"You're stuck in the middle here": a qualitative study of GPs' experiences of managing knee pain attributed to a degenerative meniscal tear.

BACKGROUND: Exercise is the recommended first-line therapy for a degenerative meniscal tear (DMT). Despite this, knee pain attributed to DMTs are a common presentation to specialist orthopaedic clinics. In the primary care setting, the general practitioner (GP) plays a central role in managing patients with knee pain, but to date their perspective has not been explored in relation to DMTs. This study explored GPs' experiences of managing people with knee pain attributed to a DMT. METHODS: A qualitative research design was adopted and practices in the South and Mid-West of Ireland were contacted via recruitment emails circulated through professional and research networks. Interested GPs contacted the researchers via email, and purposive and snowball sampling was used for recruitment. Semi-structured interviews were conducted online or over the telephone. Interviews were digitally recorded and transcribed. Data was analysed using an inductive approach to thematic analysis. Ethical approval was granted by the Irish College of General Practitioners (ICGP_REC_21_0031). RESULTS: Seventeen semi-structured one-on-one interviews were conducted. Three main themes were identified with related subthemes: (1) GPs' experiences of relational aspects of care, (2) GP beliefs about what constitutes best care for patients with a DMT, and (3) how GP practice is enacted within the current healthcare setting. GPs described the challenge of maintaining a strong clinical alliance, while managing perceived patient expectations of a 'quick fix' and advanced imaging. They reported slowing down clinical decisions and feeling 'stuck' with limited options when conservative treatment had failed. GPs believed that exercise should be the core treatment for DMTs and emphasised engaging patients in an active approach to recovery. Some GPs believed arthroscopy had a role in circumstances where patients didn't improve with physiotherapy. Limited access to public physiotherapy and orthopaedic services hampered GPs' management plans and negatively impacted patient outcomes. CONCLUSIONS: GP beliefs around what constitutes best care for a DMT generally aligned with the evidence base. Nonetheless, there was sometimes tension between these beliefs and the patient's own treatment expectations. The ability to enact their beliefs was hampered by limited access to conservative management options, sometimes leading to early escalation of care.

Readability and quality assessment of internet-based patient education materials related to deep vein thrombosis.

Access to health-related internet information has increased dramatically during the past decade. A significant proportion of this information has been demonstrated to be set at too high a level for general comprehension. The goal of this study was to evaluate the readability and quality of information available on the internet relating to deep vein thrombosis (DVT). A search for 'DVT' and 'Deep Vein Thrombosis' was performed on five most commonly accessed search engines. Top hundred websites were reviewed. Website authorship was classified. Each site was assessed using the recognized quality and readability scoring systems. The presence of the health on the net foundation code of conduct (HON-code), a reported quality-assurance marker, was noted. The majority of web sites (45%) were academic or physician compiled. Only 36% of the websites were HON-code certified. HON-code certified sites achieved significantly greater DISCERN and Journal of the American Medical Association (JAMA) scores. Seventy-three percent of the websites were above the recommended sixth-grade readability level. Flesch--Kincaid readability test (FRES) of more than half of the websites (56%) was below 60, which makes them fairly difficult to read by general public. Internet information relating to DVT is of variable quality and largely set at an inappropriate readability level. Given this variability in quality, healthcare providers should direct patients to known sources of reliable, readable online information. Identification of reliable sources may be aided by known markers of quality such as HONcode certification and to educate them to use academic and physician-provided sites which have been shown to contain better-quality information. Moreover, academic and physician-compiled websites should be written in a fashion appropriate for general public consumption.

Management for Bony Mallet Thumb with a Single Extension Blocking Kirschner Wire.

