Shorter and sweeter: the 16-item version of the SRS questionnaire shows better structural validity than the 20-item version in young patients with spinal deformity

PURPOSE

In patients with adult spinal deformity, it was previously shown that 16 of the non-management items of the SRS-instrument showed a better fit to the theoretical four-factor model (pain, function, self-image, mental health) than did all 20 items. Whether the same phenomenon is observed in data from younger (< 20y) patients, for whom the questionnaire was originally designed, is not currently known.

METHODS

Confirmatory factor analysis was used to evaluate the factor structure of the 20 non-management items of the SRS-instrument completed by 3618 young patients with spinal deformity (75.5% female; mean age, 15.0 ± 2.0 years) and of its equivalence across language versions (2713 English-speaking, 270 Spanish, 264 German, 223 Italian, and 148 French). The root mean square error of approximation (RMSEA) and comparative fit index (CFI) indicated model fit.

RESULTS

Compared with the 20-item version, the 16-item solution significantly increased the fit (p < 0.001) across all language versions, to achieve good model fit (CFI = 0.96, RMSEA = 0.06). For both 16-item and 20-item models, equivalence across languages was not reached, with some items showing weaker item-loading for some languages, in particular German and French.

CONCLUSION

In patients with adolescent idiopathic scoliosis, the shorter 16-item version showed a better fit to the intended 4-factor structure of the SRS-instrument. The wording of some of the items, and/or their equivalence across language versions, may need to be addressed. Questionnaire completion can be a burden for patients; if a shorter, more structurally valid version is available, its use should be encouraged.

Implant survival after deep infection of an instrumented spinal fusion

This study evaluates the long-term survival of spinal implants after surgical site infection (SSI) and the risk factors associated with treatment failure. A Kaplan-Meier survival analysis was carried out on 43 patients who had undergone a posterior spinal fusion with instrumentation between January 2006 and December 2008, and who consecutively developed an acute deep surgical site infection. All were appropriately treated by surgical debridement with a tailored antibiotic program based on culture results for a minimum of eight weeks. A 'terminal event' or failure of treatment was defined as implant removal or death related to the SSI. The mean follow-up was 26 months (1.03 to 50.9). A total of ten patients (23.3%) had a terminal event. The rate of survival after the first debridement was 90.7% (95% confidence interval (CI) 82.95 to 98.24) at six months, 85.4% (95% CI 74.64 to 96.18) at one year, and 73.2% (95% CI 58.70 to 87.78) at two, three and four years. Four of nine patients required re-instrumentation after implant removal, and two of the four had a recurrent infection at the surgical site. There was one recurrence after implant removal without re-instrumentation. Multivariate analysis revealed a significant risk of treatment failure in patients who developed sepsis (hazard ratio (HR) 12.5 (95% confidence interval (CI) 2.6 to 59.9); p < 0.001) or who had > three fused segments (HR 4.5 (95% CI 1.25 to 24.05); p = 0.03). Implant survival is seriously compromised even after properly treated surgical site infection, but progressively decreases over the first 24 months.

Human adipose tissue-derived mesenchymal stromal cells as vehicles for tumor bystander effect: a model based on bioluminescence imaging

Human adipose tissue mesenchymal stromal cells (AMSCs) share common traits, including similar differentiation potential and cell surface markers, with their bone marrow counterparts. Owing to their general availability, higher abundance and ease of isolation AMSCs may be convenient autologous delivery vehicles for localized tumor therapy. We demonstrate a model for tumor therapy development based on the use of AMSCs expressing renilla luciferase and thymidine kinase, as cellular vehicles for ganciclovir-mediated bystander killing of firefly luciferase expressing tumors, and noninvasive bioluminescence imaging to continuously monitor both, tumor cells and AMSCs. We show that the therapy delivering AMSCs survive long time within tumors, optimize the ratio of AMSCs to tumor cells for therapy, and asses the therapeutic effect in real time. Treatment of mice bearing prostate tumors plus therapeutic AMSCs with the prodrug ganciclovir induced bystander killing effect, reducing the number of tumor cells to 1.5 % that of control tumors. Thus, AMSCs could be useful vehicles to deliver localized therapy, with potential for clinical application in inoperable tumors and surgical borders after tumor resection. This approach, useful to evaluate efficiency of therapeutic models, should facilitate the selection of cell types, dosages, therapeutic agents and treatment protocols for cell-based therapies of specific tumors.

