Do Children With Spinal Deformity Who Have Metal Implants and Frequent Exposure to X-Rays Increase Their Risk of Cancer?

STUDY DESIGN: Spinal surgery cohort. OBJECTIVE: The authors assess the risk of cancer in children who have undergone frequent radiographs and have metal implants for the treatment of spinal deformity. SUMMARY OF BACKGROUND DATA: Concerns have been raised regarding the cancer risk to children exposed to repeated radiological examinations as part of routine surveillance to monitor progression of spinal deformity. Additionally, there are reports of increased cancer risk in adults having joint replacement with metal implants causing raised metal ion levels in the blood. METHODS: A large number of consecutive children undergoing instrumented spinal surgery since 1979 were examined for their development of malignancy. High quality data on all invasive cancers from the South Australian Cancer Registry and deaths were linked to the spinal surgery cohort with the calculation of standardized incidence ratios (SIRs) using the Quinquinquennium method. RESULTS: The study cohort was formed by 865 children. The average follow-up time from date of surgery to either death or censoring date was 18 years with a maximum of 36 years. A total of 15,921 person years were examined. There was no increased rate of cancer in these patients. For the total cohort, the SIR was 1.00 (95% confidence interval [CI] 0.50-1.79). For females the SIR was 0.83 (95% CI 0.33-1.70) and for males the SIR was 1.33 (95% CI 0.36-3.40). The male SIR reflected an expected cancer incidence of three cases, when four cases were observed, and was not statistically significant. CONCLUSION: This study has found that radiation exposure and possible exposure to circulating metal ions as a result of routine instrumented spine surgery in children since 1979 is not associated with an increased risk of cancer in up to 36 years of follow up. LEVEL OF EVIDENCE: 2.

Multiple injections for low back pain: What's the future?

AIMS: To examine the strength of evidence available for multiple facet joint injections (FJIs) and medial branch blocks (MBBs), and to report on the variations in the NHS England framework using the getting it right first time (GIRFT) data. METHODS: Systematic review using patient, intervention, comparison, outcome and study strategy. The literature search using Cochrane, MEDLINE and EMBASE databases using MeSH terms: lumbar spine, spinal injection and facet joint ("Appendix A"). RESULTS: Three studies were identified that investigated the efficacy of multiple FJIs or MBBs. None of these studies reported sustained positive outcomes at long-term follow-up. CONCLUSION: There is a paucity of levels I and II evidence available for the efficacy of multiple FJIs and MBBs in treating low back pain. GIRFT data show a high degree of variation in the use of multiple FJIs, which would not be supported by the literature. These slides can be retrieved under Electronic Supplementary Material.

Degenerative spondylolisthesis: a prospective cross-sectional cohort study on the role of weakened anterior abdominal musculature on causation.

PURPOSE: Degenerative spondylolisthesis (DS) is a degenerative condition of the spine which, unlike others, is more common in a female population. Previous studies have highlighted possible causative factors such as facet tropism and pregnancy as reasons for this. This study sets out to assess the possible link between abdominal musculature and DS. METHOD: A prospective cross-sectional cohort study in a single surgeon practice assessed all patients aged over 50 years attending for degenerative lumbar spinal complaints. Patient demographics, as well as the number of pregnancies, children, abdominal surgical procedures, were recorded. RESULTS: We found 205 patients that met our inclusion criteria (98 Males/107 Females). Women with multiple pregnancies (p = 0.036) and abdominal surgeries (p = 0.021) were more likely to develop DS. Males with ventral hernias were more likely to have developed DS (p = 0.004). CONCLUSION: This study highlights the important role that the abdominal musculature plays in stabilization of the spine and highlights its potential role as a factor in the development of DS. These slides can be retrieved under Electronic Supplementary Material.

Anterior Cervical Discectomy and Fusion YouTube Videos as a Source of Patient Education.

STUDY DESIGN: Cross sectional study. PURPOSE: To assess the quality of anterior cervical discectomy and fusion (ACDF) videos available on YouTube and identify factors associated with video quality. OVERVIEW OF LITERATURE: Patients commonly use the internet as a source of information regarding their surgeries. However, there is currently limited information regarding the quality of online videos about ACDF. METHODS: A search was performed on YouTube using the phrase 'anterior cervical discectomy and fusion.' The Journal of the American Medical Association (JAMA), DISCERN, and Health on the Net (HON) systems were used to rate the first 50 videos obtained. Information about each video was collected, including number of views, duration since the video was posted, percentage positivity (defined as number of likes the video received, divided by the total number of likes or dislikes of that video), number of comments, and the author of the video. Relationships between video quality and these factors were investigated. RESULTS: The average number of views for each video was 96,239. The most common videos were those published by surgeons and those containing patient testimonies. Overall, the video quality was poor, with mean scores of 1.78/5 using the DISCERN criteria, 1.63/4 using the JAMA criteria, and 1.96/8 using the HON criteria. Surgeon authors' videos scored higher than patient testimony videos when reviewed using the HON or JAMA systems. However, no other factors were found to be associated with video quality. CONCLUSIONS: The quality of ACDF videos on YouTube is low, with the majority of videos produced by unreliable sources. Therefore, these YouTube videos should not be recommended as patient education tools for ACDF.

