Arthritis or an Adjacent Fascial Response? A Case Report of Combined Pyomyositis and Aseptic Arthritis.

Pyomyositis, accompanied by aseptic arthritis, has been previously documented in several publications. However, none of the authors in the mentioned case reports offered a pathophysiological explanation for this unusual phenomenon or proposed a treatment protocol. We present a case of a healthy, 70-year-old male who was presented to the emergency department 4 days after tripping over a pile of wooden planks and getting stabbed by a nail to his thigh. The right thigh was swollen. Unproportional pain was produced by a light touch to the thigh. A laboratory test and a CT scan were obtained. The working diagnosis was pyomyositis of the thigh and septic arthritis of the ipsilateral knee. The patient underwent urgent debridement and irrigation of his right thigh. An arthroscopic knee lavage was performed as well. Intraoperative cultures from the thigh revealed the growth of Streptococcus pyogenes and Staphylococcus aureus. Cultures from synovial fluid were sterile; thus, septic arthritis was very unlikely. The source of the knee effusion might have been an aseptic inflammatory response due to the proximity of the thigh infection. Anatomically, the quadriceps muscle inserts on the patella, and its tendon fuses with the knee capsule, creating a direct fascial track from the thigh to the knee. The inflammatory response surrounding the infection may have followed this track, creating a domino effect, affecting adjacent capillaries within the joint capsule, and causing plasma leakage into the synovial space, leading to joint effusion. Our suggested treatment is addressing the primary infection with antibiotics and considering adding anti-inflammatory therapy, given our suspicion that this process has an inflammatory component.

Comparative evaluation of postoperative outcomes and expenditure between robotic and conventional single-level lumbar fusion surgery: a comprehensive analysis of nationwide inpatient sample data.

INTRODUCTION: In this study, we investigate the evolution of lumbar fusion surgery with robotic assistance, specifically focusing on the impact of robotic technology on pedicle screw placement and fixation. Utilizing data from the Nationwide Inpatient Sample (NIS) covering 2016 to 2019, we conduct a comprehensive analysis of postoperative outcomes and costs for single-level lumbar fusion surgery. Traditionally, freehand techniques for pedicle screw placement posed risks, leading to the development of robotic-assisted techniques with advantages such as reduced misplacement, increased precision, smaller incisions, and decreased surgeon fatigue. However, conflicting study results regarding the efficacy of robotic assistance in comparison to conventional techniques have prompted the need for a thorough evaluation. With a dataset of 461,965 patients, our aim is to provide insights into the impact of robotic assistance on patient care and healthcare resource utilization. Our primary goal is to contribute to the ongoing discourse on the efficacy of robotic technology in lumbar fusion procedures, offering meaningful insights for optimizing patient-centered care and healthcare resource allocation. METHODS: This study employed data from the Nationwide Inpatient Sample (NIS) spanning the years 2016 to 2019 from USA, 461,965 patients underwent one-level lumbar fusion surgery, with 5770 of them having the surgery with the assistance of robotic technology. The study focused primarily on one-level lumbar fusion surgery and excluded non-elective cases and those with prior surgeries. The analysis encompassed the identification of comorbidities, surgical etiologies, and complications using specific ICD-10 codes. Throughout the study, a constant comparison was made between robotic and non-robotic lumbar fusion procedures. Various statistical methods were applied, with a p value threshold of < 0.05, to determine statistical significance. RESULTS: Robotic-assisted lumbar fusion surgeries demonstrated a significant increase from 2016 to 2019, comprising 1.25% of cases. Both groups exhibited similar patient demographics, with minor differences in payment methods, favoring Medicare in non-robotic surgery and more private payer usage in robotic surgery. A comparison of comorbid conditions revealed differences in the prevalence of hypertension, dyslipidemia, and sleep apnea diagnoses-In terms of hospitalization outcomes and costs, there was a slight shorter hospital stay of 3.06 days, compared to 3.13 days in non-robotic surgery, showcasing a statistically significant difference (p = 0.042). Robotic surgery has higher charges, with a mean charge of $154,673, whereas non-robotic surgery had a mean charge of $125,467 (p < 0.0001). Robotic surgery demonstrated lower rates of heart failure, acute coronary artery disease, pulmonary edema, venous thromboembolism, and traumatic spinal injury compared to non-robotic surgery, with statistically significant differences (p < 0.05). Conversely, robotic surgery demonstrated increased post-surgery anemia and blood transfusion requirements compared to non-robotic patients (p < 0.0001). Renal disease prevalence was similar before surgery, but acute kidney injury was slightly higher in the robotic group post-surgery (p = 0.038). CONCLUSION: This is the first big data study on this matter, our study showed that Robotic-assisted lumbar fusion surgery has fewer post-operative complications such as heart failure, acute coronary artery disease, pulmonary edema, venous thromboembolism, and traumatic spinal injury in comparison to conventional methods. Conversely, robotic surgery demonstrated increased post-surgery anemia, blood transfusion and acute kidney injury. Robotic surgery has higher charges compared to non-robotic surgery.