Analysis of nutritional parameters in idiopathic scoliosis patients after major spinal surgery

OBJECTIVE

The aim of the study is to investigate the evolution of nutritional parameters after major spinal surgery in patients with idiopathic scoliosis.

METHODS

This retrospective study included 31 patients with a mean age of 18 y, diagnosed with idiopathic scoliosis. The following variables were analyzed: demographic, surgical (type, number of fused segments, duration, and blood loss), nutritional assessment (proteins, albumin, prealbumin, transferrin, lymphocytes, and body mass index), and duration of hospitalization at different time points. Statistical analyses were performed with the SPSS 6.1 software.

RESULTS

Before surgery, nutritional status was normal in all patients. At 24-48 h after surgery, statistically significant decrease with respect to preoperative values was recorded for all the parameters studied: proteins (P < 0.001), albumin (P < 0.001), prealbumin (P < 0.01), transferrin (P < 0.001), and lymphocytes (P < 0.001).

CONCLUSION

Our results showed a significant postoperative decrease in the nutritional parameters analyzed in a previously well-nourished population considered to be at low risk for nutritional depletion.

[Total parenteral nutrition in major surgery of the spine]

This paper presents clinical experience with the use of total parenteral nutrition (TPN) in patients undergoing major spinal surgery, as well as the identification of possible risk factors involved in the extended duration of TPN. Although TPN is an expensive therapy, it may even represent a cost saving in patients with a high risk of developing malnutrition. Therefore, it is necessary to identify those patients with the greatest likelihood of presenting nutritional deterioration in order to select those who would benefit from post-operative TPN. During the period under analysis (1995-1998), 137 patients were operated on and could be analyzed retrospectively. The variable considered were: age, sex, weight, body mass index, height, diagnosis, type and time of surgery involved, bleeding, duration of TPN and number of days admitted. The statistical analysis was carried out using the SPSS 6.1 for Windows software package. It comprised a descriptive univariate study, a bivariate comparative means analysis using Student's t test and multi-variant analysis using multiple regression. In the bivariate analysis, a greater duration of TPN was found in those patients subjected to circumferential arthrodesis (p = 0.0001), as well as in patients diagnosed as having kyphoscoliosis following neuromuscular disease (p = 0.0041). The multi-variant analysis gave a correlation statistically significant duration of TPN and surgery time (p = 0.00001), intra-operative bleeding (p = 0.01) and weight (p = 0.0002). No link was found between the duration of TPN and age, nor with the number of days spent in hospital.

Isolated thrombosis of the external jugular vein

Thrombosis of the external jugular vein (EJV) is an infrequent clinical condition that has been associated with central venous catheterization, head and neck infections, intravenous drug abuse, and compression at the affected site. The authors report a case of thrombotic obstruction of the EJV in the late postoperative period after laparoscopic anterior lumbar interbody fusion. A 40-year-old morbidly obese woman with a depressive syndrome was diagnosed with L5-S1 discopathy and was submitted to laparoscopic anterior isthmic fusion. The operation lasted approximately 6 hours, during which the patient remained in a supine decubitus and Trendelenburg position. The left radial artery, peripheral veins, and right internal jugular vein were canalized. The internal jugular vein catheter was electively withdrawn 24 hours after the intervention. The postoperative period was satisfactory, and the patient was started on prophylaxis with low-molecular-weight heparin. She sat up and began walking at 24 hours and was discharged to her home 4 days after the procedure. Eight days after discharge she returned, experiencing right cervical pain. Palpation revealed a painful induration and erythematous area under the anterior edge of the sternocleidomastoid muscle. Results of otoscopy and laryngoscopy were normal. Cervical echo-Doppler disclosed an image consistent with EJV thrombosis. The most frequent causes of jugular vein thrombosis are mentioned above. A higher incidence has been described after upper abdomen and pelvic surgery; other contributing factors are age, obesity, and associated illness. There are few references in the literature to position-induced EJV thrombosis in the late postoperative period. The authors' patient presented signs and symptoms of EJV thrombosis (probably because of various factors), which was confirmed by echo-Doppler study and treated with 10 days of calcic heparin.

Traumatic lumbosacral dislocation

STUDY DESIGN

Case report of a patient with lumbosacral dislocation.

