Thoracic Spine Fracture After Cardiopulmonary Resuscitation in a Patient with Ankylosing Spondylitis: A Case Report.

CASE: A 32-year-old man with a history of ankylosing spondylitis presented to the emergency department because of sepsis secondary to Fournier's gangrene and subsequently went into cardiac arrest requiring cardiopulmonary resuscitation (CPR). On the twelfth hospital day, a fracture through the T5-T6 intervertebral disk space was incidentally found on a chest, abdominal, and pelvic Computed Tomography (CT) scan. The rounds of CPR were the only traumatic event that the patient underwent before the discovery of the spine fracture. CONCLUSION: A low threshold for advanced imaging should be held to rule out occult spine fractures in patients with ankylosed spines after receiving CPR.

Facilitators and barriers to the uptake of COVID-19 vaccine precaution dose among adult population: qualitative analysis across six different states of India.

Introduction: India launched the COVID-19 vaccination drive on 16th January 2021 by vaccinating the adult population above 18 years of age. This was followed by the introduction of an additional precaution dose. As on 18th October 2022, 1,02,66,96,808 (1.02 Billion) first dose and 94, 95, 39,516 (949 Million) second doses of COVID-19 vaccine were administered. However, when compared to the uptake of the primary doses, the precaution dose uptake lagged behind with only 21,75, 12,721 (217 million) doses administered. Even though, the uptake of the primary doses remained optimal, irrespective of different interventions by the Government of India, the uptake of the precaution dose remained poor. In this context, the Ministry of Health & Family Welfare wanted to understand the facilitators and Barriers for precaution dose uptake among adults so that future immunization campaigns could address these issues. Methods: An exploratory qualitative study was conducted to assess the facilitators and barriers for COVID-19 precaution dose uptake at community level across 6 different states in India. From each of the states, two districts with the highest and lowest rates of COVID-19 vaccine precaution dose uptake were selected. In each of these districts, 2 block Primary Healthcare Centres (PHCs), one with high and one with low uptake were identified. Within these block PHCs, a PHC field area with high and low precaution dose uptakes was identified. From the identified sites a minimum of four IDIs, four FGDs were conducted among the community members. KIIs of the State Immunization Officers, District Immunisation Officers, PHC Medical Officers, healthcare workers like Accredited Social Health Activist/Auxiliary Nurse Midwife were also conducted. The data was audio recorded and it was transcribed, translated and analysed using framework approach. Results: It was observed that rise in COVID-19 cases prompted the community to take the precaution dose, this along with the cost of hospitalization and the number of productive days being lost as a result of being infected resulted in vaccine uptake. The fear of non-availability of COVID-19 vaccines latter on also prompted people for vaccine uptake. While the barriers were, poor accessibility to vaccination centers, long hours of travel, poor road connectivity and lack of transportation facilities. However, the most prominent barriers observed across all study sites was that a sense of pandemic fatigue and complacency had developed both among the providers as well as the beneficiaries. Other barriers include differences in vaccination schedules and longer duration between the primary doses of some vaccines. Media was identified to be both a barrier and facilitator for Covid-19 Precaution dose uptake. Even though media played an important role in disseminating information in the beginning of the campaign, it was soon followed by the circulation of both misinformation and disinformation. Discussion: The study identified that dissemination of accurate information and community involvement at each stage of planning and implementation are crucial for the success of any campaign. Efforts should be constantly made to address and re-invent strategies that will be most suitable for the needs of the community. Therefore, in order to ensure successful vaccination campaigns, it is crucial that along with political will it is also important to have a decentralized approach with inter-sectoral coordination with different stakeholders such as healthcare workers, community members and the different departments such as the local self-governments, education department, law & order department etc. These lessons learnt from COVID-19 vaccination campaigns must not be forgotten and must be applied in future vaccination campaigns and while framing public health policies.

Surgical Treatment of Single Level Cervical Radiculopathy: A Comparison of Anterior Cervical Decompression and Fusion (ACDF) Versus Cervical Disk Arthroplasty (CDA) Versus Posterior Cervical Foraminotomy (PCF).