Effect of Compressive Shoulder Draping With Adhesive Incise Drape on Soft Tissue Swelling in Shoulder Arthroscopy: A Prospective Randomized Trial.

Background: Soft tissue swelling in shoulder arthroscopy is common and may lead to complications. Measures aimed at reducing this phenomenon are routinely used with limited efficacy. Purpose/Hypothesis: The purpose of the study was to assess (1) soft tissue swelling of the shoulder (the operated site) and (2) soft tissue swelling of the neck, chest, and arm (the surrounding tissue) in patients with versus without compressive draping during shoulder arthroscopy. It was hypothesized that compressive draping of the shoulder with adhesive incise drape would reduce soft tissue swelling during shoulder arthroscopy. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 50 patients undergoing arthroscopic rotator cuff repair were prospectively randomized to either the study group (in which the shoulder was draped with adhesive incise drape tightened around the shoulder) or the control group (in which a standard shoulder arthroscopy drape was used). The circumferences of the shoulder, arm, chest, and neck were measured preoperatively and postoperatively and compared between the groups. Results: The shoulder circumference in the standard draping group increased by 16% during the procedure (from 21.2 ± 1.5 cm preoperatively to 24.5 ± 1.7 cm postoperatively) compared with only 6% in the compressive draping group (from 21.0 ± 1.3 cm preoperatively to 22.3 ± 1.1 cm postoperatively) (P < .01). No serious postoperative complications were observed in either group. Conclusion: Compressive shoulder draping with adhesive incise drape was effective in reducing soft tissue swelling around the shoulder in arthroscopic rotator cuff repair compared with standard arthroscopic draping and was not associated with any adverse reactions. Registration: NCT03216590 (ClinicalTrials.gov identifier).

Acute disc herniation following surgical decompression of lumbar spinal stenosis: a retrospective comparison of mini-open and minimally invasive techniques.

BACKGROUND: Disc herniation following decompression of lumbar spinal stenosis is a less familiar surgical complication. Previous studies suggested that open lumbar decompression techniques, associated with relative segmental instability especially in the presence of degenerated disc in older patients, are more likely to result in disc herniation compared to minimally invasive techniques. The current study compares the incidence of acute disc herniation following mini-open and minimally invasive decompression of lumbar spinal stenosis. METHODS: This was a retrospective study reviewing 563 patients who underwent spinal decompression for symptomatic lumbar stenosis by mini-open bilateral partial laminectomy technique or minimally invasive laminotomy utilizing a tubular system. Demographic and clinical data were collected and compared between the groups. RESULTS: Postoperative disc herniation rate was significantly lower in the minimally invasive group with 2 of 237 cases (0.8%) versus 19 of 326 cases (5.8%) in the mini-open group (p = 0.002). This finding was more noticeable following multi-level procedures with no case of postdecompression disc herniation in the minimally invasive group compared to 8 of 39 cases (20.5%) in the mini-open group (p = 0.003). CONCLUSION: The incidence of postoperative disc herniation following spinal decompression for symptomatic lumbar stenosis was 5.8% following mini-open bilateral partial laminectomy compared to only 0.8% after minimally invasive laminotomy (p = 0.002). These findings highlight the more extensive nature of mini-open surgery associated with relative segmental instability that poses a greater risk for postoperative disc herniation.

