Emergency Pediatric Orthopaedic Transfer Criteria: A Pilot Study.

The purpose of this study was to define pediatric orthopaedic transfer criteria for patients coming from a smaller facility to a Level I pediatric trauma center. A 10-question phone survey was utilized for every transfer request. Fifty-eight transfer requests were prospectively collected and retrospectively reviewed. The criteria were based on The American Academy of Pediatrics (AAP) guidelines and the expert opinion of the senior author. The AAP criteria included complex fractures/dislocations and bone and joint infections. The expert opinion criteria included a patient requiring admission to the hospital or a patient needing surgery. All centers requesting transfers were staffed by an on-call board-certified general orthopaedic surgeon with the ability to care for pediatric orthopaedic injuries. Of the 58 transfers, 37 (64%) did not meet transfer criteria; 21 (36%) met transfer criteria. Transfer requests came from Emergency Department (ED) physicians in 25/58 cases (43%), physician assistants in 11/58 (19%), orthopaedic attending physicians in 3/58 (5%), and orthopaedic residents in 3/58 (5%). The orthopaedic surgeon at the referring hospital examined the patient in only six instances (10%) prior to transfer. Of the 58 patients, 18 (31%) required a hospital admission, and 17 (29%) patients were indicated for surgery. In the current study, 64% of pediatric orthopaedic transfers did not meet criteria for an inter-facility hospital to hospital transfer and were potentially avoidable. (Journal of Surgical Orthopaedic Advances 32(3):182-186, 2023).

Does Routine Subspecialty Consultation Before High-Risk Pediatric Spine Surgery Decrease the Incidence of Complications?

BACKGROUND: Children with neuromuscular disorders and syndromic scoliosis who require operative treatment for scoliosis are at increased risk for postoperative complications. Complications may include surgical site infection and pulmonary system problems including respiratory failure, gastrointestinal system disorders, and others. The purpose of our study was to determine the effect of a standardized perioperative pathway specifically designed for management of high-risk pediatric patients undergoing surgery for scoliosis. METHODS: The High-Risk Protocol (HRP) at our institution is a multidisciplinary process with subspecialty consultations before scoliosis surgery. This was a retrospective chart and radiographic review at a single institution. Inclusion criteria were high-risk subjects, age 8 to 18 years old, who underwent surgery between January, 2009 and April, 2009 with a minimum 2-year follow-up. Diagnoses included neuromuscular scoliosis or Syndromic scoliosis. RESULTS: Seventy one subjects were analyzed. The mean age was 13 (±2 SD) years. Follow-up was 63 (±24 SD) months. The study group consisted of 35 subjects who had fully completed the HRP and the control group consisted of 36 subjects who did not. Nine of the 35 (26%) subjects in the HRP had surgery delayed while interventions were performed. Compared with controls, the study group had larger preoperative and postoperative curve magnitudes: 90 versus 73 degrees ( P =0.002) and 35 versus 22 degrees ( P =0.001). Pulmonary disease was more common in the HRP, 60 versus 31% ( P =0.013). The overall incidence of complications in the study group was 29% (10 of 35 subjects) and for controls 28% (10 of 36). There were no differences between groups for types of complications or Clavien-Dindo grades. Three subjects in the study group and 1 in the controls developed surgical site infection. Eleven subjects required unplanned reoperations during the study period. CONCLUSIONS: The findings of our study suggest a structured pathway requiring routine evaluations by pediatric subspecialists may not reduce complications for all high-risk pediatric spine patients. Selective use of consultants may be more appropriate. LEVEL OF EVIDENCE: Level III, Retrospective Cohort study.

Late presenting developmental dysplasia of the hip after a normal hip ultrasound at 6 weeks of age: A report of two cases.

Developmental hip dysplasia (DDH) is a paediatric condition in which the 'ball and socket' hip joint fails to form properly during infancy. The increased mechanical stress on the hip joint from DDH can contribute to the development of osteoarthritis during adulthood. Therefore, careful physical examination and imaging of all infants to diagnose DDH is critical to provide the best possible functional outcome. Ultrasonography (US) is a useful diagnostic test in providing a real-time evaluation and three-dimensional view of the hip in infants less than 4 months. In infants with a normal hip ultrasound, the risk of subsequent development of hip dysplasia at an older age and the need for further follow-up is assumed to be unnecessary. In the present study, we report 2 cases of late presenting DDH in infant girls born breech with a previous normal hip exam and normal hip ultrasound at 6 weeks of age.

