[Surgical Correction of Scoliosis: Does Intraoperative CT Navigation Prolong Operative Time?] / Operacní korekce skoliózy: prodluzuje peroperacní CT navigace trvání operace?

PURPOSE OF THE STUDY The aim of the study was to compare the duration of corrective surgery for scoliosis in relation to the intra-operative use of either fluoroscopic or CT navigation. MATERIAL AND METHODS The indication for surgery was adolescent idiopathic scoliosis in younger patients and degenerative scoliosis in middleage or elderly patients. In a retrospective study, treatment outcomes in 43 consecutive patients operated on between April 2011 and April 2014 were compared. Only patients undergoing surgical correction of five or more spinal segments (fixation of six and more vertebrae) were included. RESULTS Transpedicular screw fixation of six to 13 vertebrae was performed under C-arm fluoroscopy guidance in 22 patients, and transpedicular screws were inserted in six to 14 vertebrae using the O-arm imaging system in 21 patients. A total of 246 screws were placed using the C-arm system and 340 screws were inserted using the O-arm system (p < 0.001). The procedures with use of the O-arm system were more complicated and required an average operative time longer by 48% (measured from the first skin incision to the completion of skin suture). However, the mean time needed for one screw placement (the sum of all surgical procedures with the use of a navigation technique divided by the number of screws placed using this technique) was the same in both techniques (19 min). DISCUSSION With good teamwork (surgeons, anaesthesiologists and a radiologist attending to the O-arm system), the time required to obtain one intra-operative CT scan is 3 to 5 minutes. The study showed that the mean time for placement of one screw was identical in both techniques although the average operative time was longer in surgery with O-arm navigation. The 19- minute interval was not the real placement time per screw. It was the sum of all operative times of surgical procedures (from first incision to suture completion including the whole approach within the range of planned stabilization) which used the same navigation technique divided by the number of all screws inserted during the procedures. The longer average operative time in procedures using O-arm navigation was not related to taking intra-operative O-arm scans. The authors consider surgery with an O-arm imaging system to be a safer procedure and use it currently in surgical correction of scoliosis. CONCLUSIONS The study focused on the length of surgery to correct scoliosis performed using either conventional fluoroscopy (C-arm) or intra-operative CT scanning (O-arm) showed that the mean placement time for one screw was identical in both imaging techniques when six or more vertebrae were stabilised. The use of intra-operative CT navigation did not make the surgery longer, and the higher number of inserted screws provides evidence that this technique is safer and allows us to achieve good stability of the correction procedure. Key words: virtual CT guidance, O-arm, scoliosis, transpedicular screw.

[Intraoperative CT navigation in spinal and pelvic surgery: initial experience]. / Peroperacní CT navigace u operací pátere a pánve: první zkusenosti.

INTRODUCTION: The authors describe their first experience with virtually navigated pelvic and spine screws based on perioperative CT navigation. MATERIAL AND METHODS: From 22 October 2012 (launching the device) to 9 January 2013, a total of 15 CT-navigated pelvic and spine operations were performed in 14 patients. Nerve root compression, scoliosis, vertebral fracture and spondylodiscitis were the indications for spine procedures; B-type and C-type fractures according to the AO classification were the indications in pelvic surgical procedures. The preparation and the course of the procedures were in accordance with current standards and recommendations in all the cases. Perioperative navigation and subsequent examination of the screw trajectory were performed via O-arm imaging system (Medtronic Navigation, Louisville, Colorado) instead of the standard C-arm fluoroscopy. RESULTS: A total of 73 screws were inserted (60 transpedicular screws into cervical, thoracic and lumbar vertebrae, 9 iliosacral screws into the first sacral vertebra and 4 pubic screws). Only one of the pubic screws (1.4% of all screws) was found malpositioned at the subsequent perioperative examination and was extracted immediately and replaced. Further complications were not observed and none of the procedures had to be converted into a standard fluoroscopy guided operation. CONCLUSION: A short but intensive experience with perioperative CT navigation allows us to state: 1. CT navigation shortens the operating time and minimalizes the risk of screw malposition in multiple screw spine procedures; 2. CT navigation improves the introduction of iliosacral and pubic screws in pelvic fixations; 3. there is virtually no radiation load to the staff using the CT navigation; 4. mastering this technique will allow a wider use of miniinvasive screw insertion in the pelvis and other regions where minimal dislocation will enable miniinvasive internal fixation.

Bacterial meningitis after craniocerebral trauma in the community.

Craniocerebral trauma is one of major risk factors for development of meningitis. We reviewed 30 cases of bacterial meningitis occurring in community after craniocerebral trauma. Alcohol abuse was significant risk factor occurring in trauma patients with meningitis present in 50% in our cohort (p=0.0001). The most common pathogen in posttraumatic meningitis was Str. pneumoniae (90% vs. 33.8%, p=0.0001). However mortality was very low, only 5% probably because of early diagnosis and treatment of patients at risk for bacterial meningitis but neurologic sequellea were significantly more common (p=0.00001) in patients after craniocerebral trauma.

Adrenal and pituitary emergencies.

