammatory drugs, opioid analgesia, and gradually mobilized. After 3 days, the pain had sufficiently subsided and CRP was 17.8 mg/L. Follow-up MRI scan showed some reduction in the T2 hyperintensity and size of the intraosseous herniation. Patient gradually returned to full activities and had no recurrence of symptoms. MRI scan 8 months after the initial scan showed almost complete resolution of the T2 hyperintensity and pan-vertebral marrow edema.

Conclusion

Symptomatic SN should be part of the differential diagnosis of unexplained thoracolumbar pain. Modality of choice for diagnosis would be MRI. Once diagnosed, several treatment options are available with the most likely being spontaneous resolution of symptoms and bone healing within a few months. The conservative approach is recommended when the symptoms can be medically well controlled.

A prospective study of the role of bladder scanning and post-void residual volume measurement in improving diagnostic accuracy of cauda equina syndrome

AIMS

Diagnosis of cauda equina syndrome (CES) remains difficult; clinical assessment has low accuracy in reliably predicting MRI compression of the cauda equina (CE). This prospective study tests the usefulness of ultrasound bladder scans as an adjunct for diagnosing CES.

METHODS

A total of 260 patients with suspected CES were referred to a tertiary spinal unit over a 16-month period. All were assessed by Board-eligible spinal surgeons and had transabdominal ultrasound bladder scans for pre- and post-voiding residual (PVR) volume measurements before lumbosacral MRI.

RESULTS

The study confirms the low predictive value of 'red flag' symptoms and signs. Of note 'bilateral sciatica' had a sensitivity of 32.4%, and a positive predictive value (PPV) of only 17.2%, and negative predictive value (NPV) 88.3%. Use of a PVR volume of ≥ 200 ml was a demonstrably more accurate test for predicting cauda equina compression on subsequent MRI (p < 0.001). The PVR sensitivity was 94.1%, specificity 66.8%, PPV 29.9% and NPV 98.7%. The PVR allowed risk-stratification with 13% patients deemed 'low-risk' of CES. They had non-urgent MRI scans. None of the latter scans showed any cauda equina compression (p < 0.006) or individuals developed subsequent CES in the intervening period. There were considerable cost-savings associated with the above strategy.

CONCLUSION

This is the largest reported prospective evaluation of suspected CES. Use of the PVR volume ≥ 200 ml was considerably more accurate in predicting CES. It is a useful adjunct to conventional clinical assessment and allows risk-stratification in managing suspected CES. If adopted widely it is less likely incomplete CES would be missed. Cite this article: Bone Joint J 2020;102-B(6):677-682.

Essential lordosis revisited

AIMS

Significant correction of an adolescent idiopathic scoliosis in the coronal plane through a posterior approach is associated with hypokyphosis. Factors such as the magnitude of the preoperative coronal curve, the use of hooks, number of levels fused, preoperative kyphosis, screw density, and rod type have all been implicated. Maintaining the normal thoracic kyphosis is important as hypokyphosis is associated with proximal junctional failure (PJF) and early onset degeneration of the spine. The aim of this study was to determine if coronal correction per se was the most relevant factor in generating hypokyphosis.

METHODS

A total of 95 patients (87% female) with a median age of 14 years were included in our study. Pre- and postoperative radiographs were measured and the operative data including upper instrumented vertebra (UIV), lower instrumented vertebra (LIV), metal density, and thoracic flexibility noted. Further analysis of the post-surgical coronal outcome (group 1 < 60% correction and group 2 ≥ 60%) were studied for their association with the postoperative kyphosis in the sagittal plane using univariate and multivariate logistic regression.

RESULTS

Of the 95 patients, 71.6% (68) had a thoracic correction of > 60%. Most (97.8%) had metal density < 80%, while thoracic flexibility > 50% was found in 30.5% (29). Preoperative hypokyphosis (< 20°) was present in 25.3%. A postoperative thoracic hypokyphosis was four times more likely to occur in patients with thoracic correction ≥ 60% (odds ratio (OR) 4.08; p = 0.005), after adjusting for confounding variables. This association was not affected by metal density, thoracic flexibility, LIV, UIV, age, or sex.

CONCLUSION

Our study supports the 'essential lordosis' hypothesis of Roaf and Dickson, i.e. with a greater ability to translate the apical vertebra towards the midline, there is a commensurate lengthening of the anterior column due to the vertebral wedging. Cite this article: Bone Joint J 2020;102-B(4):513-518.

A Cost-Effectiveness Analysis of Intradiscal Electrothermal Therapy Compared with Circumferential Lumbar Fusion

STUDY DESIGN

Cost-effectiveness analysis.

OBJECTIVE

To evaluate the cost-effectiveness of intradiscal electrothermal therapy (IDET) relative to circumferential lumbar fusion with femoral ring allograft (FRA) in the United Kingdom.

SUMMARY OF BACKGROUND DATA

Circumferential lumbar fusion is an established treatment for discogenic low back pain. However, IDET could be a cost-effective treatment alternative as it can be carried out as a day case.

METHODS

Patient-level data were available for patients with discogenic low back pain treated with FRA (n = 37) in a randomized trial of FRA vs. titanium cage, and for patients recruited to a separate study evaluating the use of IDET (n = 85). Both studies were carried out at a single institution in the United Kingdom. Patients were followed-up for 24 months, with data collected on low back disability (Oswestry Disability Index), back and leg pain (visual analog scale), quality of life (Short Form 36), radiographic evaluations, and U.K. National Health Service (NHS) resource use. Cost-effectiveness was measured by the incremental cost per quality-adjusted life year (QALY) gained.

RESULTS

Both treatments produced statistically significant improvements in outcome at 24-month follow-up. NHS costs were significantly lower with IDET due to a shorter mean procedure time (377.4 minutes vs. 49.9 minutes) and length of stay (7 days vs. 1.2 days). At a threshold of £20,000 per QALY, the probability that IDET is cost effective is high.