INTRODUCTION: Mallet finger injury is defined by disruption of the terminal extensor tendon distal-to-distal interphalangeal (DIP) joint. While in the fingers, it is a relatively common injury, it is a rarely encountered entity when involving the thumb. Various conservative and operative treatment strategies have been reported for the management of mallet thumb with no consensus by clinicians. CASE REPORT: We present the case of a 27-year-old right hand dominant man with a left bony mallet thumb injury that occurred while playing hurling. Hurling is traditional Irish sport that is one of the fastest field games in the world, involving the use of a wooden Hurley and ball. Clinically, there was loss of active extension at the DIP joint of the non-dominant thumb with radiographs revealing an avulsion fracture involving more than one-third of the articular surface at the base of the distal phalanx. Closed reduction and percutaneous fixation using a single extension block Kirschner wire was performed without a transfixion wire across the DIP joint. Four months postoperatively, the patient had regained that good functional dexterity was able to return to playing hurling. CONCLUSION: A single K-wire technique may be beneficial with theoretical reduction of chance of iatrogenic nail bed, bone fragment rotation, chondral damage, and bone injury. To the best of our knowledge, no previous reports of its application to bony mallet thumb have been described.

Lessons from lockdown: Virtual Clinics and service reorganisation in fracture management during COVID 19 experience of an Irish Regional Trauma Unit.

BACKGROUND: Trauma places a burden on healthcare services accounting for a large proportion of Emergency Department presentations. COVID-19 spread rapidly affecting over 30 million worldwide. To manage trauma presentations the Department of Trauma & Orthopaedic Surgery reorganised service delivery. AIM: To assess the impact of service reorganisation and Virtual Clinics on patients in a Regional Unit in Ireland. METHODS: A retrospective review of trauma activity following introduction of Virtual Fracture Clinics and Theatre COVID Pathways for a 10 week period in comparison with the same 2019 period. All patients underwent both nasopharyngeal and oropharyngeal swabs PCR testing prior to operations. Theatre and outpatient activity were evaluated. Clinic data were accumulated using the Integrated Patient Management System. RESULTS: Theatre Activity: 242 patients underwent surgery in our trauma unit (mean 2.98 per list) during the COVID- 19 period. 29 cases were performed in repurposed elective hospital giving a total of 271 during the 2020 study period. 371 cases were performed in the same 2019 period (mean 4.58 per list). Outpatient Activity: We noted a 25.86% fracture clinic referral reduction during the COVID 19 period compared to 2019. There was a 150.77% increase in patients managed through Trauma Assessment Clinic. 639 patients were managed through the Virtual Fracture Clinic Pathway during COVID 19 period. CONCLUSIONS: Over one in four fracture clinic patients can be managed virtually. A new dedicated Acute Fracture Unit within our institution permitted streamlining of care and social distancing. The "Non-COVID" pathway for ambulatory trauma was essential in managing the growing presentations of these injuries.

Platelet-rich plasma injections for hip osteoarthritis: a review of the evidence.

Osteoarthritis is a significant cause of chronic pain in the elderly population with hip osteoarthritis as one of the main causes of functional disability and joint pain in adults older than 55 years. Recently, platelet rich plasma (PRP) injections have been introduced for treatment of osteoarthritis. The aim of this systematic review is to assess its effectiveness in the management of hip osteoarthritis. We performed a search of the literature for published prospective studies that assessed the effectiveness of PRP injections in the treatment of hip osteoarthritis, with a minimum follow-up of 3 months. Primary outcome measures were WOMAC and VAS scores. Five trials were identified with 185 patients undergoing treatment with ultrasound-guided intra-articular injections of PRP, compared with patients treated with hyaluronic acid alone (n = 148) or hyaluronic acid combined with PRP (n = 31) in one study. PRP was shown to improve patient outcome scores at follow-up at 6 and 12 months; however, there was no significant difference seen between patients treated with PRP or hyaluronic acid alone. Following this systematic review, we cannot currently recommend the use of intra-articular injections of PRP for the treatment of hip OA. Given that intra-articular steroid injections are the only such injection recommended by international guidelines for the treatment of hip OA, further studies comparing PRP to steroid would be of benefit to determine the value of PRP injections in hip OA.

Aged Osteoporotic Bone Marrow Stromal Cells Demonstrate Defective Recruitment, Mechanosensitivity, and Matrix Deposition.