Neurophysiological Intraoperative Monitoring in Patients with Cochlear Implant Undergoing Posterior Spinal Fusion: A Case Report.

CASE: Transcranial electric stimulation motor-evoked potentials (tcMEPs) are the most sensitive technique in multimodality intraoperative neuromonitoring (IONM) for posterior spinal fusion (PSF). The presence of a cochlear implant (CI) is considered a contraindication to IONM because of theoretical risk of implant device and local tissue damage from voltages induced by tcMEPs. We present the case of a 10-year-old girl with CI who underwent successful PSF with tcMEP and monopolar electrocautery (MoEC) without perioperative complications or CI damage. CONCLUSION: With proper precautions, such as MoEC usage at a minimal voltage, motor-evoked potential monitoring can be safely performed in pediatric patients with CI undergoing PSF.

The Pediatric Open Supracondylar Fracture: Associated Injuries and Surgical Management.

BACKGROUND: While supracondylar (SC) fractures are relatively common in children, the incidence of open injuries is believed to be only 1%. Two prior studies on open SC fractures in children reported an increased incidence of vascular injuries. The purposes of our study were to clarify the incidence, associated conditions, and current treatment for open SC fractures. METHODS: The Pennsylvania Trauma Outcome Study database was queried. Subjects age 25 to 156 months old admitted to trauma centers between January 2000 and December 2015 with a SC fracture were included. Controls were those with closed fractures and the study group, those with open injuries. Study variables were age, sex, weight, injury severity score, length of stay (LOS), nerve injury, ipsilateral forearm fracture, compartment syndrome/fasciotomy, requirement for a vascular procedure. Other variables were mode of treatment, provisional reduction, repeat reduction, time interval between referring facility admission and operation, and time from emergency department admission to operation. RESULTS: A total of 4308 subjects were included, 104 (2.4%) of whom had an open SC fracture. LOS was 2 days for the study group versus 1 day for controls (P<0.001). Open SC fractures were more likely than closed to be associated with a nerve injury (13.5% vs. 3.7%), ipsilateral forearm fracture (18.3% vs. 6.4%) and/or a vascular procedure (6.7% vs. 0.3%) (P<0.001). 5.9% of those in the study group required repeat surgery compared with 0.4% for controls (P<0.001). Time from emergency department admission to operation was 3.2 versus 10.3 hours (P<0.001). CONCLUSIONS: We report the largest series to date of open SC fractures in children. Surgeons caring for such patients should be aware of their increased risks for both associated injuries and potential requirement for vascular reconstruction. The majority of children with an open SC fracture are managed with 1 operation and in the absence of vascular injury, seldom require an extended LOS. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Compartment Syndrome in Children With a Supracondylar Fracture: Not Everyone has Risk Factors.

OBJECTIVES: To clarify the incidence, associated conditions, and timing of fasciotomy for compartment syndrome (CS) in children with a supracondylar (SC) fracture of the humerus. DESIGN: A retrospective trauma system database study. SETTING: Accredited trauma centers in Pennsylvania. PATIENTS: A statewide trauma database was searched for children 2-13 years of age admitted with a SC fracture between January 2001 and December 2015. Four thousand three hundred eight children met inclusion criteria. INTERVENTION: Treatment of a SC fracture. MAIN OUTCOME MEASUREMENT: Diagnosis of CS/performance of a fasciotomy. RESULTS: During the study period, 21 (0.49%) children admitted with a SC fracture of the humerus were treated with fasciotomy. CS/fasciotomy was more likely in males (P = 0.031), those with a nerve injury (P = 0.049), and/or ipsilateral forearm fracture (P < 0.001). Vascular procedure, performed in 18 (0.42%) children, was strongly associated with CS/fasciotomy (P < 0.001). Closed reduction and fixation of a forearm fracture was associated with CS (P = 0.007). Timing of SC fracture treatment did not influence outcome. Fasciotomy was performed subsequent to reduction in 13 subjects; mean interval between procedures was 23.4 hours (r = 4.5-51.3). CONCLUSIONS: Risk factors for CS exist; however, they are not required for the condition to develop. CS may develop subsequent to admission and/or SC fracture treatment. In timing of operative management and hospitalization, the results support contemporary practice. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Pediatric Orthopaedic Consults From Chiropractic Care.