Minimally invasive stabilization of the fractured ankylosed spine: a comparative case series study.

BACKGROUND: To compare the outcome of minimally invasive fracture stabilization to traditional open methods in the thoracolumbar region in patients with an ankylosing disorder of the spine. METHODS: A prospective, ethics-approved database (Spine Tango) at a tertiary referral center was retrospectively reviewed for results of surgery on fractures of the ankylosed thoracolumbar spine. These were then split by surgical technique into two cohorts: minimally invasive surgical fixation (MIS group) or standard open surgery (open group). RESULTS: We identified 17 patients who presented with fractures in an ankylosed spine from 2010 to 2017. MIS fixation was performed on 10 and open surgery and fixation on 7. Average age in the MIS group was older than the traditional cohort. There was no difference in the average number of levels stabilized (open =6.9, MIS =7). There was a shorter duration in the operative time and a significant difference in blood loss in favor of the MIS group (P=0.00079). Radiation exposure time and dose were significantly higher in the MIS group (P=0.006). There were no cases of non-union, implant malposition or failure in either group. Two significant complications occurred with the death of one patient in the MIS group, and one death in the open group. CONCLUSIONS: The MIS technique for fractures of the ankylosed spine has shown an acceptable complication rate and good results comparable to open surgery for a high-risk patient population.

Most Cited Publications in Cervical Spine Surgery.

PURPOSE: The purpose of this study is to perform a citation analysis on the most frequently cited articles in the topic of cervical spine surgery and report on the top 100 most cited publication in this topic. METHODS: We used the Thomson Reuters Web of Science to search citations of all articles from 1945 to 2015 relevant to cervical spine surgery and ranked them according to the number of citations. The 100 most cited articles that matched the search criteria were further analyzed by number of citations, first author, journal, year of publication, country and institution of origin. RESULTS: The top 100 cited articles in the topic of cervical spine surgery were published from 1952-2011. The number of citations ranged from 106 times for the 100th paper to 1206 times for the top paper. The decade of 1990-1999 saw the most publications. The Journal of Spine published the most articles, followed by Journal of Bone and Joint Surgery America. Investigators from America authored the most papers and The University of California contributed the most publications. Cervical spine fusion was the most common topic published with 36 papers, followed by surgical technique and trauma. CONCLUSION: This article identifies the 100 most cited articles in cervical spine surgery. It has provided insight to the history and development in cervical spine surgery and many of which have shaped the way we practice today.

A multi-centred audit of secondary spinal assessments in a trauma setting: are we ATLS compliant?

PURPOSE: The global incidence of spinal cord injuries varies with the developed world having improved survival and 1 year mortality in a poly-trauma setting. This improved survival has been estimated at 20 % in a recent Cochrane review of Advanced Trauma Life Support (ATLS).The aim of this audit is to evaluate the management of patients with suspected spinal cord injury by the trauma and orthopaedic team in three centres in South Wales. METHODS: A retrospective case note review of the secondary survey was performed. Inclusion criteria were patients 18 years and above, with poly-trauma and presenting to Accident and Emergency department at the treating hospital. We used ATLS guidelines as an audit tool and reviewed the documentation of key components of the secondary assessment. RESULTS: Forty-nine patients were included (29 males, 20 females) with an average age of 53.7 years (19-92 years). We found that completion of all components of the secondary survey for spinal injury was poor, 29 % receiving a digital per rectal examination despite suspected spinal injury. Paralysis level was not documented in 20.4 % of patients. Medical Research Council grade was only documented in 24.5 % although was assessed in 73.5 %. The secondary survey took place after 2 h in 54.6 % of patients. CONCLUSION: We found that the documentation of the performance of a secondary survey was poor. We found that most patients included in this study are not currently meeting the minimal standard suggested by the ATLS guidelines.

Should a Lumbar MRI for back pain routinely include the sacro-iliac joint?