Bone formation requires the replenishment of the osteoblast from a progenitor or stem cell population, which must be recruited, expanded, and differentiated to ensure continued anabolism. How this occurs and whether it is altered in the osteoporotic environment is poorly understood. Furthermore, given that emerging treatments for osteoporosis are targeting this progenitor population, it is critical to determine the regenerative capacity of this cell type in the setting of osteoporosis. Human bone marrow stromal cells (hMSCs) from a cohort of aged osteoporotic patients were compared to MSCs isolated from healthy donors in terms of the ability to undergo recruitment and proliferation, and also respond to both the biophysical and biochemical cues that drive osteogenic matrix deposition. hMSCs isolated from healthy donors demonstrate good recruitment, mechanosensitivity, proliferation, and differentiation capacity. Contrastingly, hMSCs isolated from aged osteoporotic patients had significantly diminished regenerative potential. Interestingly, we demonstrated that osteoporotic hMSCs no longer responded to chemokine-directing recruitment and became desensitised to mechanical stimulation. The osteoporotic MSCs had a reduced proliferative potential and, importantly, they demonstrated an attenuated differentiation capability with reduced mineral and lipid formation. Moreover, during osteogenesis, despite minimal differences in the quantity of deposited collagen, the distribution of collagen was dramatically altered in osteoporosis, suggesting a potential defect in matrix quality. Taken together, this study has demonstrated that hMSCs isolated from aged osteoporotic patients demonstrate defective cell behaviour on multiple fronts, resulting in a significantly reduced regenerative potential, which must be considered during the development of new anabolic therapies that target this cell population.

Isolation and Characterization of an Adult Stem Cell Population from Human Epidural Fat.

STUDY DESIGN: Isolation and characterization of human epidural fat (HEF) stem/progenitor cells. OBJECTIVE: To identify a progenitor population within HEF and to determine if they meet the minimal criteria of a mesenchymal stem cell (MSC). SUMMARY OF BACKGROUND DATA: The biological function, if any, has yet to be determined for HEF. The presence of MSCs within HEF may indicate a regenerative potential within the HEF. METHODS: HEF was isolated from 10 patients during elective spinal surgery. HEF cells were differentiated along osteo-, adipo-, and chondrogenic lineages, with differentiation analyzed via qPCR and histology. The cell surface receptor profile of HEF cells was examined by flow cytometry. HEF cells were also assayed through the collagen contraction assay. Prx1 CreERT2GFP:R26R TdTomato MSC lineage-tracking mice were employed to identify EF MSCs in vivo. RESULTS: HEF cell lines were obtained from all 10 patients in the study. Cells from 2/10 patients demonstrated full MSC potential, while cells from 6/10 patients demonstrated progenitor potential; 2/10 patients presented with cells that retained only adipogenic potential. HEF cells demonstrated MSC surface marker expression. All patient cell lines contracted collagen gels. A Prx1-positive population in mouse epidural fat that appeared to contribute to the dura of the spinal cord was observed in vivo. CONCLUSIONS: MSC and progenitor populations are present within HEF. MSCs were not identified in all patients examined in the current study. Furthermore, all patient lines demonstrated collagen contraction capacity, suggesting either a contaminating activated fibroblast population or HEF MSCs/progenitors also demonstrating a fibroblast-like phenotype. In vivo analysis suggests that these cell populations may contribute to the dura. Overall, these results suggest that cells within epidural fat may play a biological role within the local environment above providing a mechanical buffer.

The Role of Prognostic Scoring Systems in Assessing Surgical Candidacy for Patients With Vertebral Metastasis: A Narrative Review.