Alternative medicine in pediatrics is expanding, with chiropractic now a common choice for families seeking alternative medical care. Currently, there is sparse information in the literature exploring the role of chiropractic in orthopaedic pathology. The objective of this case series is to present pediatric patients who received treatment from chiropractors and orthopaedic physicians as well as to review the respective existing research. Data collected included chiropractic diagnosis, orthopaedic diagnosis, imaging studies, treatments, and complications. Twenty-three patients were studied. Scoliosis, Legg-Calvé-Perthes disease, developmental dysplasia of the hip, cerebral palsy, skeletal dysplasia, and slipped capital femoral epiphysis were diagnoses included. Children had multiple sessions of chiropractic for management of these conditions. The parents' perception for chiropractic was positive in every case. Delayed referral, misdiagnosis, adverse events from manipulative therapy, and ineffective treatments were observed in the present study. More research is indicated to validate chiropractic in children with orthopaedic pathology. (Journal of Surgical Orthopaedic Advances 27(1):58-63, 2018).

Role of Computed Tomography in the Classification of Pediatric Pelvic Fractures-Revisited.

OBJECTIVES: To determine the need for computerized tomography (CT) scans in the assessment of pediatric pelvic fractures. DESIGN: Retrospective Chart Review. SETTING: Level-1 Pediatric Trauma Center. PATIENTS/PARTICIPANTS: Thirty pediatric trauma patients with pelvic fractures who have obtained both a radiograph and CT scan. MAIN OUTCOME MEASUREMENTS: Fleiss Kappa coefficient to compare interreliability. RESULTS: The average age of the patients was 7 years (range 1-13 years). Seventeen were males and 13 were females. The Torode and Zieg classification included 3 type I, 6 type II, 13 type III, and 8 type IV. The Kappa value for interobserver agreement comparing radiographs was 0.453, and for CT was 0.42. Three patients (10%) were treated with a spica cast, and none required surgery for their pelvic fracture. Four patients (11%) demonstrated liver, spleen, or kidney injuries on CT. Out of those 4, 1 had indications for laparotomy and drain placement, 1 died secondary to shock, and 2 were treated conservatively. CONCLUSIONS: The results of this study demonstrated that plain radiographs alone can be used to classify and manage most pediatric fractures, confirming Silber previous findings. Furthermore, we recommend the specific instances of Schreck and Haasz et al in which CT scans should be used, sparing the general pediatric population unnecessary radiation. Such cases include patients with an abnormal abdominal or pelvic examination, complex fracture patterns, displacement greater than 1 cm, femur deformities, hematuria, Glasgow Coma Scale <13, hemodynamic instability, an aspartate aminotransferase > 200 U/L, an Hct < 30%, or an abnormal chest x-ray.

The growing need for resources to help older adults manage their financial and healthcare choices.

BACKGROUND: Both financial literacy (managing personal finances) and health literacy (managing personal health) become increasingly important for older adults, potentially impacting their quality of life. Resources in these constructs of literacy tend to be distinct, although the skills and decision-making involved overlap as financial issues impact healthcare choices. Thus the primary purpose of this commentary is to propose a new area of research focus that defines the intersection of financial and health literacy (i.e., financial health literacy). METHODS: We conducted a limited literature review related to financial, health, and health insurance literacy to demonstrate gaps in the literature and support our position. Online search engines were utilized to identify research in our primary areas of interest. RESULTS: We define the intersection of financial and health literacy as an area of need labeled financial health literacy, with a focus on four domains. These include: 1) the ability to manage healthcare expenses; 2) pay medical bills; 3) determine health needs and understand treatment options; and 4) make sound healthcare decisions with financial resources available. Despite some overlap with health insurance literacy, financial health literacy would define an area of need encompassing health management choices and health plan selections integrated with other financial management issues including living arrangements, financial planning, and retirement planning. CONCLUSIONS: Potential initiatives should be considered to help at-risk older adults find resources to improve their financial health literacy, which in turn will enhance their abilities to manage medical choices in the environment of an increasingly complex healthcare system.

A qualitative study to examine older adults' perceptions of health: Keys to aging successfully.

Older adult health is often defined in clinical terms. Research has demonstrated that many older adults self-report aging successfully regardless of clinical health status. This qualitative study used claims data to identify older adults on three levels of health status: healthy and active, managing diseases, or very sick, to better understand how health is defined and maintained. In total, 32 participants from two cities were interviewed. Interviews were audio- and video-recorded and then transcribed. Thematic analysis identified five themes: disconnectedness between objective and subjective health; health defined to include psychological and social components; resilience and coping mechanisms indicative of successful aging; social support systems integral to health; and the goal of maintaining functioning. These results indicate the importance of individual perceptions of health rather than just counts of chronic diseases. Health management programs should provide holistic approaches to maximize health outcomes and to promote successful aging.