Although loss of normal pituitary function may be silent and asymptomatic, sudden loss of gland function (pituitary apoplexy) typically results in characteristic presentations. Sheehan's syndrome is the development of hypopituitarism after postpartum hemorrhage or shock. Patients with Sheehan's syndrome may have typical or atypical presentations based on the extent of pituitary gland destruction. Patients with typical symptoms fail to lactate after giving birth; subsequently these patients also develop symptoms and signs of hypopituitarism. Measuring the serum prolactin level after giving thyrotropin-releasing hormone is a reasonable first step in the diagnosis of this condition in patients who fail to lactate after giving birth. The diagnosis of hypopituitarism is delayed for up to 7 years in patients with atypical symptoms. Acute symptomatic failure of the pituitary gland (pituitary apoplexy) commonly occurs in patients who have asymptomatic pituitary tumors. Many patients with pituitary tumors do not have signs of abnormal endocrine gland secretion and have a normal appearance. Most patients have the following signs or symptoms: headache; acute disturbances in visual acuity or visual fields; ophthalmoplegia, and changes in the level of consciousness. The syndrome of pituitary apoplexy usually evolves over hours to days. Subarachnoid hemorrhage and acute bacterial meningitis are the two most important mimics of pituitary apoplexy. Intravenous steroids and prompt neurosurgical consultation are mandatory in cases of pituitary apoplexy since both steroids and surgery can improve vision. Testings for acute or chronic hypopituitarism is challenging in the Emergency Department setting; however, carefully chosen tests will aid in the subsequent early correct diagnosis after initial Emergency Department management.

Unusual presentation of cervicothoracic actinomycosis complicated by pericardial effusion: a case report.

Actinomycosis is a chronic-suppurative disease characterized by abscesses and draining sinus tracts, with fibrosis and granulation involving the face and neck and thoracic or pelvic-abdominal regions. Dermatological findings in patients at high risk are the key to the correct diagnosis. Actinomycosis is frequently undiagnosed or misdiagnosed until the correct diagnosis is made after surgical resection. Alcoholic, homeless, and disadvantaged individuals and patients with other factors predisposing to infection including poor dentition, alcoholism, seizures, and trauma are common in the emergency department; thus, emergency physicians should be aware of the different presentations and complications of this disease. The treatment of choice is a high dose of penicillin in conjunction with surgical debridement. The prognosis is excellent with correct diagnosis and therapy.

The value of outpatient blood cultures in the emergency department.

The value of adult outpatient blood cultures was assessed by a retrospective chart review of all patients for whom cultures were obtained in an emergency department. Eighty-six of 411 patients for whom cultures were obtained were not admitted. Five of these 86 patients were identified as being bacteremic by positive blood culture growth the next day, and three of the five had endocarditis. All endocarditis patients had identifiable risk factors for this disease. Although blood cultures cannot be recommended for most patients discharged from the emergency department with a febrile illness, they are helpful in detecting endocarditis and other bacteremic conditions before obvious signs develop.

MAST conversion of paroxysmal supraventricular tachycardia in Wolff-Parkinson-White syndrome.

A 48-year-old man with Wolff-Parkinson-White syndrome presented with paroxysmal supraventricular tachycardia. Prior episodes had required inpatient drug therapy or cardioversion. Attempts at conversion to normal sinus rhythm with vagal maneuvers were unsuccessful. Inflation of military antishock trousers resulted in rapid termination of the arrhythmia and avoidance of hospitalization.

Autonomous departments of emergency medicine in contemporary academic medical centers.

There are currently 20 autonomous departments of emergency medicine in United States medical schools. EDs seeking autonomous status should institute a faculty development program to channel faculty energy into worthwhile research projects; establish protected time for clinical faculty to increase research productivity; develop expertise to compete for extramural funding; initiate an intramural research program so that faculty can learn the basics of grantsmanship; teach health care issues in ambulatory medicine; become involved in interdisciplinary teaching programs and curriculum development; maintain the present faculty commitment to 24-hour attending coverage; and develop university-based programs that originate from the ED. Program directors should establish liaisons with the medical school dean to acquaint him with the advantages of an autonomous department of emergency medicine; attempt to assess other relationships within the medical school to determine support for emergency medicine and to uncover and address opposition to autonomous departmental status; attempt to serve on medical school committees to meet other faculty, solve problems with them and develop trusting relationships; and develop broad-based support for autonomous departmental status both within and outside of the university. By devising and following a deliberate approach to attaining departmental status, emergency medicine will be assured of continued growth in the important decade ahead.

Acute neonatal scalp abscess and E coli bacteremia in the ED.

An atypical presentation of newborn scalp abscess is described in a 9-day-old infant. The infant appeared nontoxic upon presentation on day 9 after birth with a scalp abscess and Escherichia coli bacteremia. The infant had been admitted from the emergency department to the newborn intensive care unit on day 4 after birth with the same diagnosis; however, she was discharged within hours without treatment. This case report demonstrates the subtle clinical features, presentation, microbiology, and appropriate emergency department management of neonatal scalp abscesses.

Misdiagnosis of acute appendicitis: common features discovered in cases after litigation.