CONCLUSIONS

Both treatments led to significant improvements in patient outcomes that were sustained for at least 24 months. Costs were lower with IDET, and for appropriate patients IDET is an effective and cost-effective treatment alternative.

Intrathecal baclofen pumps do not accelerate progression of scoliosis in quadriplegic spastic cerebral palsy

PURPOSE

To compare scoliosis progression in quadriplegic spastic cerebral palsy with and without intrathecal baclofen (ITB) pumps.

METHODS

A retrospective matched cohort study was conducted. Patients with quadriplegic spastic cerebral palsy, GMFCS level 5, treated with ITB pumps with follow-up >1 year were matched to comparable cases by age and baseline Cobb angle without ITB pumps. Annual and peak coronal curve progression, pelvic obliquity progression and need for spinal fusion were compared.

RESULTS

ITB group: 25 patients (9 female), mean age at pump insertion 9.4 and Risser 0.9. Initial Cobb angle 25.6° and pelvic tilt 3.2°. Follow-up 4.3 (1.0-7.8) years. Cobb angle at follow-up 76.1° and pelvic tilt 18.9°. Non-ITB group: 25 patients (14 female), mean age at baseline 9.2 and Risser 1.0. Initial Cobb angle 29.7° and pelvic tilt 7.1°. Follow-up 3.5 (1.0-7.5) years. Cobb angle at follow-up 69.1° and pelvic tilt 21.0°. The two groups were statistically similar for baseline age, Cobb angle and Risser grade. Mean curve progression was 13.6°/year for the ITB group vs 12.6°/year for the non-ITB group (p = 0.39). Peak curve progression was similar between the groups. Pelvic tilt progression was comparable; ITB group 4.5°/year vs non-ITB 4.6°/year (p = 0.97). During follow-up 5 patients in the ITB group and 9 in the non-ITB group required spinal fusion surgery for curve progression (p = 0.35).

CONCLUSIONS

Patients with quadriplegic spastic cerebral palsy with and without ITB pumps showed significant curve progression over time. ITB pumps do not appear to alter the natural history of curve progression in this population.

Does transcranial stimulation for motor evoked potentials (TcMEP) worsen seizures in epileptic patients following spinal deformity surgery?

PURPOSE

To investigate the effect of Transcranial Motor Evoked Potentials (TcMEP) in increasing the severity or frequency of post-operative seizures in patients undergoing deformity corrective spine surgery with a known history of seizures pre-operatively.

METHODS

The information on all patients with history of epilepsy/seizures who underwent spinal TcMEP cord monitoring for deformity correction surgery was retrospectively collected through a review of the hospital notes. The benefits of TcMEP in the early detection of potential cord ischemia were deemed by the operating surgeon to outweigh the increased risks of seizures, tongue biting, etc. Data on age, gender, pre-operative diagnosis, curve type, intra-operative monitoring alerts, duration of hospital stay, and post-operative in-hospital seizures were collected. Additionally, the patients were contacted following discharge and data on any change in the frequency of the seizures or an alteration in seizure-related medication post-operatively was also collected.

RESULTS

The records of 449 consecutively monitored patients were reviewed and 12 (2.7 %) patients with a history of seizures pre-operatively were identified. The mean age was 23 (9-59) years, 7 females, 11 scoliosis corrections (4 neuromuscular, 1 degenerative, 6 idiopathic adolescent), and one sagittal balance correction surgery. Intra-operatively, all patients had TcMEP monitoring, were catheterised, and had no neuromonitoring alerts or record of tongue biting or laceration. Post-operatively, the mean hospital stay was 12 (4-25) days with no recorded seizures. At a mean of 23 (12-49) months post-discharge, none of the patients reported a worsening of seizures (pattern or frequency) or required an alteration in the seizure-related medications.

CONCLUSION

TcMEP does not appear to trigger intra-operative or post-operative seizures and is not associated with deterioration in the seizure control of patients suffering seizures pre-operatively.

Outcome of embolised vascular metastatic renal cell tumours causing spinal cord compression

PURPOSE

To present the results of the surgical management of metastatic renal cell tumours of the spine with cord compression who underwent pre-operative embolisation.

METHODS

We conducted a retrospective cohort study of all embolised vascular metastatic renal cell tumours of the spine that underwent urgent surgical intervention over a 7-year period (2005-2011). All medical notes, images and angiography/embolisation details were studied. We recorded the timing (immediate vs. delayed) and grade of embolisation and compared this to the estimated blood loss (EBL); extent of metastatic spinal cord compression (using the Tomita score and Bilsky scores) was also compared to EBL. Finally, neurological (Frankel grade), surgical outcome and complications were reviewed in all patients.

RESULTS

During the study period, we operated on 25 emergency patients with metastatic renal cell carcinoma causing spinal cord compression who had received pre-operative embolisation (mean age 59.6 (24-78) years; 8 females, 17 males). All but one of our patients had hypervascularisation/arterio-venous fistulae on angiography. We were able to achieve greater than 90 % embolisation in the majority (17/25, 68 %) The estimated blood loss was 1,696 (400-5,000) ml; mean operating time was 276 (90-690) min and an average of 2.3 (0-7) units of whole blood was transfused. Nine patients had a posterior only decompression/stabilisation, nine patients had a posterior decompression ± cement augmentation, six had combined anterior/posterior procedures and one had anterior corpectomy/reconstruction alone. There was no statistical difference in the EBL between immediate versus delayed surgery after embolisation or the grade of embolisation. Immediate surgery after embolisation and interestingly less complete embolisation showed a trend towards less EBL. The extent of the tumour as graded by the Bilsky score correlated with increased EBL (p = 0.042). No complications occurred during the embolisation procedure. The surgical complication rate was 32 % (8/25) including two major complications (septicaemia (1) and metal work failure (2)) and five minor complications. Postoperatively, 52 % (13/25) had no change in neurological status, 36 % (9/25) improved by at least one Frankel grade and 12 % (3/25) had neurological deterioration by one Frankel grade. The average survival following surgery was 14.1 (0.5-72) months.