BACKGROUND: Back pain is a common problem and has been shown to affect approximately 85% of the adult population at any one time. The source of this pain can be difficult to identify and the sacroiliac joint (SIJ) has been proposed as a possible pain source. Its percentage contribution to lower back pain is controversial. Clinical provocative tests for SIJ pathology have been developed but these have high intra and inter-observer variability and the significant of positive findings is unclear. This study proposes that the SIJ should not be imaged as part of a routine MRI lumbar spine series. METHODS: We retrospectively reviewed the images of 353 patients who had MRI lumbar spine scans. 130 had the SIJ imaged. We recorded the clinical findings and diagnosis at referral. We reviewed the images and documented the radiological findings. RESULTS: SI joint pathology was most frequently identified when clinical suspected. Overall SIJ pathology found on MRI in only 0.02% of patients. CONCLUSIONS: We conclude that routinely imaging the SIJ in MRI lumbar spine series is not cost-effective or a useful use of resources. The SIJ should be imaged only if significant clinical findings are demonstrated.

The rheumatoid forefoot.

Rheumatoid arthritis (RA) manifests itself in a variety of ways, with its effect being seen in around 90 % of sufferers' feet. The foot has been found to be the most common reason for incapacity in patients with RA, with the forefoot the most common area. The foot is second, behind only the hand, as the most common place for manifestation of RA. Pain in the foot is commonly the most debilitating condition, which causes the patient to seek specialist help. As well as pain, foot deformities such as hallux valgus and claw toes are common complaints. These symptoms often arise as a result of continued walking on an unstable foot, leading to painful callosities and dislocation of the metatarsophalangeal joints. Other conditions, such as pannus formation and Morton's neuroma, can be related to RA. This review sets out what we believe to be a successful approach to the rheumatoid forefoot, which aims at the relief of pain and the preservation of ambulation. Key to a successful outcome is appropriate medical control with a multidisciplinary approach that enables close liaison between orthopaedic surgeons, orthotists, and rheumatologists. Combined clinics provide this multidisciplinary care. Those treating RA need to be aware of the high incidence of foot involvement and how early intervention may benefit the patient. The aim of this article is to present current evidence to enable people to develop a treatment algorithm for this condition.

Patient estimates of healthcare costs in trauma and orthopaedics.

AIM: The cost of treating trauma and musculoskeletal conditions per head of population in Wales in 2007-2010 increased from £183 to £236, representing an increase in National Health Service total expenditure of 13.11 %. This study was set up to determine whether the public is aware of the general costs of treatment within the trauma and orthopaedic department. METHOD: Patients completed a questionnaire asking them what they thought the cost was for common orthopaedic treatments, investigations and implants. This questionnaire was completed whilst they were waiting to be seen in clinic. RESULTS: We had 183 completed questionnaires from patients with an average age of 43.47 years (range, 18-85 years). All patients were members of the public, with no previous experience of NHS work or costing. The inter-rater reliability was 0.39(95 % CI, 0.178-0.559). A product was accurately assessed if the estimates were between 50 and 200 % of the true cost. Costs of arm slings and crutches were well estimated by >80 % of the respondents. Approximately 60 % accurately estimated the cost of a fracture clinic visit, hospital transport and physiotherapy and lower limb plaster. Only 22.5 % accurately estimated the cost of a knee X-ray with 37.6 % overestimating the cost by more than tenfold. Other expenses that were underestimated by patients were the costs of a total hip replacement (in 58.3 %), fixation of an ankle fracture (in 32.2 %) and an overnight inpatient stay (in 10.9 %). CONCLUSION: Whilst the costs of physical products were well estimated by our cohort of patients, the costs of less tangible products, such as radiology and operations, were poorly estimated. Our study shows that there is a poor public perception of the true cost for investigation and operative treatment of common trauma and orthopaedic conditions.

Early results with a patient specific interpositional knee device.

The iForma ConforMIS Interpositional knee device is a recently developed patient specific implant used for the treatment of mild to moderate uni-compartmental osteoarthritis. The benefits over traditional methods of surgical management are: it is less invasive, can be performed as a day procedure and does not limit future options. Bespoke implants are produced from data extracted from MRIs. Twenty-six patients with the iForma ConforMIS interpositional knee implant from November 2007 were retrospectively reviewed. The average age was 54.7 years, The average pre-operative WOMAC score was 37.8 improving to 67.6 post-operatively. Five patients required revision. No dislocations were reported. Our early experience suggests this device is a viable and safe treatment option. However, patient selection plays an important role in the outcome following surgery and long term results should be awaited.

Surfers ankle: a bony spur of the talar neck.

A 27-year-old competitive surfer presented with a history of a painful right ankle. He was able to recall an injury to his right ankle 4-5 years previously, sustained while surfing. The mechanism described was that he had dropped a considerable height during take-off, sustaining an impact injury from the board. He recalled immediate pain and swelling followed by 2-3 weeks of pain and a limp; he continued to surf, albeit with difficulty, despite this.Investigations found him to have a bony spur on the anterolateral part of the talus. This case shows how this injury is similar to those observed in other sports.