Higher Mortality Rate in Patients with Vertebral Compression Fractures is due to Deteriorated Medical Status Prior to the Fracture Event.

Introduction: Vertebral compression fractures (VCF) are the most common low-energy fractures in older people and are associated with increased mortality. To assess mortality risk in patients suffering from VCF, we conducted a retrospective observational long-term cohort study. Patients and Methods: The study included 270 patients. 221 patients were treated conservatively, and 49 were treated with vertebroplasty. The study group was compared to a control group of 1641 random individuals age and sex-matched. Electronic healthcare data extracted included monthly chronic medications taken regularly 3 months before hospitalisation, analgesics excluded, and date of death. Results: Patients who suffer from VCF tend to consume more chronic medications. The mean count of chronic medication prescriptions in the 3 months before hospitalisation was 16.41 (±9.11) in the VCF group and 11.52 (± 7.17) in the control cohort (P < .0001). In univariate analysis, patients with VCF showed decreased long-term survival (P < .00). However, when controlled for age, sex, and chronic medications uptake, no significant difference was observed between the groups in a multivariate model (P = .12). Conclusions: The study demonstrates that VCF as an independent variable has a marginal effect on mortality. The higher mortality prevalent in these patients is due to the deteriorated health status of the patients before fracture.

A Quick and Comprehensive Guide to Differential Diagnosis of Neck and Back Pain: a Narrative Review.

The list of diagnostic options when approaching a patient with axial pain is impressively complex. Many offer limited diagnostic workups, but we could not find a truly comprehensive diagnostic guide to assist in the diagnostic evaluation. In this short paper, we briefly described a long list of medical conditions, each of which can manifest as back or neck pain, and whose prevalence ranges from common to very rare. We then proposed an algorithm for classifying them into subgroups. Further referral to diagnostic tests and specialist consultations, after assignment to one of those subgroups, could save time and unnecessary tests. We believe that this review and the proposed diagnostic algorithm can be valuable for medical education and for use in the primary care setting for the diagnostic evaluation of any type of back or neck pain in all patient groups.

Age-related Differences in Clinical Outcomes of Lumbar Discectomy.

INTRODUCTION: Lumbar discectomy is a common and effective treatment for symptomatic disk herniation. It has been suggested that lumbar discectomy in older patients may result in poorer clinical outcomes and lesser satisfaction. The purpose of this study was to assess age-related difference in patient reported outcomes of patients undergoing lumbar discectomy for chronic low back and radicular pain. MATERIALS AND METHODS: Patients with chronic lumbar radiculopathy without neurological deficit underwent non-urgent single level lumbar discectomy in our institution between 2014 and 2017. Pain level (using VAS score), Oswestry Disability Index, and SF-12 scores were retrospectively reviewed and compared between younger patients (<60 years, group 1) and older patients (>60 years, group 2). RESULTS: Seventy-three patients, aged between 34-76 years participated in this study. VAS, ODI, and SF-12 scores improved significantly after the surgery for each group (P < .01). When comparing between the groups, no significant differences in the outcomes measured were found after the surgery in both early post-operative follow-up and late post-operative follow-up (P > .05). DISCUSSION: Elderly patients undergoing lumbar discectomy report a significant reduction in VAS, ODI, and SF-12 scores justifying the procedure. CONCLUSION: Lumbar discectomy improved function and decreased pain level to similar extent in both younger and older patients suffering from radicular symptoms related to lumbar disc herniation.

Bilateral traumatic C6-C7 facet dislocation with C6 spondyloptosis and large disk sequestration in a neurologically intact patient.