STUDY DESIGN: Narrative review. OBJECTIVES: To review the relevant literature regarding scoring systems for vertebral metastases and quantify their role in contemporary orthopedic practice. METHODS: A literature search of PubMed, Google Scholar, and Embase was performed on February 7, 2017. Eight scoring systems were selected for detailed review-7 of which were scores focused solely on patient prognosis (Tokuhashi, Tomita, Bauer, Oswestry Spinal Risk Index, Van der Linden, Rades, and Katagiri). The eighth system reviewed was the Spinal Instability Neoplastic Score, which examines for impending spinal instability in patients with vertebral metastases and represents a novel approach compared with hitherto scoring systems. RESULTS: The Bauer and Oswestry Spinal Risk Index have the most accurate prognostic predictive ability, with the newer Oswestry Spinal Risk Index being favored by the contemporary literature as it demands less investigation and is therefore more readily accessible. There was a growing trend in studies designed to customize scoring systems for individual cancer pathological subtypes. The Spinal Instability Neoplastic Score shows good reliability for predicting instability among surgeons and oncologists. CONCLUSIONS: The increased understanding of cancer pathology and subsequent development of customized treatments has led to prolonged survival. For patients with vertebral metastases, this affects surgical candidacy not only on the basis of prognosis but also provides prolonged opportunity for the development of spinal instability. Scoring systems have a useful guidance role in these deciding for/against surgical intervention, but in order to remain contemporary ongoing review, development, and revalidation is mandatory.

Financial impact of inaccurate Adverse Event recording post Hip Fracture surgery: Addendum to 'Adverse event recording post hip fracture surgery'.

INTRODUCTION: A study in 2011 by (Doody et al. Ir Med J 106(10):300-302, 2013) looked at comparing inpatient adverse events recorded prospectively at the point of care, with adverse events recorded by the national Hospital In-Patient Enquiry (HIPE) System. METHODS: In the study, a single-centre University Hospital in Ireland treating acute hip fractures in an orthopaedic unit recorded 39 patients over a 2-month (August-September 2011) period, with 55 adverse events recorded prospectively in contrast to the HIPE record of 13 (23.6%) adverse events. With the recent change in the Irish hospital funding model from block grant to an 'activity-based funding' on the basis of case load and case complexity, the hospital financial allocation is dependent on accurate case complexity coding. A retrospective assessment of the financial implications of the two methods of adverse incident recording was carried out. RESULTS: A total of €39,899 in 'missed funding' for 2 months was calculated when the ward-based, prospectively collected data was compared to the national HIPE data. Accurate data collection is paramount in facilitating activity-based funding, to improve patient care and ensure the appropriate allocation of resources.

Validation of the manual inclinometer and flexicurve for the measurement of thoracic kyphosis.

INTRODUCTION: Physiotherapists commonly use the manual inclinometer and Flexicurve for the clinical measurement of thoracic spinal posture. The aim of this study is to examine the concurrent validity of the Flexicurve and manual inclinometer in relation to the radiographic Cobb angle for the measurement of thoracic kyphosis. METHODS: Eleven subjects (seven males, four females) underwent a sagittal plane spinal radiograph. Immediately following the radiograph, a physiotherapist measured thoracic kyphosis using the Flexicurve and manual inclinometer before the subjects moved from position. Cobb angles were subsequently measured from the radiographs by an independent examiner. RESULTS: A strong correlation was demonstrated between both the Cobb angle and the Flexicurve angle (r = 0.96) and the Cobb angle and the manual inclinometer angle (r = 0.86). On observation of the Bland-Altman plots, the inclinometer showed good agreement with the Cobb angle (mean difference 4.8 ° ± 8.9 °). However, the Flexicurve angle was systematically smaller than the Cobb angle (mean difference 20.3 ° ± 6.1 °), which reduces its validity. CONCLUSION: The manual inclinometer is recommended as a valid instrument for measuring thoracic kyphosis, with good agreement with the gold standard. While the Flexicurve is highly correlated to the gold standard, they have poor agreement. Therefore, physiotherapists should take caution when interpreting its results.

Recording Adverse Events Following Joint Arthroplasty: Financial Implications and Validation of an Adverse Event Assessment Form.