Motivations for Compliance With Bracing in Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Cross-sectional study. OBJECTIVE: To determine motivations for compliance with bracing among female patients with adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Bracing prevents the need for surgery for the majority of girls with AIS with curves of 20° to 40° and 2 or more years of growth remaining. The main obstacle to success is compliance. The factors that either promote or impede compliance previously have not been fully clarified. METHODS: Participants were females 10 to 16 years of age who were prescribed a brace to be worn 16 hours per day for AIS. Each completed a "Scoliosis Compliance Questionnaire" composed of the SRS-22r and five original sections focused on patients' attitudes to scoliosis, situations in which they found wearing the brace to be most and least difficult, factors that motivate brace wear, and interventions that could potentially improve compliance. RESULTS: Thirty-nine subjects completed the study, mean age 13 years (range 11-15 years), at a mean of 15.4 months (range 4-39 months) of brace wear at the time of recruitment. More than 90% of patients stated that their main motivations for compliance were the desire to avoid surgery and to prevent curve progression. Compliance was most challenging during the summer and while at school. Many patients reported pain and skin irritation in the brace. The majority reported they would likely improve their hours of wear if they were able to communicate with a peer in the same situation. SRS-22r scores were similar to those of healthy adolescents. CONCLUSIONS: The most important influences promoting brace wear are the patient's desire to avoid surgery and to prevent curve progression. Peer support potentially may improve compliance. LEVEL OF EVIDENCE: Level III.

Lawnmowers Versus Children: The Devastation Continues.

BACKGROUND: Accidents with lawnmowers can cause mutilating injuries to children. Safety guidelines regarding the use of lawnmowers were promoted by professional organizations beginning in 2001. The Pennsylvania Trauma Systems Foundation maintains a database including all admissions to accredited Levels 1 to 4 trauma centers in the state. The annual rates of admission for children in our state and the severity of injuries subsequent to introduction of safety guidelines have not been reported, to our knowledge. Ride-on lawnmowers have been associated with more severe injuries in children. QUESTIONS/PURPOSES: We asked: (1) What was the incidence of hospital admissions for children with lawnmower-related injuries during 2002 to 2013 and did the incidence vary by age? (2) What was the severity of injuries and did the severity vary by age? (3) How often did these injuries result in amputation? (4) What types of lawnmowers were involved? METHODS: This was a retrospective study using a statewide trauma registry. We queried the Pennsylvania Trauma Outcome Study database for children 0 to 17 years old admitted to trauma centers in Pennsylvania between January 2002 and January 2014 with injuries resulting from lawnmower-related accidents. All accredited Levels 1 to 4 trauma centers in the state are required to submit their data to the Pennsylvania Trauma Systems Foundation which maintains the Pennsylvania Trauma Outcome Study database. Demographic information, Injury Severity Scores, International Classification of Diseases procedure codes, and injury location codes were recorded. Type of lawnmower was determined from the narratives and was identified in 60% (119/199) of patients. Traumatic and surgical amputations performed during the index hospitalization were included in the analysis. Information on later surgeries was not available. Subjects were stratified by age: 0 to 6, 7 to 12, and 13 to 17 years old. RESULTS: The incidence of lawnmower injuries in Pennsylvania was a median five of 100,000 children (range, 4-12/100,000) during the study period. The median age was 6 years (range, 1-17 years). The median Injury Severity Score was 4 (range, 1-75). Children 0 to 6 years old had higher median Injury Severity Scores (median, 8; range, 1-75) compared with those 13-17 years old (median, 4; range, 1-20; difference of the medians, 4; p < 0.001). A total of 53% of the patients (106/199) underwent at least one amputation. There were 83 amputations in or of the foot, 18 in the leg, 14 in the hand, and three in the arm. Ride-on lawnmowers accounted for 92% (110/119) of mowers identified by type. CONCLUSIONS: The incidence of serious injuries to children owing to lawnmower-related trauma did not change during the 12-year study period. If children younger than 6 years had not been near the lawnmower and those younger than 12 years had not been operating one, at least 69% of the accidents might have been prevented. We recommend annual publicity campaigns during spring to remind the public of the dangers of lawnmowers to children. LEVEL OF EVIDENCE: Level IV, therapeutic study.

The Mini C-arm Adds Quality and Efficiency to the Pediatric Orthopedic Outpatient Clinic.