Traumatic cervical spondyloptosis is an uncommon and severe form of facet joint dislocation that commonly leads to severe neurological damage. Decision making regarding the reduction and fixation technique is challenging, especially when a patient is neurologically intact, since an undiagnosed prolapsed disk at the involved level may lead to severe neurological consequences during reduction. A 24-year-old male was admitted after sustaining a severe direct axial blow to his head. Computed tomographic and magnetic resonance imaging scans revealed an acute C6C7 fracture dislocation with spondyloptosis of C6 vertebra and a large disk fragment posterior to C6 vertebral body. The patient was neurologically intact, apart from mild bilateral numbness over C6 distribution. The patient underwent C6 corpectomy to avoid acute cord compression related to the large sequestered disk behind C6 vertebra. Following C6 corpectomy, we were unable to exert enough axial pull to reduce the facet dislocation through the anterior approach. Therefore, the reduction was performed through a posterior approach with C5T1 posterior fusion, followed by anterior cage placement and C5-7 anterior fusion (front-back-front approach). At postoperative follow-up of 24 months, the patient demonstrated a full and pain-free cervical range-of-motion and remained neurologically intact. Follow-up radiographs of the cervical spine demonstrated good instrumental alignment with solid fusion at 6-month follow-up.

A Novel Spine Fixation System Made Entirely of Carbon-Fiber-Reinforced PEEK Composite: An In Vitro Mechanical Evaluation.

BACKGROUND: Semirigid spine fixation systems utilizing nonmetallic materials have emerged as a promising innovation to overcome the inherent disadvantages of metal instrumentation in spine surgery. This study tests the mechanical properties of a novel spine fixation system made entirely of carbon-fiber-reinforced PEEK (CFR-PEEK) composite material (CarboClear System, CarboFix Orthopedics Ltd., Israel). METHODS: An in vitro mechanical evaluation of the CFR-PEEK CarboClear system was conducted in compliance with the American Society for Testing and Materials (ASTM) F1717, F2193, and F543 standards. RESULTS: The mean bending yield load, bending ultimate load, and bending stiffness of the construct were 322 N, 363 N, and 45 N/mm, respectively. All tested samples completed 5 × 106 dynamic cycles successfully, with no evidence of fatigue failure at increasing load levels, up to 83% of ultimate bending load. The mean torsional stiffness was 1.0 Nm/deg and the mean screw axial pull-out strength was 2,037 N. CONCLUSION: The CarboClear Pedicle Screw System has mechanical properties comparable to those of other commonly used titanium-made systems, with superior fatigue properties. The fatigue resistance, modulus of elasticity which is very similar to that of bone, radiolucency, and CT/MRI artifact-free feature of this spine fixation system made entirely of CFR-PEEK may offer advantages over traditional spine fixation systems made of metal alloys.

A Reimbursement System Based on a 48-Hour Target Time for Surgery Shortens the Waiting Time for Hip Fracture Fixation in Elderly Patients.

OBJECTIVES: To evaluate whether a pay-for-performance reimbursement system, aimed at expediting surgical fixation of hip fractures in elderly patients, has, in fact, succeeded in shortening the waiting time for surgery. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Academic Level II trauma center. PATIENTS/PARTICIPANTS: One hundred fifty patients older than 70 years with femoral neck fractures (OTA/AO 31 A1-A3). INTERVENTION: Implementation of a reimbursement system which incentivizes meeting a 48-hour target time for surgical fixation of hip fractures in elderly patients. METHODS: Medical records of 75 consecutive patients operated on 1 year before the implementation of the reimbursement system were compared with records of 75 consecutive patients operated on 1 year after the implementation of the reimbursement system. The collected data included age, sex, American Society of Anesthesiologist score, time from injury to hospital admission, time from admission to surgery, reason for surgical delay beyond 48 hours, perioperative complication rate, and length of postoperative hospitalization. RESULTS: Patients' mean age, sex distribution, American Society of Anesthesiologist score, and time from injury to hospital admission were similar in both groups. The average waiting time for surgery shortened from a mean of 77 hours before implementing the reimbursement system to 28 hours after the implementation (P < 0.001). Before the reimbursement system implementation, 41% of the surgeries were delayed beyond 48 hours due to medical causes, compared with 20% only after the implementation (P < 0.001). Fewer patients developed perioperative complications in the postimplementation group in comparison with the preimplementation group (9% vs. 13%, respectively); however, because the study was not powered to examine differences in complication rate, the significance of this difference remains unclear. CONCLUSIONS: A reimbursement system which incentivizes meeting a 48-hour target time for surgery has led to a substantial shortening in the waiting time for surgical fixation of hip fractures in elderly patients in our institution.