CONCLUSION

Blood loss (mean 1,696 ml) and complications (32 %) remain a concern in the operative treatment of vascular metastatic spinal cord compression. Most patients remained the same neurologically or improved by at least 1 grade (22/25, 88 %). Paradoxically, greater embolisation showed a trend to more blood loss which could be due to more extensive surgery in this group, a rebound 'reperfusion' phenomena or even the presence of arterio-venous fistulae. Interestingly, we also found that the extent of the tumour, as graded by the Bilsky score, correlated with increased blood loss suggesting that more extensive cord compression by metastases could lead to more blood loss intra-operatively.

Access related complications in anterior lumbar surgery performed by spinal surgeons

PURPOSE

Anterior lumbar surgery is a common procedure for anterior lumbar interbody fusion (ALIF) and artificial disc replacement (ADR). Our aim was to study the exposure related complications for anterior lumbar spinal surgery performed by spinal surgeons.

METHODS

A retrospective review was performed for 304 consecutive patients who underwent anterior lumbar spinal surgery over 10 years (2001-2010) at our institution. Each patient's records were reviewed for patients' demographics, diagnosis, level(s) of surgery, procedure and complications related to access surgery. Patients undergoing anterior lumbar access for tumour resection, infection, trauma and revision surgeries were excluded.

RESULTS

All patients underwent an anterior paramedian retroperitoneal approach from the left side. The mean age of patients was 43 years (10-73; 197 males, 107 females). Indications for surgery were degenerative disc disease (DDD 255), degenerative spondylolisthesis (23), scoliosis (18), iatrogenic spondylolisthesis (5) and pseudoarthrosis (3). The procedures performed were single level surgery--L5/S1 (n = 147), L4/5 (n = 62), L3/4 (n = 7); two levels--L4/5 and L5/S1 (n = 74), L3/4 and L4/5 (n = 4); three levels--L3/4, L4/5, L5/S1 (n = 5); four levels--L2/3, L3/4, L4/5, L5/S1 (n = 5). The operative procedures were single level ADR (n = 131), a single level ALIF (n = 87) with or without posterior fusion, two levels ALIF (n = 54), two levels ADR (n = 14), a combination of ADR/ALIF (n = 10), three levels ALIF (n = 1), three levels ADR/ALIF/ALIF (n = 1), ADR/ADR/ALIF (n = 2), four levels ALIF (n = 1) and finally 3 patients underwent a four level ADR/ADR/ALIF/ALIF. The overall complication rate was 61/304 (20 %). This included major complications (6.2 %)--venous injury requiring suture repair (n = 14, 4.6 %) and arterial injury (n = 5 [1.6 %], 3 repaired, 2 thrombolysed). Minor complications (13.8 %) included venous injury managed without repair (n = 5, 1.6 %), infection (n = 13, 4.3 %), incidental peritoneal opening (n = 12, 3.9 %), leg oedema (n = 2, 0.6 %) and others (n = 10, 3.3 %). We had no cases of retrograde ejaculation.

CONCLUSION

We report a very thorough and critical review of our anterior lumbar access surgeries performed mostly for DDD and spondylolisthesis at L4/5 and L5/S1 levels. Vascular problems of any type (24/304, 7.8 %) were the most common complication during this approach. The incidence of major venous injury requiring repair was 14/304 (4.6 %) and arterial injury 5/304 (1.6 %). The requirement for a vascular surgeon with the vascular injury was 9/304 (3 %; 5 arterial injuries; 4 venous injuries). This also suggests that the majority of the major venous injuries were repaired by the spinal surgeon (10/14, 71 %). Our results are comparable to other studies and support the notion that anterior access surgery to the lumbar spine can be performed safely by spinal surgeons. With adequate training, spinal surgeons are capable of performing this approach without direct vascular support, but they should be available if required.

Upper arm length model suggests transient bilateral asymmetry is associated with right thoracic adolescent idiopathic scoliosis (RT-AIS) with implications for pathogenesis and estimation of linear skeletal overgrowth

INTRODUCTION

In girls with adolescent idiopathic scoliosis (AIS) the finding of abnormal extra-spinal bilateral skeletal length asymmetries in upper limbs, periapical ribs, and ilia begs the question whether these bilateral asymmetries are connected in some way with pathogenesis.

MATERIAL AND METHODS

We investigated upper arm length (UAL) asymmetries in two groups of right-handed girls aged 11-18 years with right thoracic adolescent idiopathic scoliosis (RT-AIS, n=95) from preoperative and screening referrals (mean Cobb angle 46°) and healthy controls (n=240). Right and left UAL were measured with a Harpenden anthropometer of the Holtain equipment, Asymmetry was calculated as UAL difference, right minus left, in mm. Repeatability of the measurements was assessed as technical error of the measurement and coefficient of reliability.

RESULTS

In girls with RT-AIS, UAL asymmetry was greater than in healthy girls, regressed negatively with age and correlated significantly with Cobb angle and apical vertebral rotation. In healthy girls, UAL asymmetry was unrelated to age. Plotted against years after estimated menarcheal age, UAL asymmetry decreased significantly for girls with RT-AIS but not for healthy girls.

DISCUSSION AND CONCLUSIONS

The apparent transience of the abnormal UAL asymmetry suggests it is not secondary to spinal deformity but pathogenetically associated with it. We suggest two hypotheses to account for these changes: (1) a transient asymmetry process with growth velocity; and (2) in the light of subsequent research, early skeletal overgrowth with catch-down growth affecting right but not left upper arm. The relation of the upper arm length asymmetry to the increased length of periapical left ribs reported for RT-AIS is unknown. Right upper arm length may provide a more simple model than arm span, for estimating linear skeletal overgrowth of girls with RT-AIS.