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: The objective of this study is to retrospectively compare the clinical outcomes, complication rates, and reoperation rates among the 4 treatments in patients with cervical radiculopathy. SUMMARY OF BACKGROUND DATA: Surgical options for cervical radiculopathy include anterior cervical discectomy and fusion (ACDF), open posterior cervical foraminotomy (O-PCF), minimally invasive posterior cervical foraminotomy (MI-PCF), and cervical disk arthroplasty (CDA). MATERIALS AND METHODS: Retrospective chart review after Review Board approval. Of the 384 patients in the study-257 ACDF, 18 O-PCF, 52 MI-PCF, and 56 CDA. Information was obtained from the charts and compared between the groups. PATIENT SAMPLE: Patients above 18 years of age with single-level, unilateral cervical radiculopathy correlating with magnetic resonance imaging, failure of nonoperative management, and 1-level ACDF, O-PCF, MI-PCF, or CDA with >24 months of follow-up. OUTCOME MEASURES: Neck Disability Index (NDI), Visual Analog Score neck and arm pain, minimum clinically significant difference (MCID), complication rates, and reoperation rates. RESULTS: Operative time was significantly shorter for MI-PCF. Median estimated blood loss was small, but greater with O-PCF compared with other interventions. The length of hospital stay was longest for the ACDF group. At 2 years' follow-up, 36 subjects (9%) had subsequent neck surgery. The most common indication for additional surgery was recurrent symptoms (3.4%) followed by adjacent segment disease (2.6%), pseudoarthrosis (2.1%), adjacent segment disease + pseudoarthrosis (0.5%), and implant-related complications (0.3%). There was no statistically significant difference in complication rates between groups. MCID in NDI was achieved in 40% of MI-PCF subjects, 42% of O-PCF subjects, 66% of CDA subjects and 46% of ACDF subjects. CONCLUSIONS: All 4 treatment options confer good clinical results on patients for cervical radiculopathy. Intraoperative and postoperative complications were low and comparable in all 4 groups. MI-PCF had the shortest surgical time and length of hospital stay. More CDA patients achieved MCID in NDI compared with the others, and the rate for additional surgery at 2 years was lowest in the CDA group.

Minimally Invasive Percutaneous Fasciotomy in Lumbar Paraspinal Compartment Syndrome: A Case Report and Review of Literature.

CASE: Lumbar paraspinal compartment syndrome (LPCS) is a rare but potentially catastrophic pathology caused by increased intracompartmental pressures leading to potential ischemic necrosis of muscle, local denervation, and complications of rhabdomyolysis. A combination of unique clinical history and examination findings, laboratory findings, and radiologic imaging help in diagnosis. CONCLUSION: Early detection and intervention with minimally invasive percutaneous fasciotomy can minimize local soft tissue trauma while providing extensive fascial release with good clinical outcomes. Radiographic follow-up in this case suggests that the muscle at risk in LPCS can be spared with early surgical intervention.

Pediatric femoral shaft fractures secondary to tombstone uprooting - Two case reports.

CASE: Two cases are reported of femoral shaft fractures involving tombstones. A four and six year old child had similar histories of uprooting of tombstones during play, toppling them and causing injury. Treatment included non-operative and operative approaches, with both patients yielding bony union at the three month follow up. CONCLUSION: We present the involvement of tombstones as a unique mechanism of injury for femoral shaft fractures in two pediatric cases. From our review of the literature, we believe this to be a first report. We hope to highlight the associated safety implications for the primary prevention of a similar traumatic injury.

The Effect of Proximal Anchor Choice During Distraction-based Surgeries for Patients With Nonidiopathic Early-onset Scoliosis: A Retrospective Multicenter Study.