[WAITING TIME FOR SURGICAL FIXATION OF FEMORAL NECK FRACTURES: DOES A DIAGNOSIS-RELATED GROUP PAYMENT METHOD MATTER?]

BACKGROUND: Early surgical fixation of femoral neck factures in elderly patients has been suggested to decrease morbidity and mortality and to improve treatment outcome. This study evaluates the effect of the implementation of a diagnosis-related group payment method in our hospital on waiting time for surgery and the short-term outcomes of elderly patients following surgical fixation of hip fractures. METHODS: Demographic and clinical characteristics of 75 consecutive patients, who underwent surgery for hip fracture in our hospital, before the implementation of a diagnosis-related group payment method, were compared with those of 75 consecutive patients, who were operated on after the implementation of the payment system. RESULTS: Demographic characteristics were similar for both groups. Before the implementation of a diagnosis-related group payment method, 84% of the patients waited longer than 48 hours for surgery, compared to only 24% of patients after the implementation (p<0.001). Medical considerations and operation room availability were the main reasons for delaying surgery in both groups. Mortality and morbidity rates during the hospital stay remained similar, regardless of the implementation of the payment method. CONCLUSIONS: The implementation of a diagnosis-related group payment method shortened the waiting time for surgical hip fixation in elderly patients treated in our hospital, with no effect on the mortality and complication rate during the hospital stay.

Local implantation of autologous adipose-derived stem cells increases femoral strength and bone density in osteoporotic rats: A randomized controlled animal study.

BACKGROUND: Deficient osteogenic capacity of bone marrow stem cells plays a critical role in the pathophysiology of osteoporosis. Adipose-derived stem cells (ADSCs) have emerged as a promising source of skeletal progenitor cells. The capacity of ADSCs to undergo osteogenic differentiation and induce mineralized tissue formation may be beneficial in the treatment of osteoporosis. We question whether administration of autologous ADSCs into the proximal femur of osteoporotic rats will induce osteogenesis and enhance bone quality and strength. MATERIALS AND METHODS: Thirty ovariectomized female rats were randomly assigned to one of the two treatment groups: (1) percutanous implantation of autogenous ADSCs-seeded scaffold into the proximal femur and (2) percutanous implantation of non-seeded scaffold. The contralateral untreated femur served as control. The effect of treatment on bone characteristics was assessed at 12-week follow-up by micro-computed tomography analysis, mechanical testing, and histological analysis. RESULTS: The mean cortical thickness, total bone volume density, and bone load to failure in femora injected with autologous ADSCs-seeded scaffold was significantly higher compared to femora injected with non-seeded scaffold and compared to the untreated control femora ( p < 0.01). Histological examination of the injected specimens revealed complete osseo-integration of the scaffolds with direct conversion of the ADSCs into osteoblasts and no inflammatory response. CONCLUSIONS: Autogenous ADSCs implantation into the proximal femur of rats with ovariectomy-related osteoporosis promoted bone regeneration and increased bone strength at short-term follow-up. These findings highlight the potential benefit of autogenous ADSCs in the treatment of osteoporosis. LEVEL OF EVIDENCE: Level I, randomized controlled trial, animal study.

Carbon-Fibre-Reinforced PEEK radiolucent intramedullary nail for humeral shaft fracture fixation: technical features and a pilot clinical study.