Congenital kypho-scoliosis: a case of thoracic insufficiency syndrome and the limitations of treatment

INTRODUCTION

Congenital spinal vertebral anomalies may present with deformity resulting in congenital scoliosis and kyphosis. This leads to abnormal spinal growth. The latter when combined with associated rib fusions may impair normal thoracic cage development and resultant pulmonary hypoplasia. Most congenital scoliosis can be detected in utero by ultrasound scan or recognized in the neonatal period, but a few spinal defects can remain undetected.

MATERIALS AND METHODS

In this Grand Round, we present the case of a 7-year-old girl with a severe scoliosis and thoracic insufficiency syndrome (TIS). 3D CT reconstruction imaging demonstrated a mixed picture of fusion and segmentation abnormalities. A marked kyphoscoliosis was demonstrated at the thoraco-lumbar junction. Via a left thoracotomy, anterior excision of intervertebral discs was performed together with, interbody fusion, and in situ stabilisation of the kyphosis with double allograft (femur) strut grafts.

CONCLUSIONS

This article highlights the features of congenital kypho-scoliosis and TIS. The difficulties of treating kyphosis when combined with TIS are discussed together with the limitations of current surgical techniques.

Pathogenesis of adolescent idiopathic scoliosis in girls - a double neuro-osseous theory involving disharmony between two nervous systems, somatic and autonomic expressed in the spine and trunk: possible dependency on sympathetic nervous system and hormones with implications for medical therapy

Anthropometric data from three groups of adolescent girls - preoperative adolescent idiopathic scoliosis (AIS), screened for scoliosis and normals were analysed by comparing skeletal data between higher and lower body mass index subsets. Unexpected findings for each of skeletal maturation, asymmetries and overgrowth are not explained by prevailing theories of AIS pathogenesis. A speculative pathogenetic theory for girls is formulated after surveying evidence including: (1) the thoracospinal concept for right thoracic AIS in girls; (2) the new neuroskeletal biology relating the sympathetic nervous system to bone formation/resorption and bone growth; (3) white adipose tissue storing triglycerides and the adiposity hormone leptin which functions as satiety hormone and sentinel of energy balance to the hypothalamus for long-term adiposity; and (4) central leptin resistance in obesity and possibly in healthy females. The new theory states that AIS in girls results from developmental disharmony expressed in spine and trunk between autonomic and somatic nervous systems. The autonomic component of this double neuro-osseous theory for AIS pathogenesis in girls involves selectively increased sensitivity of the hypothalamus to circulating leptin (genetically-determined up-regulation possibly involving inhibitory or sensitizing intracellular molecules, such as SOC3, PTP-1B and SH2B1 respectively), with asymmetry as an adverse response (hormesis); this asymmetry is routed bilaterally via the sympathetic nervous system to the growing axial skeleton where it may initiate the scoliosis deformity (leptin-hypothalamic-sympathetic nervous system concept = LHS concept). In some younger preoperative AIS girls, the hypothalamic up-regulation to circulating leptin also involves the somatotropic (growth hormone/IGF) axis which exaggerates the sympathetically-induced asymmetric skeletal effects and contributes to curve progression, a concept with therapeutic implications. In the somatic nervous system, dysfunction of a postural mechanism involving the CNS body schema fails to control, or may induce, the spinal deformity of AIS in girls (escalator concept). Biomechanical factors affecting ribs and/or vertebrae and spinal cord during growth may localize AIS to the thoracic spine and contribute to sagittal spinal shape alterations. The developmental disharmony in spine and trunk is compounded by any osteopenia, biomechanical spinal growth modulation, disc degeneration and platelet calmodulin dysfunction. Methods for testing the theory are outlined. Implications are discussed for neuroendocrine dysfunctions, osteopontin, sympathoactivation, medical therapy, Rett and Prader-Willi syndromes, infantile idiopathic scoliosis, and human evolution. AIS pathogenesis in girls is predicated on two putative normal mechanisms involved in trunk growth, each acquired in evolution and unique to humans.

The reliability of the Vernon and Mior neck disability index, and its validity compared with the short form-36 health survey questionnaire

Prospective single cohort study. To evaluate the NDI by comparison with the SF36 health Survey Questionnaire. The NDI is a simple ten-item questionnaire used to assess patients with neck pain. The SF36 measures functional ability, well being and the overall health of patients. It is used as a gold standard in health economics to assess the health utility, gain and economic impact of medical interventions. One hundred and sixty patients with neck pain attending the spinal clinic completed self-assessment questionnaires. A second questionnaire was completed in 34 patients after a period of 1-2 weeks. The internal consistency of the NDI and SF36 was calculated using Cronbach's alpha. The test-retest reliability was assessed using the Bland and Altman method. The concurrent validity of the NDI with respect to the SF-36 was assessed using Pearson correlations. Both questionnaires showed robust internal consistency: Cronbach's alpha for the NDI scale was acceptable (0.864, 95% confidence limits 0.825-0.894) though slightly smaller than that of the SF36. The correlations between each item of the NDI scores and the total NDI score ranged from 0.447 to 0.659, (all with P < 0.001). The test-retest reliability of the NDI was high (intra-class correlation 0.93, 95% confidence limits 0.86-0.97) and comparable with the best values found for SF36. The correlations between NDI and SF36 domains ranged from -0.45 to -0.74 (all with P < 0.001). We have shown that the NDI has good reliability and validity and that it compares well with the SF36 in the spinal surgery out patient setting.