BACKGROUND: It is unclear whether the type of proximal anchor affects the spine length achieved with distraction-based surgeries in patients with nonidiopathic early-onset scoliosis (EOS). Since distraction may produce kyphosis, spine length should be assessed in the sagittal plane using the sagittal spine length (SSL-curved arc length of the spine in the sagittal plane). Our purpose was to determine if the type of proximal anchor in distraction-based surgeries will affect final spine length. METHODS: Patients with nonidiopathic EOS treated with distraction-based systems (minimum 5 y follow-up, 5 lengthenings) were identified from 2 EOS registries. Radiographic analysis preoperative, postimplant (L1), and after each lengthening (L2-L5, L6-L10, L11-L15) was performed with the primary outcome of T1-S1 SSL. RESULTS: We identified 126 patients-70 had rib-based implants (52 congenital, 9 syndromic, 9 neuromuscular) and 56 had spine-based implants (15 congenital, 29 syndromic, 12 neuromuscular) with preoperative age 4.6 years, scoliosis 75 degrees, and kyphosis 48 degrees. After initial correction (P<0.05), scoliosis remained constant [58 degrees (13 to 104 degrees) at L11-L15] and kyphosis increased over time [38 degrees (9 to 108 degrees) at L1 to 60 degrees (17 to 134 degrees) at L11-L15] (P<0.05). Preoperative SSL was higher in the spine-based group (29.6 cm) when compared with the rib-based group (25.2 cm) (P<0.05). This difference was maintained after initial implantation (spine-based: 32.2 cm vs. rib-based: 26.7 cm, P<0.05) and at final follow-up (spine-based: 37.0 cm vs. rib-based: 34.4 cm, P<0.05). As preoperative SSL differed between groups, maximum SSL gains per interval were also normalized to preoperative SSL. There was no statistically significant difference between groups at L1, L2-L5, and L6-L10. However, at L11-L15, the rib-based group achieved a more relative increase in spine length compared with the spine-based group (45% vs. 31%, P<0.05). CONCLUSION: At minimum 5 year follow-up, distraction-based surgeries increased spine length for patients with nonidiopathic EOS; regardless of proximal anchor type.

Long-term experience with simultaneous prone video-assisted thoracoscopic anterior spinal release and posterior spinal fusion in severe rigid pediatric spinal deformities.

PURPOSE: While posterior-alone techniques have been successful for most pediatric spinal deformities, anterior spinal release may be useful for severe rigid deformities. Traditional lateral-positioned video-assisted thoracoscopic surgical release (VATSR) followed by prone posterior spinal fusion (PSF) has been criticized for adding extensive operative morbidity. We aimed to reduce its disadvantages by performing prone VATSR and PSF simultaneously and evaluate its long-term outcomes. METHODS: All consecutive patients from 1991 to 2012 undergoing VATSR and PSF at one institution were retrospectively reviewed. The inclusion criteria comprised severe rigid thoracic scoliosis (> 70°, bending correction > 45°) or kyphosis (> 75°, bolster correction > 45°), and a minimum 2 year follow-up. Demographics, operative data, hospital stay, and radiographic correction data were compared between patients who had undergone sequential VATSR followed by PSF and those who had undergone these procedures simultaneously. RESULTS: Of 153 patients who had undergone VATSR and PSF, 53 met the inclusion criteria (31 sequential, 22 simultaneous; average follow-up, 50 [range, 24-86] months). Age, preoperative measurements and flexibility, and perioperative complications did not differ significantly. The simultaneous group showed significantly lower operative time (449 vs. 618 min), blood loss (1039 vs. 1906 cc), and hospital stay (6.3 vs. 8.5 days) (all, p < 0.05). Postoperative radiographic correction and maintenance at the final follow-up showed a non-significant trend favoring the simultaneous group. CONCLUSION: Our simultaneous prone VATSR and PSF technique showed significantly lower operative time, blood loss, and hospital stay compared with the traditional sequential VATSR and PSF method, suggesting its value in treating rigid deformities.

Optimizing pharmacologic thromboprophylaxis use in pediatric orthopedic surgical patients through implementation of a perioperative venous thromboembolism risk screening tool.