PURPOSE: This prospective pilot study investigated the safety and efficacy of a novel radiolucent intramedullary nail (IMN) made of Carbon-Fibre-Reinforced Polyaryl-Ether-Ether-Ketone (CFR-PEEK) for humeral shaft fracture fixation. STUDY DESIGN: A prospective, single-arm, four-centre study. PATIENTS AND METHODS: A total of 46 patients with 46 humeral fractures classified as 12 A-B were treated with a novel CFR-PEEK IMN and followed for 12 months. RESULTS: Most of the patients (65%) were female; the mean age was 65 ± 17 years. The average operating time was 66.75 ± 19.84 minutes and X-ray exposure was 104.11 ± 98.01 seconds. All patients postoperatively reported selflimiting shoulder pain and three patients developed iatrogenic transient radial palsy. Two patients required repositioning of the implant. No implant-related complications were observed. Radiological consolidation was achieved in all 43 patients who completed the 12-month follow-up. CONCLUSIONS: The CFR-PEEK IMN is user-friendly and safe. Its bone-matching elastic modulus seems to contribute to its clinical efficacy. This, together with compatibility with modern imaging techniques, can be considered a further evolution of IMN designed to stabilise humeral shaft fractures.

Can MRI Predict Flexibility in Scheuermann Kyphosis Patients?

STUDY DESIGN: Retrospective, blinded analysis of imaging studies. OBJECTIVE: The aim of this study is compare the use of magnetic resonance imaging (MRI) to lateral radiograph using bolster in the evaluation of Scheuermann kyphosis (SK) curve flexibility measurement. SUMMARY AND BACKGROUND DATA: The flexibility of the thoracic curve [thoracic kyphosis (TK)] in SK is of primary importance in its preoperative planning. Several methods have been described for SK curve flexibility measurement. The most commonly used method is lateral hyperextension radiography on hard bolster [hyperextension radiograph (HE)]. No current methods use MRI for flexibility assessment. MATERIALS AND METHODS: Flexibility of TK in SK patients was measured as a difference between standing radiograph and bolster-assisted lateral HE or supine MRI. The sagittal Cobb angle of the TK was measured between the superior endplate of T4 and the inferior endplate of T12 vertebral body. Flexibilities measured by these 2 methods were compared and analyzed using the generalized estimating equation analysis and the correlation analysis. RESULTS: We assessed 18 SK patients (14 males and 4 females) with mean age of 20.06±6.03 years. The standing TK x-rays showed 83.8±6.1 degrees. On HE, TK curve reduced by 39.3 degrees (95% confidence interval, 35.8-42.9) to 44.5±6.2 degrees (P<0.001). Preoperative MRI images showed TK of 53.8±5.9 degrees which means reduction by 30 degrees (95% confidence interval, 26.6-33.4) from the standing radiographs (P<0.001). Linear dependency between HE and MRI flexibility with a mean difference of 9.3 degrees was found (R=0.61, P<0.001). CONCLUSIONS: Our study shows that preoperative MRI can be used for SK flexibility assessment with similar predictive value as routinely used bolster-assisted hyperextension lateral radiograph. Consequently, patient exposure to preoperative hyperextension ionizing radiation may be reduced.

A Comparison of Different Minimally Invasive and Open Posterior Spinal Procedures Using Volumetric Measurements of the Surgical Exposures.