BACKGROUND: In Ireland, funding of joint arthroplasty procedures has moved to a pay-by-results national tariff system. Typically, adverse clinical events are recorded via retrospective chart-abstraction methods by administrative staff. Missed or undocumented events not only affect the quality of patient care but also may unrealistically skew budgetary decisions that impact fiscal viability of the service. Accurate recording confers clinical benefits and financial transparency. The aim of this study was to compare a prospectively implemented adverse events form with the current national retrospective chart-abstraction method in terms of pay-by-results financial implications. METHODS: An adverse events form adapted from a similar validated model was used to prospectively record complications in 51 patients undergoing total hip or knee arthroplasties. Results were compared with the same cohort using an existing data abstraction method. Both data sets were coded in accordance with current standards for case funding. RESULTS: Overall, 114 events were recorded during the study through prospective charting of adverse events, compared with 15 events documented by customary method (a significant discrepancy). Wound drainage (15.8%) was the most common complication, followed by anemia (7.9%), lower respiratory tract infections (7.9%), and cardiac events (7%). A total of €61,956 ($67,778) in missed funding was calculated as a result. CONCLUSION: This pilot study demonstrates the ability to improve capture of adverse events through use of a well-designed assessment form. Proper perioperative data handling is a critical aspect of financial subsidies, enabling optimal allocation of funds.

Review of quality of x-rays for templating for total hip arthroplasty.

Digital templating of x-rays for total hip arthroplasty is used routinely for pre-operative planning. This is to assure that appropriately sized implants are selected to replicate patient's hip biomechanics. Multiple studies have shown that templating does not always correspond to the final implants used. The aim of this study was to assess the suitability of the x-rays taken pre-operatively for templating for total hip arthroplasty. We undertook a review of a series of pre-operative templating pelvis x-rays in 100 consecutive patients undergoing total hip arthroplasty. These x-rays were compared against set criteria to determine their suitability for use for templating. We determined that six x-rays met the criteria whereas ninety four x-rays did not meet the criteria for suitable x-rays. Twenty patients had repeat x-rays. The reasons for unsuitability were inadequate opposite femur (66%), absence or incomplete template (54%), inadequate femur length (47%), external rotation (39%), absence of opposite hip (4%). The twenty repeated x-rays were also reviewed for the same parameters and two (10%) satisfied the established criteria. It is imperative that x-rays for templating for total hip arthroplasty are done to a strict standard to obtain an x-ray that is appropriate for templating and there is minimal exposure of the patient to irradiation.

Simultaneous bilateral septic arthritis of the knee after intraarticular steroid injection: A clinical report.

Osteoarthritis of knee is one of the common problems in elderly population. Intraarticular corticosteroid injection is a conservative management modality in osteoarthritis of knee. Septic arthritis is an infective complication of intraarticular corticosteroid injection. Septic arthritis in rheumatoid arthritis patients have worse prognosis because of delay in diagnosis. A higher rate of infectious complications following intraarticular injection is expected in immunocompromised and rheumatoid patients. We would like to report an extremely rare case of simultaneous bilateral knee septic arthritis after bilateral knee intraarticular steroid injection in a rheumatoid arthritis patient. Patient was treated successfully with multiple bilateral knee arthroscopic washouts and long-term intravenous antibiotics. This case report emphasizes the increased risk of infection in rheumatoid arthritis patients and a risk benefit assessment on individual basis before carrying out intraarticular steroid injection. Patient should be aware of this increased risk of infection.

Relevance of World Health Organization surgical safety checklist to trauma and orthopaedic surgery.

Surgery like civil aviation is a risk-prone occupation. Civil Aviation has reported a death rate of less than 1 in a million exposures. On the other hand, surgery has a reported mortality rate of 100 per million surgeries. The National Reporting and Learning System (NRLS) database in England reported 152,017 'incidents' occurred during 4.2 million surgeries in 2008. Trauma and orthopaedic surgery accounted for 32.4 percent of these 'incidents'. Wrong-site surgery occurred in a total of 133 patients, with an incidence of 31.6 per million surgeries. A system to implement and maintain safe surgical practice is mandatory to prevent these 'incidents'. The factors identified in the genesis of these incidents are errors in decision making, lack of communication, leadership and teamwork. These human errors can easily be prevented using a formal structured communication, like the checklists. In 2008, the WHO published a set of guidelines to ensure the safety of surgical patients. In 2009, the checklist was modified with an intention to reduce major surgical complications and was proved to be effective. Wrong level spinal surgery needs special emphasis. There may be an increasing role for checklists in Trauma and Orthopaedic surgical practice to improve its safety profile by being procedure-specific.