Fixed lumbar apical vertebral rotation predicts spinal decompensation in Lenke type 3C adolescent idiopathic scoliosis after selective posterior thoracic correction and fusion

Retrospective radiographic review of surgically treated double major curves (Lenke type 3C) in adolescent idiopathic scoliosis. To evaluate the role of selective posterior thoracic correction and fusion in double major curves with third generation instrumentation and to identify preoperative radiographic parameters that predict postoperative coronal spinal decompensation. Traditionally the surgical treatment of double major curves consists of fusion of both the thoracic and the lumbar curve. Few attempt to perform selective thoracic fusion in this curve pattern because of the potential to create spinal imbalance. Thirty-six patients with Lenke type 3C curves underwent a selective posterior thoracic correction and fusion with either Cotrel-Dubousset instrumentation or the Universal Spine System. Radiographs were evaluated to assess coronal and sagittal balance, curve flexibility, and curve correction at a minimum follow up of 2 years. Postoperative coronal spinal decompensation was investigated with respect to preoperative radiographic parameters on standing anteroposterior (AP), standing lateral radiographs, thoracic and lumbar supine side-bending radiographs. Coronal spinal decompensation was defined as plumbline deviation of C7 of more than 2 cm with respect to the centre sacral vertical line (CSVL) within 2 years of surgery. Twenty-six patients (72%) showed satisfactory frontal plane alignment patients (28%) showed coronal spinal decompensation. Significant group differences, however, were identified for lumbar apical vertebral rotation, measured according to Perdriolle (La scoliose. Son êtude tridimensionnelle. Maloine, Paris, pp 179, 1979) (A 16 degrees , B 22 degrees , P = 0.02), percentage correction (derotation) of lumbar apical vertebrae in lumbar supine side-bending films in comparison to standing AP radiographs (A 49%, B 27%, P = 0.002) and thoracic curve flexibility (A 43%, B 25%, P = 0.03). High correlation was noted between postoperative decompensation and derotation of lumbar apical vertebrae in pre-operative lumbar supine side-bending films with a critical value of 40% (Pearson correlation coefficient; P = 0.62, P < 0.001). Ten of 36 patients (28%) with Lenke type 3C adolescent idiopathic scoliosis showed coronal spinal decompensation of more than 2 cm after selective posterior thoracic correction and fusion. Lumbar apical vertebral derotation of less than 40% provided the radiographic prediction of postoperative coronal spinal imbalance. We advise close scrutiny of the transverse plane in the lumbar supine bending film when planning surgical strategy.

Clinical outcome of symptomatic unilateral stress injuries of the lumbar pars interarticularis

STUDY DESIGN

A prospective case-series study.

OBJECTIVE

To evaluate the results of nonoperative and operative treatment of symptomatic unilateral lumbar pars stress injuries or spondylolysis.

SUMMARY OF BACKGROUND DATA

Most patients become asymptomatic following nonoperative treatment for unilateral lumbar pars stress injuries or spondylolysis. Surgery, however, is indicated when symptoms persist beyond a reasonable time affecting the quality of life in young patients, particularly the athletic population.

METHODS

We treated 42 patients (31 male, 11 female) with unilateral lumbar pars stress injuries or spondylolysis. Thirty-two patients were actively involved in sports at various levels. Patients with a positive stress reaction on single photon emission computerized tomography imaging underwent a strict protocol of activity restriction, bracing, and physical therapy for 6 months. At the end of 6 months, patients who remained symptomatic underwent a computed tomography (CT) scan to confirm the persistence of a spondylolysis. Eight patients subsequently underwent a direct repair of the defect using the modified Buck's Technique. Baseline Oswestry Disability Index (ODI) and Short-Form-36 (SF-36) scores were compared with 2-year ODI and SF-36 scores for all patients.

RESULTS

Eight of nine fast bowlers in cricket were right-handed. The spondylolytic defect appeared on the left side of their lumbar spine. In the nonoperated group, the mean pretreatment ODI was 36 (SD = 10.5), improving to 6.2 (SD = 8.2) at 2 years. In SF-36 scores, the mean score for physical component of health (PCS) improved from 30.7 (SD = 3.2) to 53.5 (SD = 6.5) (P < 0.001), and the mean score for the mental component of health (MCS) improved from 39 (SD = 4.1) and 56.5 (SD = 3.9) (P < 0.001) at 2 years. Twenty of 32 patients resumed their sporting career within 6 months of onset of treatment, and a further 4 of 32 patients returned to sports within 1 year. The 8 patients who remained symptomatic at 6 months underwent a unilateral modified Buck's repair. The most common level of repair was L5 (n = 5). One patient with spina bifida and a right-sided L5 pars defect remained symptomatic following direct repair. The mean preoperative ODI was 39.4 (SD = 3.6), improving to 6.4 (SD = 5.2) at the latest follow-up. The mean score of PCS (SF-36) improved from 29.6 (SD = 4.4) to 49.2 (SD = 6.2) (P < 0.001), and the mean score of MCS (SF-36) improved from 38.7 (SD = 1.9) to 54.5 (SD = 6.4) (P < 0.001).

CONCLUSIONS

The increased incidence of the unilateral lumbar pars stress injuries or frank defect on the contralateral side in a throwing sports, e.g., cricket (fast bowling), may be related to the hand dominance of the individual. Nonoperative treatment for patients with a unilateral lumbar pars stress injuries or spondylolysis resulted in a high rate of success, with 81% (34/42) of patients avoiding surgery. If symptoms persist beyond a reasonable period, i.e., 6 months, and reverse gantry CT scan confirms a nonhealing defect of the pars interarticularis, one may consider a unilateral direct repair of the defect with good functional outcome. Direct repair in patients with spina bifida at the same lumbar level as the unilateral defect may be complicated by nonunion.

Cauda equina syndrome: factors affecting long-term functional and sphincteric outcome

STUDY DESIGN

Retrospective cohort study with prospective clinical follow-up.

OBJECTIVE

To determine the factors that influence outcome after surgery for cauda equina syndrome (CES).

SUMMARY OF BACKGROUND DATA

CES is a rare but serious consequence of lumbar disc prolapse and can have devastating long-lasting neurologic consequences. The timing of surgical decompression remains controversial.

METHODS

Fifty-six patients with evidence of a sphincteric disturbance who underwent urgent surgery were identified and invited to follow-up. The outcome measures comprised history and examination and several validated self-assessment questionnaires.