STUDY DESIGN: A Prospective observational study. SUMMARY OF THE BACKGROUND DATA: Minimally invasive (MI) spine surgery techniques strive to minimize the damage to paraspinal soft tissues. Previous studies used only the length of the surgical incision to quantify the invasiveness of certain MI procedures. However, this method does not take into account the volume of muscle tissue that is dissected and retracted from the spine to achieve sufficient exposure. To date, no simple method has been reported to measure the volume of the surgical exposure and to quantify the degree of surgery invasiveness. STUDY OBJECTIVES: To obtain and compare volumetric measures of various MI and open posterior-approached spinal surgical exposures. METHODS: The length, the depth, and the volume of the surgical exposure were obtained from 57 patients who underwent either open or MI posterior lumbar surgery. MI procedures included the following: tubular discectomy, laminotomy, and transforaminal interbody fusion. Open procedures included the following: discectomy, laminectomy, transforaminal interbody fusion, or posterior-lateral instrumented fusion. Four attending spine surgeons at our unit performed the surgeries. To reduce variability, only single-level procedures performed between L4 and S1 vertebrae were used. The volume of exposure was obtained by measuring the amount of saline needed to fill the surgical wound completely once the surgical retractors were deployed and opened. RESULTS: The average volumes in mililiters of exposure for a single-level MI procedure ranged from 9.8±2.8 to 75±11.7 mL and were significantly smaller than the average volumes of exposure for a single level open procedures that ranged from 44± 21 to 277±47.9 P<0.001. The average skin-incision lengths for single-level MI procedures ranged from 1.7±0.2 to 7.7±1.6 cm and were significantly smaller than the average skin-incision lengths for open procedures [5.2±1.4 (Table 3) to 11.3±2 cm, P<0.001]. The measured surgical depths were similar in MI and open groups (P=0.138). MI decompression and posterior fusion procedures yielded 92% and 73% reductions in the volumes of exposure, respectively. However, absolute differences in exposure volumes were larger for fusion (202 mL) compared with decompression alone (110.7 mL). CONCLUSIONS: Direct volumetric measurement of the surgical exposure is obtained easily by measuring the amount of saline needed to fill the exposed cavity. Using this method, the needed surgical exposure of different spinal procedures can be quantified and compared. This volumetric measurement combined with the measure of retraction force, the duration of retraction, and the impact on soft tissue vascularity can help build a model that assesses the relative invasiveness of different spinal procedures.

Staged Correction of Severe Thoracic Kyphosis in Patients with Multilevel Osteoporotic Vertebral Compression Fractures.

Study Design Technical report. Objective Multilevel osteoporotic vertebral compression fractures may lead to considerable thoracic deformity and sagittal imbalance, which may necessitate surgical intervention. Correction of advanced thoracic kyphosis in patients with severe osteoporosis remains challenging, with a high rate of failure. This study describes a surgical technique of staged vertebral augmentation with osteotomies for the treatment of advanced thoracic kyphosis in patients with osteoporotic multilevel vertebral compression fractures. Methods Five patients (average age 62 ± 6 years) with multilevel osteoporotic vertebral compression fractures and severe symptomatic thoracic kyphosis underwent staged vertebral augmentation and surgical correction of their sagittal deformity. Clinical and radiographic outcomes were assessed retrospectively at a mean postoperative follow-up of 34 months. Results Patients' self-reported back pain decreased from 7.2 ± 0.8 to 3.0 ± 0.7 (0 to 10 numerical scale; p < 0.001). Patients' back-related disability decreased from 60 ± 10% to 29 ± 10% (0 to 100% Oswestry Disability Index; p < 0.001). Thoracic kyphosis was corrected from 89 ± 5 degrees to 40 ± 4 degrees (p < 0.001), and the sagittal vertical axis was corrected from 112 ± 83 mm to 38 ± 23 mm (p = 0.058). One patient had cement leakage without subsequent neurologic deficit. Decreased blood pressure was observed in another patient during the cement injection. No correction loss, hardware failure, or neurologic deficiency was seen in the other patients. Conclusion The surgical technique described here, despite its complexity, may offer a safe and effective method for the treatment of advanced thoracic kyphosis in patients with osteoporotic multilevel vertebral compression fractures.

Athletic Population with Spondylolysis: Review of Outcomes following Surgical Repair or Conservative Management.