The epidemiology of traumatic spinal cord injury in British Columbia, Canada.

STUDY DESIGN: Retrospective observational study utilizing prospectively collected population-based data. OBJECTIVE: To describe the epidemiology and demographics of all patients with traumatic spinal cord injury (TSCI) treated at a single institution, which represents the sole referral center and specialized SCI unit for a population of 4 million people. SUMMARY OF BACKGROUND DATA: Although many studies report on the epidemiology of TSCI, studies in which patients are prospectively characterized in the acute setting with precise recording of their baseline neurological impairment are uncommon. METHODS: Data on all patients admitted to a level 1 trauma center with TSCI between 1995 and 2004 were prospectively collected using a customized, fully relational, locally designed, spine database. RESULTS: The incidence of TSCI averaged 35.7 per million and did not change substantially during 10 years of data collection. However, the median age of TSCI patients increased from 34.5 to 45.5 years during this period. The men-to-women ratio was 4.4:1. In those older than 55 years, cervical-level injuries with incomplete American Spinal Injury Association (ASIA) Impairment Scale (AIS) scores C and D were most common, with men demonstrating predominantly lower cervical injuries and women more likely to exhibit upper cervical injuries. Increasing rates of surgical treatment during 10 years of this study (61.8%-86.4%) were not associated with improvements in mortality rate or length of hospital stay. Patients older than 75 years who presented with an acute TSCI had a mortality rate of 20% while in hospital. CONCLUSION: The incidence of TSCI in our population has remained remarkably stable, and age-related changes mirror those in the population across 10 years. An increased tendency to surgical treatment during the 10 years of this study has not resulted in concomitant changes in patients' in-hospital mortality or length of stay.

Morbidity and mortality of major adult spinal surgery. A prospective cohort analysis of 942 consecutive patients.

BACKGROUND CONTEXT: To date, most reports on the incidence of adverse events (AEs) in spine surgery have been retrospective and dependent on data abstraction from hospital-based administrative databases. To our knowledge, there have been no previous rigorously performed prospective analysis of all AEs occurring in the entire population of patients presenting to an academic quaternary referral center. PURPOSE: To determine the mortality and true incidence and severity of morbidity (major and minor, medical and surgical) in adults undergoing complex spinal surgery, both trauma and elective, in a quaternary referral center. To examine the influence of the introduction of a dedicated weekly multidisciplinary rounds, and a formal abstraction tool, on the recording of this prospective perioperative morbidity data. To examine the validity and inter- and intraobserver reliability of a dedicated Spine AdVerse Events Severity system, version 2 (SAVES V2) AE abstraction tool. STUDY DESIGN: Ours is an academic quaternary referral center serving a population of 4.5 million people. Beginning in April 2008, a spine-specific AE-recording instrument, entitled SAVES V2, was introduced at our center for reporting, categorization, and classification of AEs. The use of this system remains an ongoing prospective study. PATIENT SAMPLE: All adult patients admitted to the spine service of a quaternary referral center for a 12-month period. OUTCOME MEASURES: A validity and an inter- and intraobserver reliability examination of the SAVES V2 system, as used at our institution. Morbidity and inhospital deaths, unplanned second surgeries during index admission, wound infections requiring reoperation, and readmissions during the same calendar year. We also examined in detail all intraoperative and nonsurgical postoperative AEs, as well as hospital length of stay (LOS). METHODS: Data on all patients undergoing surgery over a 12-month period were prospectively collected using a perioperative morbidity abstraction tool at weekly dedicated mortality and morbidity rounds. This tool allows identification of each specific AE and grades the severity. Before the introduction of this system, and using the hospital inpatient database, our documented perioperative morbidity rate (major and minor, medical and surgical) was 23%. Diagnosis, operative data, hospital data, major and minor complications both medical and surgical, and deaths were recorded. RESULTS: One hundred percent of all patients discharged from the unit had complete data available for analysis. Nine hundred forty-two patients with an age range of 16 to 90 years (mean, 54 years; mode, 38 years) were identified. There were 552 males and 390 females. Around 58.5% of patients had undergone elective surgery. Thirty percent of patients were American Spinal Injury Association class D or worse on admission. The average LOS was 13.5 days (range, 1-221 days). Eight hundred twenty-two (87%) patients had at least one documented complication. Thirty-nine percent of these adversely affected hospital LOS. There were 14 mortalities during the study period. The rate of intraoperative surgical complication was 10.5% (4.5% incidental durotomy and 1.9% hardware malposition requiring revision and 2.2% blood loss >2 L). The incidence of postoperative complication was 73.5% (wound complications, 13.5%; delerium, 8%; pneumonia, 7%; neuropathic pain, 5%; dysphagia, 4.5%; and neurological deterioration, 3%). CONCLUSIONS: Major spinal surgery in the adult is associated with a high incidence of intra- and postoperative complications. We identified a very high rate of previously unrecognized postoperative complications, which adversely affect LOS. Without strict adherence to a prospective data collection system, the true complexity of this surgery may be greatly underestimated.