RESULTS

Forty-two patients (78%) attended with a mean follow-up of 60 months (range, 25-114 months). Mean age at onset was 41 years (range, 24-67 years) with 23 males and 19 females. Twenty-six patients were operated on within 48 hours of onset of sphincteric symptoms; 5 of these were within 24 hours. Acute onset of sphincteric symptoms and the time to operation did not influence the outcomes. Leg weakness at onset persisted in a significant number of patients at follow-up (P < 0.005). Urinary disturbance at presentation did not affect the outcomes. At follow-up, significantly more females had urinary incontinence (P < 0.005). Bowel dysfunction at presentation was associated with sexual problems at follow-up (P < 0.005). The 13 patients who failed their post operative trial without catheter had worse outcomes. The SF-36 scores at follow-up were reduced compared with age-matched controls in the population. The mean ODI was 29, Low Back Outcome Score 42, and VAS 4.5. The time elapsed from operation to follow-up was not found to influence the outcomes.

CONCLUSIONS

In our series, the symptom duration before operation and the speed of onset do not affect the outcome more than 2 years after surgery. Based on the SF-36, ODI, and Low Back Outcome Scores, patients who have had CES do not return to a normal status.

Anterior instrumentation for thoracolumbar adolescent idiopathic scoliosis: do structural interbody grafts preserve sagittal alignment better than morselized rib autografts?

STUDY DESIGN

This is a retrospective, sequential cohort study of 34 patients treated by anterior instrumented fusion with single solid rod, single screw constructs with at least 2-year follow-up. Sixteen of the patients received structural grafts as interbody spacers in disc levels below T12, while the other 18 patients received only morselized rib autograft.

OBJECTIVE

To determine if structural interbody grafts preserve sagittal alignment better than morselized rib autograft.

SUMMARY OF BACKGROUND DATA

Some studies have shown that structural grafts are more effective in preserving sagittal alignment, while others have found them to be no more effective than morselized rib graft.

METHODS

Anterior-posterior radiographs were measured for primary, secondary, and fractional Cobb curves, and C7-sacrum plumb lines. Lateral radiographs were measured for: T5-HIV (highest instrumented vertebrae), instrumented levels, LIV (lowest instrumented vertebrae)-S1, T12-LIV, and T12-S1 angles, C7-sacrum plumb lines, and LID-A (lowest instrumented disc-angle).

RESULTS

The increase in kyphosis from preoperative to follow-up radiographs of the angle between T12-LIV was significantly more for the patients with morselized rib graft compared with those with structural grafts, 9 degrees and 1 degree, respectively (P < 0.05).

CONCLUSIONS

The structural grafts placed in disc spaces below T12 were able to maintain sagittal alignment over this region, while the spines that received only morselized rib graft collapsed into kyphosis.

A prospective, randomised controlled trial of femoral ring allograft versus a titanium cage in circumferential lumbar spinal fusion with minimum 2-year clinical results

The literature reports on the safety and efficacy of titanium cages (TCs) with additional posterior fixation for anterior lumbar interbody fusion. However, these papers are limited to prospective cohort studies. The introduction of TCs for spinal fusion has resulted in increased costs, without evidence of superiority over the established practice. There are currently no prospective controlled trials comparing TCs to femoral ring allografts (FRAs) for circumferential fusion in the literature. In this prospective, randomised controlled trial, our objective was to compare the clinical outcome following the use of FRA (current practice) to the use of TC in circumferential lumbar spinal fusion. Full ethical committee approval and institutional research and development departmental approval were obtained. Power calculations estimated a total of 80 patients (40 in each arm) would be required to detect clinically relevant differences in functional outcome. Eighty-three patients were recruited for the study fulfilling strict entry requirements (>6 months chronic discogenic low back pain, failure of conservative treatment, one- or two-level discographically proven discogenic low back pain). The patients completed the Oswestry Disability Index (ODI), Visual Analogue Score (VAS) for back and leg pain and the Short-Form 36 (SF-36) preoperatively and also postoperatively at 6, 12 and 24 months, respectively. The results were available for all the 83 patients with a mean follow-up of 28 months (range 24-75 months). Five patients were excluded on the basis of technical infringements (unable to insert TC in four patients and FRA in one patient due to the narrowing of the disc space). From the remaining 78 patients randomised, 37 received the FRA and 41 received the TC. Posterior stabilisation was achieved with translaminar or pedicle screws. Baseline demographic data (age, sex, smoking history, number of operated levels and preoperative outcome measures) showed no statistical difference between groups (p<0.05) other than for the vitality domain of the SF-36. For patients who received the FRA, mean VAS (back pain) improved by 2.0 points (p<0.01), mean ODI improved by 15 points (p=<0.01) and mean SF-36 scores improved by >11 points in all domains (p<0.03) except that of general health and emotional role. For patients who received the TC, mean VAS improved by 1.1 points (p=0.004), mean ODI improved by 6 points (p=0.01) and SF-36 improved significantly in only two of the eight domains (bodily pain and physical function). Revision procedures and complications were similar in both groups. In conclusion, this prospective, randomised controlled clinical trial shows the use of FRA in circumferential lumbar fusion to be associated with superior clinical outcomes when compared to those observed following the use of TCs. The use of TCs for circumferential lumbar spinal fusion is not justified on the basis of inferior clinical outcome and the tenfold increase in cost.

"Does size matter?"A comparison of balloon-assisted less-invasive vs conventional retroperitoneal approach for anterior lumbar interbody fusion

This is a case-series comparison of two approaches to anterior lumbar interbody fusion. A conventional open approach (COA) was compared with a balloon-assisted minimally invasive approach (BMI). Outcome measures included operating time, blood loss and complications. Secondary outcome measures included analgesia requirements, time to mobilization and inpatient stay. There were 17 females (7 COA, 10 BMI) and 18 males (9 COA and 9 BMI). Forty-five discs (21 COA, 24 BMI) in total were fused in 35 patients. There were significant differences (in favour of the BMI) in the overall operating time between the COA and the BMI, and the single level COA and the BMI. There was no inter-group difference in the PCA requirements either overall or between one or two-level operations. The less invasive approach did have a benefit in earlier mobilization of the single-level fusions.