STUDY DESIGN: Narrative review. OBJECTIVE: The study aims to critically review the outcomes associated with the surgical repair or conservative management of spondylolysis in athletes. METHODS: The English literature listed in MEDLINE/PubMed was reviewed to identify related articles using the term "spondylolysis AND athlete." The criteria for studies to be included were management of spondylolysis in athletes, English text, and no year, follow-up, or study design restrictions. The references of the retrieved articles were also evaluated. The primary outcome was time to return to sport. This search yielded 180 citations, and 25 publications were included in the review. RESULTS: Treatment methods were dichotomized as operative and nonoperative. In the nonoperative group, 390 athletes were included. A combination of bracing with physical therapy and restriction of activities was used. Conservative measures allowed athletes to return to sport in 3.7 months (weighted mean). One hundred seventy-four patients were treated surgically. The most common technique was Buck's, using a compression screw (91/174). All authors reported satisfactory outcomes. Time to return to play was 7.9 months (weighted mean). There were insufficient studies with suitably homogenous subgroups to conduct a meta-analysis. CONCLUSION: There is no gold standard approach for the management of spondylolysis in the athletic population. The existing literature suggests initial therapy should be a course of conservative management with thoracolumbosacral orthosis brace, physiotherapy, and activity modification. If conservative management fails, surgical intervention should be considered. Two-sided clinical studies are needed to determine an optimal pathway for the management of athletes with spondylolysis.

The surgical management of atlanto-axial subluxation in juvenile rheumatoid arthritis.

Juvenile idiopathic arthritis (JIA) is a chronic condition affecting patients <16 years of age and can be associated with substantial morbidity. Atlanto-axial subluxation (AAS) is a known complication of JIA and can result in pain, reduced neck motion and neurological compromise. In this paper, we present the case of a 10-year old suffering with JIA and significant AAS; we discuss the management options and present the approach and outcome of treatment for this case.

Diagnosis and treatment of a rectal-cutaneous fistula: a rare complication of coccygectomy.

BACKGROUND: Coccygectomy may be indicated for the treatment of debilitating coccygodynia unresponsive to non-operative treatment. Perineal contamination and postoperative wound infection following coccygectomy remains a major concern. We present a rare post-coccygectomy complication of rectal-cutaneous fistula. To our knowledge no such case has been previously described. CASE PRESENTATION: A 24-year-old woman presented with recurrent wound infections 1 year after coccygectomy at another institution, which persisted despite two surgical debridements and antibiotic treatment. Wound cultures showed non-specific poly-microbial bacterial growth. MRI scan of the spine and pelvis revealed a sinus track and soft tissue edema with no evidence of abscess or osteomyelitis. Methylene blue injection to the sinus tract confirmed the presence of a rectal-cutaneous fistula. The patient underwent further debridement, fistulectomy and synchronous defunctioning colostomy and resection of the involved colon segment. The wound healed by secondary intention with complete resolution of the infection. Re-anastomosis and closure of the colostomy was performed 6 months later. At 2-year follow-up, the patient had no signs of infection and her initial coccygeal symptoms had improved. CONCLUSION: Postoperative infection following coccygectomy remains a major concern. A discharging sinus at the surgical site may suggest the presence of a rectal-cutaneous fistula, which requires a combined approach of spinal and colorectal surgeons. Methylene blue injection to the sinus tract may facilitate the diagnosis of a rectal-cutaneous fistula.

Is Hydronephrosis a Complication after Anterior Lumbar Surgery?

Study Design Prospective follow-up design. Objective Ureteral injury is a recognized complication following gynecologic surgery and can result in hydronephrosis. Anterior lumbar surgery includes procedures like anterior lumbar interbody fusion (ALIF) and total disk replacement (TDR). Anterior approaches to the spine require mobilization of the great vessels and visceral organs. The vascular supply to the ureter arising from the iliac arteries may be compromised during midline retraction of the ureter, which could theoretically lead to ureter ischemia and stricture with subsequent hydronephrosis formation. Methods Potential candidates with previous ALIF or TDR via anterior retroperitoneal access between January 2008 and March 2012 were chosen from those operated on by a single surgeon in a university hospital setting (n = 85). Renal ultrasound evaluation of hydronephrosis was performed on all participants. Simple descriptive and inferential statistics were used to generate results. Results A total of 37 voluntary participants were recruited (23 male, 14 female subjects; average age 51.8 years). The prevalence of hydronephrosis in our population was 0.0% (95% confidence interval 0 to 8.1%). Conclusions Retraction of the ureter across the midline in ALIF and TDR does not result in an increase in hydronephrosis and appears to be a safe surgical technique.