Cauda equina syndrome presenting as abdominal pain: a case report.

Cauda equina syndrome (CES) is an uncommon entity. Symptoms include bowel and bladder dysfunction, saddle anesthesia, and varying degrees of lower limb motor and sensory disturbances. The consequences of delayed diagnosis can be devastating, resulting in bowel and bladder incontinence and lower limb paralysis. There is little in literature regarding abdominal pain as a significant feature of the initial presentation of CES. We present the case of a 32-year-old woman with CES who presented to the emergency department with gradually worsening lower abdominal pain.

Primary pyogenic infection of the spine in intravenous drug users: a prospective observational study.

STUDY DESIGN: A prospective comparative analysis of surgically-treated nontuberculous primary pyogenic infection of the spine (PPIS). OBJECTIVE: To evaluate and compare the demographics, presentation, treatment and outcomes of surgically-treated PPIS between intravenous drug users (IVDU) and non-IVDU patients. SUMMARY OF BACKGROUND DATA: This is the first prospective cohort comparative analysis of the clinical outcomes of surgically-treated PPIS between IVDU and non-IVDU populations. This is also the largest cohort of consecutive surgically-treated PPIS in a population of IVDU. METHODS: Data on all patients with PPIS presenting to a quaternary referral center during a 4-year period from 2004 were collected in a prospectively maintained customized database. RESULTS: During the study period there were 102 patients treated for PPIS of which 51 were IVDU. Of this IVDU group, the mean age was 43 years (range: 25-57). Twenty-three had human immunodeficiency virus, 43 had hepatitis C, and 13 had hepatitis B. All were using cocaine, 26 were also using heroin and 44 were using at least 3 recreational drugs. Thirty patients presented with axial pain of a mean duration of 51 days (range: 3-120 days). Of the IVDU patients with neurological deficit on presentation, the mean American Spinal Injury Association (ASIA) motor score was 58.6. The most common ASIA motor levels involved were C4 and C5. Mean duration of neurological symptoms was 7 days (range: 1-60 days). Twenty-six were already receiving i.v. antibiotics for known spinal infection and 33 patients had an identifiable organism on blood cultures (19 methicillin-sensitive Staphylococcus aureus, 9 methicillin-resistant S. aureus). Forty-four of the 51 IVDU patients were treated surgically. Thirty-four of the 44 surgically treated cases involved the cervical spine. Twenty-two had a posterior approach alone, 13 had anterior only while 9 required combined anterior and posterior approaches at the index surgery. Seven required early revision for hardware failure (none of whom has combined approach) and 2 developed a postoperative surgical site infection (SSI). Thirty-seven of the 51 IVDU patients were apprehended at least once using illicit drugs while in hospital. Mean duration of antibiotic treatment after surgery was 62 days. At discharge, 28 of 44 patients had neurological improvement (mean = 20 ASIA points, range: 1-55), 11 had neurological deterioration during treatment (mean = 13, range = 1-50), and 5 were unchanged. Among the IVDUs there were no in-hospital deaths. At 2 years after index admission 13 IVDU patients were dead, and none were attending for follow-up despite all efforts to locate the patients. In the non-IVDU group, the mean age of the 51 patients was 56 years (range 25-83). Thirty-four patients presented with axial pain with a mean duration of 105 days (range 2-365). Mean ASIA motor score of patients with neurological deficit on admission was 74. Most common ASIA level was T12. Mean duration of neurological symptoms was 12 days (range 1-84). Thirteen patients were receiving i.v. antibiotics for known spinal infection and 20 patients had an