OBJECTIVES

To report a case of traumatic lumbosacral dislocation treated nonoperatively, with 10 years of follow-up.

SUMMARY OF BACKGROUND DATA

Lumbosacral dislocation is rare, with only 48 cases reported in the literature. Surgical treatment by means of open reduction and fusion is advisable. However, the literature shows six cases of patients with complete lumbosacral dislocation treated nonoperatively with good results.

METHODS

A 38-year-old man was involved in a highspeed vehicle accident. The lumbosacral dislocation (anterior displacement of L5 on S1, 44% slippage) was initially missed, and the patient was treated conservatively.

RESULTS

Slippage did not progress, and the patient returned to full, normal activity. Ten years later he is asymptomatic and is able to work and play sports.

CONCLUSIONS

This study reports a rare injury of the lumbosacral junction that was detected 3 months after injury. Satisfactory results were obtained with nonoperative treatment in this case. Although a surgical approach is advisable in acute cases to decompress the neurologic structures and to stabilize the lumbosacral junction, conservative management may be the treatment of choice in inveterate lesions.

Clinical and CT scan evaluation after direct defect repair in spondylolysis using segmental pedicular screw hook fixation

Direct defect repair using segmental pedicular screw hook fixation was carried out in nine patients with spondylolysis and a mean age of 24.2 years. One patient was fused 3 years after isthmic reconstruction. In the remaining eight patients, after a mean follow-up of 41 months (range, 12-78), three self-evaluation scales revealed a significant (p < 0.05) improvement in clinical status. Computed tomography scans were carried out in seven patients. There was bilateral bony union in two cases, in three pars healing was unilateral, and in two the isthmic defect persisted bilaterally. No correlation was observed between the status of the pars and follow-up. We conclude that repair of defects in spondylolysis may result in a favorable clinical outcome even when anatomic reconstruction of pars interarticularis is not successful.

Vertebral fracture in a fused spine for scoliosis. A case report

STUDY DESIGN

A case report.

OBJECTIVES

To document a fracture of the 11th thoracic vertebra after spine fusion for adult idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA

Three cases of vertebral fractures associated with spine fusion for scoliosis were found in the literature.

METHODS

Medical and radiologic records and related literature were reviewed.

RESULTS

A 30-year-old woman had undergone anterior and posterior fusion with Cotrel-Dubousset instrumentation for progressive idiopathic scoliosis. Two years after surgery, she was in a car accident. A radiographic study and computer tomographic scanning depicted a fracture of T11 and bending of the rods. Observation was instituted and symptoms resolved.

CONCLUSIONS

Fracture of a vertebra within an extensive spine fusion for scoliosis is rare. The 360 degrees solid fusion together with strong posterior instrumentation may have had some protective effect in this patient.

Four radiological measures to estimate shoulder balance in scoliosis

We studied four indirect radiological measures of shoulder balance, their correlation with true shoulder balance, and measurement error of each method. Thirty-three consecutive patients with idiopathic scoliosis requiring surgical treatment were selected. Actual shoulder level was determined from a line in the top margin of the acromion clearly visualized in the wide chart. Indirect references used to assess shoulder balance were tilting of cephalic end-plate of T1, inclination of a line through superior border of both first ribs, the level of top margin of coracoid processes, and the level of two specific points where the clavicle intersects the rib cage. All radiographs were assessed by three independent observers. Correlation coefficients between each measurement and true shoulder level were 0.54 for T1 tilting (p = 0.001), 0.63 for first rib inclination (p < 0.001), 0.96 for coracoid process (p = 0.0001), and 0.93 for clavicle-rib cage intersection (p = 0.0001).

Lateral distraction injury to the lumbar spine. Report of spontaneous reduction

STUDY DESIGN

A patient with a lateral distraction injury of the lumbar spine that reduced spontaneously and not associated with any thoracic or abdominal injury is reported.

SUMMARY OF BACKGROUND DATA

A brief summary of the clinical presentation is given as is the surgical technique employed. Lateral distraction injuries of the thoracolumbar spine associate a distraction injury with lateral bending in the frontal plane, causing unilateral disruption of the ligamentous and osseous restraints. The have been associated with life-threatening thoracic and abdominal injuries. Closed reduction of this spine injury is not believed to be feasible.

CONCLUSIONS

This case introduces interesting new features to this spine lesion. It is the first reported case with documented spontaneous reduction.