BACKGROUND: Although rare, venous thromboembolic events (VTE) are a significant challenge in pediatric orthopedic surgical patients (POSP). A VTE thromboprophylaxis screening tool was developed and implemented in POSPs at the IWK Health Centre since October 2016. OBJECTIVES: This retrospective cohort study was designed to evaluate and assess the impact of the VTE thromboprophylaxis screening tool in terms of use of thromboprophylaxis in POSP. METHODS: Using the tool, POSPs were screened and were categorized into risk groups. Patient groups were compared and spearman correlation analysis was performed to show the strength of association between risk factors and thromboprophylaxis. Retrospective screening of pre-algorithm patients who received thromboprophylaxis was done to further assess the screening tool. RESULTS: After the implementation of the VTE thromboprophylaxis screening tool in POSPs, there was a 47.9% reduction in the use of thromboprophylaxis (P = 0.046) as compared with before. Neither VTE nor significant bleeding complications occurred before or after screening tool implementation. Compliance with the screening tool was excellent (100% of patients in the high-risk category received thromboprophylaxis). High-risk patients were more likely to have body mass index  > 30 (35.7%), limited/altered mobility (57.1%), and to be undergoing a complicated/repeat surgery (64.3%). CONCLUSIONS: The present study demonstrates successful implementation of a VTE thromboprophylaxis screening tool that resulted in significant reduction in use of thromboprophylaxis in POSPs with no increase in VTE or change in bleeding complications.

Development of a perioperative venous thromboembolism prophylaxis algorithm for pediatric orthopedic surgical patients.

Venous thromboembolism (VTE) has been recognized as a rare but potentially serious complication in pediatric orthopedic patients. However, standardized guidelines for screening and management of at-risk patients do not exist. The aim of the study was to develop a VTE prophylaxis screening tool for postoperative orthopedic patients after conducting an institutional needs assessment survey. A needs assessment survey was conducted after institutional ethics board approval. Development of perioperative VTE prophylaxis algorithm for pediatric orthopedic surgical patients was planned after thorough literature review, consultation with national and international experts as well as using a modified nominal and consensus development conference (serial meetings) method for reaching a consensus. NAS as well as discussion with stakeholders indicated support for development of perioperative VTE prophylaxis algorithm for orthopedic patients. Using above methods, a VTE prophylaxis algorithm was developed and implemented at IWK Health Center. The present study involved development of a perioperative VTE prophylaxis algorithm for pediatric orthopedic surgical patients that could be easily and rapidly administered as a point of care assessment tool.

Dysplasia Epiphysealis Hemimelica/Trevor Disease: Report of a Lesion Solely Involving the Lunate Bone: A Case Report.

CASE: We describe the case of a dysplasia epiphysealis hemimelica (DEH) lesion affecting uniquely the lunate bone in a 16-year-old boy causing pain, stiffness, and decreased range of motion. Surgical excision was performed, leading to resolution of primary symptoms with residual limitations in terminal wrist extension. CONCLUSIONS: From our review of the literature, we believe this case to be the first report of a DEH lesion affecting solely the lunate bone. Although conservative and surgical management have both been described with DEH cases, we report a positive outcome following the excision of a symptomatic lesion.

Distraction-Based Surgeries Increase Spine Length for Patients With Nonidiopathic Early-Onset Scoliosis-5-Year Follow-up.

