Common neoplastic causes of paediatric and adolescent back pain.

Neoplasm of the spinal column in children is rare, but can involve either benign or malignant tumours. Early detection of malignant tumours is key to successful clinical outcome and long-term prognosis. In such cases, back pain is a common presenting symptom, but often has a non-neoplastic cause. Therefore, it is important for GPs and trainees who encounter paediatric patients to be aware of the clinical entity to be able to thoroughly assess them in clinical practice. This article discusses the types of paediatric spinal neoplasms, anatomical-based classification, clinical red flags, imaging modalities and outlines brief management options.

Conservative management of psoas haematoma following complex lumbar surgery.

We report psoas hematoma communicating with extradural hematoma and compressing on lumbar nerve roots during the postoperative period in a patient who underwent L3/4 level dynamic stabilization and L4/5 and L5/S1 posterior lumbar interbody fusion. Persistent radicular symptoms occurring soon after posterior lumbar surgery are not an unknown entity. However, psoas hematoma communicating with the extradural hematoma and compressing on L4 and L5 nerve roots soon after surgery, leading to radicular symptoms has not been reported. In addition to the conservative approach in managing such cases, this case report also emphasizes the importance of clinical evaluation and utilization of necessary imaging techniques such as computed tomography (CT) scan and magnetic resonance imaging (MRI) scan to diagnose the cause of persistent severe radicular pain in the postoperative period.

Predicting the underestimation of the femoral offset in anteroposterior radiographs of the pelvis using 'lesser trochanter index': a 3D CT derived simulated radiographic analysis.

We developed 'lesser trochanter index' (LTI) and estimated its accuracy in predicting the underestimation of offset in the anteroposterior (AP) pelvic radiographs. We reconstructed 320 simulated radiographs from the CT scans of 40 adult hips at different rotational projections of 10° increments from 30° internal rotation to 40° external rotation. Underestimation of femoral offset as a percentage was derived from the neck profile angle for all radiographs. Radiographs with an LTI value above 35 were 94% (95% CI, 89%-97%) likely to underestimate femoral offset by more than 5%. Radiographs with LTI between 0 and 30 demonstrated femoral offset within 5% of the true offset (predictive value 100%, CI 87%-100%). LTI could be a useful guide in preoperative templating of hip arthroplasty.

Effect of psychological status on outcome of posterior lumbar interbody fusion surgery.

STUDY DESIGN: Prospective longitudinal study. PURPOSE: To determine if preoperative psychological status affects outcome in spinal surgery. OVERVIEW OF LITERATURE: Low back pain is known to have a psychosomatic component. Increased bodily awareness (somatization) and depressive symptoms are two factors that may affect outcome. It is possible to measure these components using questionnaires. METHODS: Patients who underwent posterior interbody fusion (PLIF) surgery were assessed preoperatively and at follow-up using a self-administered questionnaire. The visual analogue scale (VAS) for back and leg pain severity and the Oswestry Disability Index (ODI) were used as outcome measures. The psychological status of patients was classified into one of four groups using the Distress and Risk Assessment Method (DRAM); normal, at-risk, depressed somatic and distressed depressive. RESULTS: Preoperative DRAM scores showed 14 had no psychological disturbance (normal), 39 were at-risk, 11 distressed somatic, and 10 distressed depressive. There was no significant difference between the 4 groups in the mean preoperative ODI (analysis of variance, p = 0.426). There was a statistically and clinically significant improvement in the ODI after surgery for all but distressed somatic patients (9.8; range, -5.2 to 24.8; p = 0.177). VAS scores for all groups apart from the distressed somatic showed a statistically and clinically significant improvement. Our results show that preoperative psychological state affects outcome in PLIF surgery. CONCLUSIONS: Patients who were classified as distressed somatic preoperatively had a less favorable outcome compared to other groups. This group of patients may benefit from formal psychological assessment before undergoing PLIF surgery.

Radius-only intramedullary nailing for both-bones diaphyseal forearm fractures in children.

Both-bones diaphyseal forearm fractures are common injuries in the paediatric age group and are potentially unstable. Both-bones intramedullary nailing for these fractures is a minimally invasive procedure that maintains alignment, and promotes rapid bony healing. Good results have also been shown with single-bone fixation. We report our experience in treating these common injuries with radius-only intramedullary nailing in 29 children. The clinical notes and radiographs were reviewed retrospectively. There were 9 girls and 20 boys; the mean age at the time of operation was 9 years (range: 5 to 17 years). Closed reduction was achieved in 21 patients, while eight patients required open reduction. Mean duration of follow-up was 6.8 months (range: 4 to 12 months). All fractures achieved clinical and radiological union at 6-8 weeks. Radius-only intramedullary nailing is a sufficient and effective option in treating both bones paediatric forearm displaced unstable type AO 22-A3 fractures, with excellent functional outcome and union rates.

Making referrals: a guide for foundation doctors.

Junior doctors rotate through different specialities as part of their foundation and early speciality training. One responsibility commonly shared by all specialities at all levels is that of making and receiving referrals. According to the General Medical Council's Good Medical Practice, a referral is defined as: 'transferring some or all of the responsibility for the patient's care, usually temporarily and for a particular purpose, such as additional investigation, care or treatment that is outside your competence' (General Medical Council, 2009). Evolving patient needs may necessitate the handing over of care to a different speciality or hospital which is more suited to deal with the problems at hand. This forms the basis of a hospital referral. For those early in their medical careers, this can be a daunting task. Although there is no substitute for practical experience, this article gives a simple guide to help you through the process of making a referral in a hospital setting.