A prospective randomized comparison of coralline hydroxyapatite with autograft in cervical interbody fusion

STUDY DESIGN

A prospective randomized trial with independent clinical and radiographic outcome review of patients receiving either hydroxyapatite or tricortical iliac crest graft for cervical interbody fusion was conducted.

OBJECTIVE

To determine whether coralline-derived hydroxyapatite is a suitable bone graft substitute in cervical interbody fusion.

SUMMARY OF BACKGROUND DATA

Tricortical iliac crest bone is the "gold standard" graft material for cervical interbody fusion. Various bone substitutes have been used for this procedure to avoid potential donor site morbidity. ProOsteon 200 is a coralline-derived hydroxyapatite product, the use of which remains unclear for cervical interbody fusion.

METHODS

In this study, 29 patients undergoing anterior cervical fusion and plating were randomized to receive either ProOsteon 200 or iliac crest grafts. The SF-36 and Oswestry Disability Index were used to measure clinical outcome. Postoperative radiographs were analyzed for graft fragmentation, loss of height, angular alignment, and hardware failure to assess structural integrity of the graft material. Plain radiographs and computed tomography scans were used to evaluate fusion.

RESULTS

Both the ProOsteon 200 and iliac crest groups demonstrated significant improvement in clinical outcome scores. There was no significant difference in clinical outcome or fusion rates between the two groups. Graft fragmentation occurred in 89% of the hydroxyapatite grafts and 11% of the autografts (P = 0.001). Significant graft settling occurred in 50% of the hydroxyapatite grafts, as compared with 11% of the autografts (P = 0. 009). One patient in the ProOsteon 200 group required revision surgery for graft failure.

CONCLUSIONS

ProOsteon 200 does not possess adequate structural integrity to resist axial loading and maintain disc height or segmental lordosis during cervical interbody fusion.

Flexion osteotomy of the cervical spine: a new technique for correction of iatrogenic extension deformity in ankylosing spondylitis

STUDY DESIGN

A new surgical technique of cervical osteotomy to correct an extension deformity of the cervical spine is described, and a case is reported.

OBJECTIVES

To emphasize the disparate effect of osteotomy level on sagittal balance and gaze angle in surgical correction of global kyphotic deformity, and to describe a new surgical technique.

SUMMARY OF BACKGROUND DATA

Previous reports of cervical osteotomy essentially have described extension osteotomy for correction of severe flexion deformity. To the authors' knowledge, flexion osteotomy to correct extension deformity of the cervical spine has not been described previously.

METHODS

A 44-year-old woman with global kyphotic deformity caused by ankylosing spondylitis underwent corrective lumbar osteotomy at another institution. Ten years later, she experienced further development of the kyphosis, predominantly at the thoracic level, with resultant restriction of forward gaze. Thoracic corrective osteotomy was performed, which resulted in an upward deviation of her visual field. A flexion osteotomy was performed at C7-T1, using two separate posterior and anterior approaches, in one-stage, in the lateral decubitus. The use of transparent drapes permitted direct visualization of the chin-brow angle during operation. Anterior plate fixation prevented any translation at the osteotomy site.

RESULTS

The osteotomy united; the gaze angle was fully corrected (45 degrees to -30 degrees ). No deterioration was noted at 2-year follow-up.

CONCLUSIONS

Osteotomy at a higher level in the spine for correction of global kyphotic deformity may result in a significant overcorrection of the gaze angle upward. The authors believe that the new technique described in this report is a technically demanding but adequate and safe approach for correcting such a rare deformity.

Anterior thoracoscopic surgery followed by posterior instrumentation and fusion in spinal deformity

Many authors believe thoracoscopic surgery is associated with a lower level of morbidity compared to thoracotomy, for anterior release or growth arrest in spinal deformity. Others believe that anterior release achieved thoracoscopically is not as effective as that achieved with the open procedure. We evaluated the clinical results, radiological correction and morbidity following anterior thoracoscopic surgery followed by posterior instrumentation and fusion, to see whether there is any evidence for either of these beliefs. Twenty-nine patients undergoing thoracoscopic anterior release or growth arrest followed by posterior fusion and instrumentation were evaluated from a clinical and radiological viewpoint. The mean follow-up was 2 years (range 1-4 years). The average age was 16 years (range 5-26 years). The following diagnoses were present: idiopathic scoliosis (n = 17), neuromuscular scoliosis (n = 2), congenital scoliosis (n = 1), thoracic hyperkyphosis (n = 9). All patients were satisfied with cosmesis following surgery. Twenty scoliosis patients had a mean preoperative Cobb angle of 65.1 degrees (range 42 degrees-94 degrees) for the major curve, with an average flexibility of 34.5% (42.7 degrees). Post operative correction to 31.5 degrees (50.9%) and 34.4 degrees (47.1%) at maximal follow-up was noted. For nine patients with thoracic hyperkyphosis, the Cobb angle averaged 81 degrees (range 65 degrees-96 degrees), with hyperextension films showing an average correction to 65 degrees. Postoperative correction to an average of 58.6 degrees was maintained at 59.5 degrees at maximal follow-up. The average number of released levels was 5.1 (range 3-7) and the average duration of the thoracoscopic procedure was 188 min (range 120-280 min). There was a decrease in this length of time as the series progressed. No neurologic or vascular complications occurred. Postoperative complications included four recurrent pneumothoraces, one surgical emphysema, and one respiratory infection. Thoracoscopic anterior surgery appears a safe and effective technique for the treatment of paediatric and adolescent spinal deformity. A randomised controlled trial, comparing open with thoracoscopic methods, is required.

Epidural abscess in an infant

We report the case of a 2-year-old infant who developed a staphylococcal septicaemia that subsequently resulted in an epidural abscess and paraparesis. The significance of early diagnosis and the roles of anterior surgery to decompress the spinal cord, debride infection and correct deformity are discussed.