To identify differences between correctly diagnosed appendicitis and misdiagnosed cases that resulted in litigation between 1982 and 1989 retrospective review of malpractice claims was conducted. A total of emergency department (ED) charts at the time of the initial ED visit were reviewed and compared with 66 concurrent controls. Missed cases appeared less acutely ill, had fewer complaints of right lower quadrant pain, received fewer rectal examinations, received intramuscular (IM) narcotic pain medication for undiagnosed abdominal pain or symptoms, and more often received an ED discharge diagnosis of gastroenteritis. Misdiagnosed patients had a 91% incidence of ruptured appendix, more extensive surgical procedures, and more postoperative complications. Data were analyzed using the Pearson's chi 2 Test, Mann-Whitney U Test, and stepwise discriminant analysis. Significance was defined as P < or = .05. Misdiagnosis of acute appendicitis is more likely to occur with patients who present atypically, are not thoroughly examined (as indexed by documentation of a rectal examination), are given IM narcotic pain medication and then discharged from the ED, are diagnosed as having gastroenteritis (despite the absence of the typical diagnostic criteria), and with patients who do not receive appropriate discharge or follow-up instructions.

Multiple trauma in the achondroplastic dwarf: an emergency medicine physician perspective case report and literature review.

Although uncommon, the achondroplastic dwarf (AD) may become the victim of multiple trauma, presenting special challenges for the emergency department (ED) physician. Traditional management of airway, breathing, circulation, and neurological disability is altered by the unique anatomic features of achondroplasia. Despite facial abnormalities observed in the AD, orotracheal and nasotracheal intubation are usually accomplished without particular difficulty; however, abnormalities of the base of the skull and cervical spine make hyperextension of the neck especially hazardous in these patients. The lungs are functionally normal, although vital capacity is decreased and thoracic case abnormalities and abdominal obesity impair lung expansion. Vascular access in the AD is difficult. Peripheral access is difficult because of excessive subcutaneous fat, whereas central venous access is complicated by neck, chest wall, and spinal abnormalities that obscure commonly used anatomic landmarks. Major neurological syndromes observed in ADs are hydrocephalus, cervical medullary compression, and thoracolumbar stenosis. The ED physician should recognize these syndromes, their potential to produce neurological disability, and their unique implications for trauma.

Transcutaneous pacing in a hypothermic-dog model.

STUDY OBJECTIVE: To evaluate the hemodynamic response to transcutaneous pacing (TCP) during rewarming from hypothermia. METHODS: We conducted a prospective, controlled laboratory investigation using 20 mongrel dogs. The animals were anesthetized, intubated, and mechanically ventilated. Arterial pressure, core temperature, and cardiac rhythm were continuously monitored. All dogs were cooled to a core temperature of 27 degrees C; experimental animals were then subjected to TCP with active rewarming, and control animals underwent sham transcutaneous pacing and rewarmed in the same manner. Serial hemodynamic measurements, time to rewarming, and cardiac isoenzyme concentrations were analyzed. RESULTS: Rewarming was accomplished significantly faster in the paced group (171.5 +/- 31.5 minutes) than in the control group (254 +/- 55.9 minutes, P < .05). After rewarming, the mean cardiac index in the paced dogs returned to 84% of baseline, compared with 63% of baseline in the nonpaced group (P < .05). None of the paced animals demonstrated significant hemodynamic deterioration, potentially lethal arrhythmias, or other evidence of myocardial injury. CONCLUSION: TCP is safe, effective and easily implemented in dogs. In this small series of dogs, TCP restored and maintained hemodynamic stability and allowed the hypothermic animals to rewarm in half the time required by their nonpaced counterparts.

Successful treatment of paroxysmal supraventricular tachycardia with MAST.

We have noted that inflation of the military antishock trousers (MAST) successfully converted five of six patients with paroxysmal supraventricular tachycardia to normal sinus rhythm. In all patients the usual "vagal" maneuvers were tried first and were unsuccessful. MAST inflation may be a safe and useful addition to the traditional vagal maneuvers used to treat paroxysmal supraventricular tachycardia.

Litigation against the emergency physician: common features in cases of missed myocardial infarction.

Adverse outcome data from two insurance companies were retrospectively studied to determine whether a constellation of clinical circumstances, data-gathering behaviors, or physician variables were common to cases of missed acute myocardial infarction (AMI) and, if so, to formulate quality assurance recommendations to decrease future occurrences of misdiagnosis. We studied AMI because missing this diagnosis accounts for the highest dollar losses in emergency department malpractice cases. Our study group consisted of 65 patients with undiagnosed AMI seen in EDs between 1982 and 1986. Univariate differences between undiagnosed cases and correctly diagnosed concurrent controls were analyzed using Student's t test and chi 2 analysis. Insurance losses for our cases averaged $113,806 +/- $178,330 (SD). Compared with concurrent controls, study patients were significantly younger, presented more atypically, and had fewer ECGs that were diagnostic of AMI. Undiagnosed patients were evaluated by physicians who documented less detailed histories, misread more ECGs, had less ED experience, and admitted fewer patients to the hospital. Preventive strategies are outlined.