Anterior instrumentation for thoracolumbar adolescent idiopathic scoliosis: do structural interbody grafts preserve sagittal alignment better than morselized rib autografts?

STUDY DESIGN: This is a retrospective, sequential cohort study of 34 patients treated by anterior instrumented fusion with single solid rod, single screw constructs with at least 2-year follow-up. Sixteen of the patients received structural grafts as interbody spacers in disc levels below T12, while the other 18 patients received only morselized rib autograft. OBJECTIVE: To determine if structural interbody grafts preserve sagittal alignment better than morselized rib autograft. SUMMARY OF BACKGROUND DATA: Some studies have shown that structural grafts are more effective in preserving sagittal alignment, while others have found them to be no more effective than morselized rib graft. METHODS: Anterior-posterior radiographs were measured for primary, secondary, and fractional Cobb curves, and C7-sacrum plumb lines. Lateral radiographs were measured for: T5-HIV (highest instrumented vertebrae), instrumented levels, LIV (lowest instrumented vertebrae)-S1, T12-LIV, and T12-S1 angles, C7-sacrum plumb lines, and LID-A (lowest instrumented disc-angle). RESULTS: The increase in kyphosis from preoperative to follow-up radiographs of the angle between T12-LIV was significantly more for the patients with morselized rib graft compared with those with structural grafts, 9 degrees and 1 degree, respectively (P < 0.05). CONCLUSIONS: The structural grafts placed in disc spaces below T12 were able to maintain sagittal alignment over this region, while the spines that received only morselized rib graft collapsed into kyphosis.

Improvement of sexual function in male patients treated surgically for cervical spondylotic myelopathy.

STUDY DESIGN: A prospective follow-up study. OBJECTIVE: To analyze the recovery of sexual function loss in surgically treated male patients with cervical spondylotic myelopathy. SUMMARY OF BACKGROUND DATA: Cervical spondylotic myelopathy is common in the elder population and can lead to sexual dysfunction. Although numerous studies have shown that surgical treatment of cervical spondylotic myelopathy achieved satisfactory neurologic and functional improvement, only few researchers mentioned sexual dysfunction. METHODS: A total of 22 patients with combined cervical spondylotic myelopathy and sexual dysfunction on admission were treated with surgery. The patients' preoperative and postoperative neurologic status was recorded according to the Japanese Orthopedic Association (JOA) Scoring System. The sexual function was assessed using the International Index of Erectile Function (IIEF). Special attention was also given to the preoperative and postoperative presence or absence of a reflexogenic and psychogenic erection. RESULTS: In most cases, there was significant improvement in neurologic status after surgery, with a mean improvement of JOA score of 3.6. The difference between the preoperative and postoperative JOA score was significant (P < 0.05). Most of these patients had an abnormal psychogenic erection (18/22, 82%) before surgery, but only few had an abnormal reflexogenic erection (4/22, 18%). After surgery, most patients had improvement in sexual function, and the average IIEF score was 28.5 before and 60.2 after surgery. The difference between preoperative and postoperative IIEF scores was statistically significant (P < 0.05). CONCLUSIONS: In addition to neurologic deficits, cervical spondylotic myelopathy also causes sexual dysfunction. Most of these patients had an abnormal psychogenic erection and normal reflexogenic erection. Along with neurologic recovery, most patients had improvement in sexual function after surgery.

Clinical and prognostic analysis of ossified ligamentum flavum in a Chinese population.

OBJECT: The authors performed a retrospective study of clinical and radiological data obtained in 27 Chinese patients with myelopathy induced by ossification of the ligamentum flavum (OLF) who underwent surgery between March 1990 and March 2002. The factors related to surgical outcome of thoracic OLF-induced myelopathy were also assessed. METHODS: The preoperative clinical features and radiological findings were reviewed retrospectively. Preoperative and postoperative neurological status was assessed using the Japanese Orthopaedic Association (JOA) scoring system and the Nurick Scale. The ossified lesions were classified into five types (lateral, extended, enlarged, fused, and tuberous). Multiple linear regression and logistic regression analyses were performed to establish the factors affecting surgical outcome. The patients' chief complaints were lower-limb weakness and gait disturbance (93%), numbness and sensory deficit (89%), and low-back pain (48%). The coexisting pathological entities were disc herniation, canal stenosis, and ossification of posterior longitudinal ligament. The ossified ligamentum flavum was mainly located at the T10-12 (67%) and T1-3 (15%) levels. Symptoms in 26 patients improved but resolved completely in only 14 after surgery. The mean overall JOA score was 5.3 +/- 1.9 preoperatively and 7.9 +/- 2.3 postoperatively. There is a significant difference between the pre- and postoperative neurological status (p < 0.05) determined by the Student t-test. The recovery rate was 46.3 +/- 9.4%. Multiple regression analysis revealed negative correlation between the duration of preoperative symptoms and surgical outcome as well as a positive correlation between the preoperative JOA score and surgical outcome. Logistic regression analysis demonstrated that fecal and/or urinary incontinence, positive patellar and/or ankle clonus, and intramedullary high T2-weighted magnetic resonance (MR) imaging signal change had negative effects on the surgical outcome. CONCLUSIONS: The clinical and radiological features of OLF in the Chinese population are similar to those observed in the Japanese population. The duration of preoperative symptoms and JOA score are the most important predictors of the postoperative JOA score and recovery rate. The patients with fecal and/or urinary incontinence, positive patellar and/or ankle clonus, and intramedullary high T2-weighted MR imaging signal change were at higher risk of poor outcome after surgery.

Eponyms: errors in clinical practice and scientific writing.

Eponymous terms are in daily use in medicine. This system of nomenclature which simply commemorates a person is inconvenient, poses difficulties to students and leads to frequent mistakes in scientific writings. Nevertheless it can be helpful in completely describing a multi-symptomatic medical condition or a complex surgical procedure which otherwise would not be neatly encapsulated in a reasonably convenient word or phrase. We used Finkelstein's test as an example to demonstrate that the use of such nomenclature in clinical practice and scientific writing creates inaccuracies. We contacted 62 consultant orthopaedic surgeons and 47 specialist orthopaedic registrars of whom 53 consultant and 39 registrars responded. Three different descriptions of Finkelstein's test were used as described in current literature. Only 10 (10.7%) surgeons recognised the correct method as described by Finkelstein and 83 (89.3%) were unable to do so. The results shows that a statistically significant proportion of surgeons uses the test (p < 0.0001) but fails to identify the correct method (p < 0.0001). We also found that Finkelstein's test was inaccurately described in literature since Leao's incorrect description in 1958 (quoting Eichhoff's manoeuvre) and the mistake persisted for over 50 years before it could be accredited. Such mistakes are frequent not only in hand surgery but in other sections of medicine as well. We conclude that in the modern era of evidence based medicine, use of such trivial nomenclature should be avoided. Efforts should be made to introduce proper descriptive nomenclature, by devising criteria systems which would be easy to use and not fictitious.