Chronic contained rupture of an aortic aneurysm mimicking infective spondylitis

Chronic contained rupture of an abdominal aortic aneurysm is rare. These aneurysms are small and affected patients are usually normotensive. The resultant pseudoaneurysmal sac may cause extensive vertebral erosion. Diagnosis is often delayed as the condition may present with symptoms referable to the lumbar spine. This report is of two cases where the initial diagnosis was infective spondylitis.

Automated percutaneous lumbar discectomy. An outcome study

We treated 137 patients with symptomatic lumbar disc prolapse by automated percutaneous lumbar discectomy (APLD). Seventeen (12%) required further operation. At a mean follow-up of 55 months, the success rate was 45%. Of those who had APLD alone, 52% were graded as either excellent or good. In this group, 76% were employed, and the mean Oswestry score was 28.2%. One-third of those patients initially rated as successful had deterioration in symptoms and increased disability from back pain. The Short Form 36 health survey questionnaire revealed that these patients had a chronic ill-health profile.

Automated percutaneous lumbar discectomy. An outcome study

We treated 137 patients with symptomatic lumbar disc prolapse by automated percutaneous lumbar discectomy (APLD). Seventeen (12%) required further operation. At a mean follow-up of 55 months, the success rate was 45%. Of those who had APLD alone, 52% were graded as either excellent or good. In this group, 76% were employed, and the mean Oswestry score was 28.2%. One-third of those patients initially rated as successful had deterioration in symptoms and increased disability from back pain. The Short Form 36 health survey questionnaire revealed that these patients had a chronic ill-health profile.

The Graf stabilisation system: early results in 50 patients

The results of the first 50 consecutive patients using the Graf stabilisation system are presented. The average age of the patients was 41 years; there were 32 women and 18 men in the group. All patients suffered from intractable symptomatic degenerative disc disease which could be localised to one or more levels. All patients gave a history of chronic back pain, but the mean period of severe disability was 24 months. The mean preoperative disability score (Oswestry questionnaire) was 59%. The average period of follow-up was 24 months (range 19-36 months). At the latest review, the mean disability score was 31%. The clinical results were classified as "excellent" or "good" in 72% of patients, "fair" in 10%, "the same" in 16% and "worse" in 2%. All but three patients felt that surgery was worthwhile. The results have not deteriorated over the period of follow-up.

Avascular necrosis of the hip treated by hemiarthroplasty. Results in renal transplant recipients

Osteonecrosis of the femoral head is common complication in renal transplant recipients. Despite the young age of these patients, replacement arthroplasty is often used in treating symptomatic individuals. Between 1983 and 1990, 22 cemented biarticular hemiarthroplasties were performed in 16 consecutive patients with advanced osteonecrosis of the hip. The average interval from initial transplant to arthroplasty was 28 months (range, 11-63 months). The mean age at the time of arthroplasty was 40 years (range, 21-66 years), and all patients were treated with steroids and immunosuppressants at the time of surgery. The average preoperative Harris hip score was 27 points (range, 4-46 points). The mean follow-up period was 40 months (range, 24-71 months). All patients had improvement in pain. Eighty percent of the patients reported a slight or mild limp, although only 25% demonstrated a positive Trendelenburg sign. The average postoperative Harris hip score was 88 points (range, 71-96 points), with 9 hips rated excellent, 12 good, and 1 fair. One patient fractured her acetabulum 26 months after arthroplasty, which resulted in progressive subluxation of the prosthesis. It was revised to a total hip arthroplasty. Another patient developed symptomatic aseptic loosening after 30 months. Apart from this patient there was no other radiologic evidence of loosening in the remainder of the series. Only one patient had demonstrable acetabular protrusion. Twenty percent of the hips had asymptomatic heterotopic ossification. The early results of using a cemented, biarticular hemiarthroplasty in this young group of renal transplant recipients appear encouraging. There was no evidence that this prosthesis causes accelerated acetabular erosion or early loosening.(ABSTRACT TRUNCATED AT 250 WORDS)

SPECT Imaging in the Diagnosis of Meniscal Tears

Sixty patients scheduled for arthroscopy of a knee because of suspected meniscal tears had preoperative planar and single photon emission computed tomography (SPECT) radionuclide scans. A crescentic pattern of uptake on the SPECT transaxial view was used as a criterion for diagnosing a tear of a meniscus. The sensitivity of the investigation was 77%, specificity 74%, negative predictive value (NPV) 65%, positive predictive value (PPV) 83%, and accuracy 76%. Tears of the posterior horn of the cartilage were also associated with intense focal uptake on the transaxial view as well as increased equilibrium activity in the adjacent femoral condyle. When these appearances were included as additional criteria the sensitivity rose to 90%, NPV 81%, and accuracy 84%. This study confirms the usefulness of SPECT imaging in identifying meniscal tears.

Treatment of fractures of the tibial shaft with inter-fragmentary screws and external fixation

In a prospective trial, 10 patients underwent inter-fragmentary screws and external fixation for unilateral tibial shaft fractures. Anatomical reduction was achieved in all cases and uncomplicated bone union occurred in nine patients with a mean time to union of 122 (SD 20) days. One patient had delayed union and the fracture malunited. A 20% pin tract sepsis rate was encountered. The high risk of infection, the demanding follow-up and availability of better methods, does not allow this technique to be recommended in the routine treatment of closed tibial diaphysial fractures.

Magnetic resonance imaging of the knee: initial experience in a district general hospital

We present the results of a prospective study comparing the accuracy of magnetic resonance imaging with arthroscopy in the assessment of knee complaints. Using a low field strength magnet, MRI was able to achieve a high diagnostic accuracy within the setting of a district general hospital.

Trauma care in a military hospital

The results of a quinquennial audit of trauma care in the Cambridge Military Hospital using the TRISS method is presented. 113 cases were analysed. The mean age was 32 years and the mean Injury Severity Score 16. Twenty-five deaths occurred of which 12 were potentially preventable. Means of reducing the number of preventable deaths are discussed.