The mini C-arm has become increasingly popular in the practice of orthopedics. To the authors' knowledge, its use in the pediatric orthopedic outpatient clinic has not been reported. The purpose of this study was to evaluate the practice efficiency and radiation exposure to the patient when the mini C-arm was used in the pediatric orthopedic outpatient clinic. One hundred consecutive midshaft and distal forearm fractures were evaluated by one orthopedic surgeon in follow-up using a mini C-arm. For each case, the radiation physicist calculated the amount of skin exposure in milligray (mGy). The average skin exposure to the patient from the mini C-arm was 0.58 mGy, compared with 0.2 mGy for anteroposterior view and lateral view radiographs. Use of the mini C-arm, in place of plain radiographs obtained in the radiology department, decreased time waiting during clinic visits by 23 minutes. This study reports 2 important findings. First, surprisingly, the mini C-arm used a slightly higher radiation dose than standard imaging with plain radiographs. Second, use of the mini C-arm saved time and improved the efficiency of the clinic visit. Overall, the mini C-arm improves quality and efficiency in the pediatric orthopedic outpatient clinic. [Orthopedics. 2016; 39(6):e1097-e1099.].

An anatomic study of the distal femoral epiphysis.

BACKGROUND: The anatomy of the undulating distal femoral physis may be relevant to growth disturbance after physeal fractures and screw fixation about the physis. The surface anatomy of this physis has not been well described. METHODS: We performed an anatomic study on 26 cadaveric distal femoral epiphyses in specimens 3 to 18 years of age. High-resolution 3-dimensional surface scans were obtained and analyzed to determine the heights, approximate surface areas, and locations of the major undulations. RESULTS: Gross examination revealed lateral and anteromedial peripheral notches at the metaphyseal-epiphyseal junction, which deepen with advancing skeletal maturity. Within the epiphysis, there are 3 major undulations: a central ridge, lateral ridge, and medial peak, with mean heights of 5.5 mm (range, 2.9 to 9.8 mm), 2.5 mm (1.0 to 5.7 mm), and 2.9 mm (0.9 to 4.7 mm), respectively. The normalized height and surface area of each undulation decreased with increasing age, most dramatically in the central ridge. With respect to a line connecting the medial and lateral aspects of the physis, we found that the central peak passes more superior with younger age, and tends to be more posteriorly located. The lowest point of the physis is located either anteromedial or posterolateral. CONCLUSIONS: The central ridge, lateral ridge, and medial peak are the 3 major undulations in the distal femoral physis. The central ridge has the greatest height and most dramatic decrease in relative size with increasing age, suggesting structural importance. This anatomic data can guide metaphyseal and epiphyseal screw fixation. CLINICAL RELEVANCE: This study provides quantitative data on the topographic anatomy of the distal femoral physis, which can guide screw placement about the physis. These data may help identify fractures patterns with a greater risk of growth disturbance and key radiographic landmarks for guiding fracture reduction.

An anatomic study of the epiphyseal tubercle and its importance in the pathogenesis of slipped capital femoral epiphysis.

BACKGROUND: It has been proposed that the epiphyseal tubercle on the inferior surface of the capital femoral epiphysis may be responsible for the clinical distinction between a stable and an unstable slipped capital femoral epiphysis (SCFE). The anatomy of the tubercle and its relationship to the lateral epiphyseal vessels have not previously been rigorously defined. METHODS: Twenty-two cadaveric capital femoral epiphyses from donors who had been three to seventeen years of age were analyzed and then digitized with use of a high-resolution laser scanner. The height, location, and approximate surface area of the epiphyseal tubercle were measured and were normalized to the size of the entire capital femoral epiphysis. RESULTS: In all specimens except that from the youngest donor, the foramina for the lateral epiphyseal vessels were visible and were located directly superior to the epiphyseal tubercle. The height of the epiphyseal tubercle was 4.4 ± 1.1 mm. When normalized to the overall size of the capital femoral epiphysis, the relative height (r = 0.71) and relative area (r = 0.56) of the epiphyseal tubercle decreased with increasing age. The epiphyseal tubercle was consistently located in the posterosuperior quadrant, with its position being more posterior and less superior in specimens from younger donors. CONCLUSIONS: The epiphyseal tubercle appears to be a major stabilizer, or keystone, of the capital femoral epiphysis and the lateral epiphyseal vessels. Its relative decrease in height and surface area with increasing age may help explain the susceptibility of individuals to SCFE in adolescence: in a stable SCFE, the physis rotates on the tubercle; however, in an unstable SCFE, the tubercle dislodges, leading to more substantial displacement of the capital femoral epiphysis and the lateral epiphyseal vessels, risking osteonecrosis.