identifiable organism on blood culture (30% methicillin-sensitive S. aureus, 50% methicillin-resistant S. aureus). Forty-four of these 51 non-IVDU patients were treated surgically. Thirty-five of the 44 surgically-treated cases involved the thoracic or lumbar spines. Twenty-nine had a posterior approach alone, 3 had anterior alone while 12 required combined approaches. No early hardware failures were seen in the non-IVDU group while 4 developed SSI. Mean duration of antibiotic treatment after surgery was 45 days. At discharge 21 patients had neurological improvement (mean 9 ASIA points, range: 1-17). Five had neurologic deterioration with a mean motor loss of 16 points (10-23). There were 4 in-hospital deaths among the non-IVDU group. At 2 years after index admission, 19 patients were dead and the remainder were all available for follow-up. CONCLUSION: There are significant differences in demographics, presentation, treatment and outcomes of primary spinal pyogenic infection between a population of IVDU and a comparable cohort of non-IVDU. The IVDU group presents with cervical quadriplegia while it is the thoracolumbar spine that is almost exclusively involved in the non-IVDU group. Among the IVDUs, surgical management is complex with a high incidence of early hardware failure. SSI is significantly more common among non-IVDU. Significant neurological improvement can be expected in the majority of IVDU patients with a high mortality rate among the non-IVDU. IVDU are unreliable patients and in-hospital, in-halo incarceration is recommended where possible.

Diversity and commonalities in the care of spine trauma internationally.

STUDY DESIGN: Questionnaires administered to practicing orthopedic and neurosurgical spine surgeons from North America, Europe, Asia, Australia, and New Zealand. OBJECTIVE: To determine diversity and commonalities in the treatment of spine trauma internationally. SUMMARY OF BACKGROUND DATA: Previous studies have had suggested that there is significant variability in the treatment of common spinal trauma conditions. METHODS: Questionnaires based on 10 commonly encountered spine trauma cases were administered to 77 experienced spinal surgeons across 4 continents. The questions for each case scenario were similar, but were tailored to be appropriate for the case being presented. Questions focused on the discipline of the specialist who would treat the injury, the treatment itself, and how long it would take for the patient to return home or to work. Questions pertaining to investigations, funding, estimated in-hospital length of stay, prehospital care, and mortality were also included. Each question was followed by 4 to 8 options from which the surgeon could chose a response. Data were analyzed using, SAS v9.2, a software analytical package, to determine the level of agreement between respondents on different items. RESULTS: Of the 77 surgeons completing the questionnaire, 66% were fellowship trained spine surgeons, 20% orthopedic surgeons, and 14% neurosurgeons. In all regions, the majority of spinal trauma care is provided in a regional trauma center with dedicated spine surgeons. In all but 1 case significant differences were found in treatment with European and Asian surgeons have a higher operative rate. A combined anterior/posterior surgical approach was more commonly used in Europe and Asia. North American patients are expected to have a shorter hospital stay and return to work earlier. Significant differences exist between Asia and the other regions with regard to prehospital care. CONCLUSION: These findings suggest that despite the subspecialty focus in the care of spinal trauma, there continues to exist a lack of consensus among treating surgeons as to the optimum management and appropriateness of multiple aspects of specific operative and nonoperative interventions and indeed the postinjury management.