The current medical practice of the pediatric orthopaedic surgeon in North America.

Musculoskeletal disorders in children are common and comprise 20% to 30% of the complaints observed by primary care physicians. Most primary care physicians prefer to refer patients with pediatric musculoskeletal conditions to the pediatric orthopaedic surgeon; most of whom are treated nonoperatively. Pediatric orthopaedic surgeons are well trained to provide efficient, cost-effective, and definitive quality care. This article supports the supposition that pediatric orthopaedic surgeons are the primary care physicians for children with musculoskeletal disorders. This article focuses on the primary clinical responsibilities of the pediatric orthopaedic surgeon, describes the value of this practice, and contrasts their responsibilities from that of other orthopaedic subspecialties.

Wound infections after surgery for neuromuscular scoliosis: risk factors and treatment outcomes.

STUDY DESIGN: Retrospective, case-control study. OBJECTIVE: Determine risk factors for postoperative wound infections after surgery for neuromuscular scoliosis as well as the causative organisms and the results of treatment. SUMMARY OF BACKGROUND DATA: Wound infection after surgery for neuromuscular scoliosis is more common than that for idiopathic scoliosis. A variety of potential risk factors have been identified, but few have demonstrated statistical significance. METHODS: The Pediatric Orthopedic Spine Database identified 151 patients with neuromuscular scoliosis who underwent surgery and had a follow-up of minimum of 2 years. A total of eight patients (5.3% prevalence) developed a postoperative wound infection. Nine patients without an infection were matched by year and type of surgery, for each patient with an infection and selected as controls (n = 72). Preoperative, intraoperative, and postoperative factors were analyzed for an association with wound infection by using stepwise logistic regression. In addition, causative organisms as well as the methods and results of treatment were recorded for each patient. RESULTS.: The control group consisted of 32 males and 40 females with a mean age of 13.3 years (range, 7-21 years) and a mean follow-up of 4.6 years (range, 2.0-20.9 years) at surgery. The infection group (n = 8) consisted of four males and four females with a mean age of 12.5 years (range, 11-14 years) and a mean follow-up of 5.1 year (range, 2.0-12.3 years) at surgery. There were five early and three late wound infections. The presence of a ventriculoperitoneal shunt before surgery was the only factor statistically associated with an increased risk for wound infection (P < 0.01). In addition, infection was associated with pseudarthrosis (P < 0.01) and an increased length of hospitalization (P < 0.01). The most common causative species was staphylococcus and the majority (88%) of infections required surgical intervention with a mean of 2.1 debridements (range, 1-4 debridements). CONCLUSIONS: The presence of a ventriculoperitoneal shunt is a statistically significant risk factor for wound infection after corrective surgery for neuromuscular scoliosis. Wound infection is associated with pseudarthrosis and prolonged hospitalization. LEVEL OF EVIDENCE: III.

Double rib penetration of the spinal canal in a patient with neurofibromatosis.

BACKGROUND: Rib head penetration into the spinal canal in patients with severe kyphoscoliosis secondary to neurofibromatosis type-1 (NF-1) is extremely rare. Double rib head penetration has only been reported once earlier. METHODS: We are reporting on an adolescent male with NF-1 and severe thoracic kyphoscoliosis with adjacent double rib head penetration into the spinal canal without neurological deficits. Only one was recognized on the initial radiographic imaging. RESULTS: A 14-year-old with NF-1 and 74 degrees left thoracic scoliosis and 75 degrees kyphosis was treated at our institution. Preoperative computed tomography (CT) demonstrated protrusion of the left T6 rib head into the spinal canal on the convexity of the curve, compressing the spinal cord. Staged surgical procedures for resection of the rib head and correction of the spinal deformity were planned. After presumed successful resection of the penetrated rib head, a postoperative CT revealed the presence of a second adjacent left T7 rib head in the spinal canal. This was not initially recognized owing to the severe deformity and image obliquity of the CT gantry. Another procedure was performed to remove this rib head. He was then placed in halo traction until anterior and posterior spinal fusion and segmental spinal instrumentation were performed. He achieved good deformity correction and had no neurological deficits throughout his treatment. CONCLUSIONS: Rib head protrusion into the spinal canal can occur with spine deformity in NF-1. If present, the imaging should be carefully reviewed for the possibility of an adjacent rib head penetration that may have been obscured by the limitations of CT in the context of a dysplastic spinal deformity. LEVEL OF EVIDENCE: Level V. Case study.