STUDY DESIGN: Retrospective, comparative. OBJECTIVES: To determine if distraction-based surgeries will increase spine length in patients with nonidiopathic EOS and whether etiology affects final spine length. SUMMARY OF BACKGROUND DATA: As early-onset scoliosis (EOS) has many etiologies, it is unclear whether etiology affects the spine length achieved with distraction-based surgeries. Since distraction may produce kyphosis, sagittal spine length (SSL; curved arc length of the spine in the sagittal plane) should be utilized. METHODS: Patients with nonidiopathic EOS treated with distraction-based systems (minimum 5-year follow-up, 5 lengthenings) were identified from two EOS registries. Radiographic analysis preoperation, postimplant (L1), and after each lengthening (L2-L5, L6-L10, L11-L15) was performed with primary outcome of T1-S1 SSL. RESULTS: We identified 126 patients (67 congenital, 38 syndromic, 21 neuromuscular) with a mean preoperative age of 4.6 years, scoliosis 75°, kyphosis 48°, and a mean of 12 lengthenings. After initial correction (p < .05), scoliosis remained constant (58° at L11-L15) and kyphosis increased (38° at L1 to 60° at L11-L15) (p < .05). SSL increased for the entire group from 27.1 cm preoperation to 35.3 cm at L11-L15 (p < .05) and during the distraction phase (29.2 cm at L1 to 35.3 cm at L11-L15) (p < .05). Preoperative SSL was higher in neuromuscular compared with congenital patients and maintained that difference until the 10th lengthening. Preoperative SSL did not differ between syndromic and congenital patients (28.0 cm vs. 25.6 cm); however, syndromic patients had greater SSL after implantation (L1: 30.5 cm vs. 26.8 cm) (p < .05) and maintained that difference until the 15th lengthening (37.1 cm vs. 34.3 cm) (p < .05). CONCLUSION: At minimum 5-year follow-up, distraction-based surgeries increased spine length for all patients with nonidiopathic EOS; however, neuromusculars had higher preoperative spine length compared with congenital patients and maintained that difference until the 10th lengthening. Although congenital and syndromic patients had similar preoperative spine length, syndromic patients had greater SSL after implantation (L1) and maintained that difference until the 15th lengthening. LEVEL OF EVIDENCE: Level III.

New Technologies in Pediatric Spine Surgery.

Spinal fusion in young children for treatment of early onset scoliosis is not optimal because it limits growth and contributes to long-term lung compromise. Various types of growth-friendly spinal implants and newer technologies have been introduced in the past few years. Similarly, in adolescent idiopathic scoliosis, fusion decreases spinal mobility and may lead to development of adjacent level disc degeneration. A variety of different new technologies have been developed for alternative surgical approaches that halt curve progression while maintaining spinal mobility.

Thoracoscopic Anterior Instrumentation and Fusion as a Treatment for Adolescent Idiopathic Scoliosis: A Systematic Review of the Literature.

STUDY DESIGN: A systematic review and meta-analysis on thoracoscopic anterior instrumentation and fusion as a treatment for adolescent idiopathic scoliosis (AIS). OBJECTIVE: The goal of this study is to determine the current status of thoracoscopic instrumentation and fusion as a treatment for AIS. SUMMARY OF BACKGROUND DATA: Traditional surgical techniques for AIS have been open anterior thoracotomy with instrumentation and posterior spinal fusion and instrumentation. With the growing clinical interest in growth modulation surgeries, such as vertebral body tethering, there is a resurgence of interest in a thoracoscopic technique. METHODS: The most commonly used medical databases (PubMed, Medline, EMBASE, CINAHL, and the Cochrane library) were searched up to November 2016 using the search terms VATS, thoracoscopic scoliosis, and thoracoscopic scoliosis instrumentation. RESULTS: Thirteen studies met the strict inclusion criteria. Five hundred thirty patients were reported: 81.7% females, with the majority diagnosed as AIS. The mean operative time was 371.5 minutes, mean blood loss of 502.85 mL, and mean hospital stay of 5.9 days. Mean preoperative curve magnitude was 52.9°; postoperative curve magnitude was 17.9°, with a correction of 62.7%. Number of levels instrumented was 6.3, pulmonary function tests returned to preoperative values by 2 years postoperation, and the complication rate was 21.3%. Compared to thoracotomy, VATS had similar complication rates, blood loss, operation theater time, curve correction, and number of fused levels. Compared to posterior fusion, VATS has higher complication rates and operation theater time. Blood loss and percentage correction were similar. VATS had a smaller number of fused segments. CONCLUSIONS: Advantages include less invasive, excellent curve correction, few levels fused, good satisfaction, and no long-term effect on pulmonary function. Drawbacks are increased operative time and incidence of pulmonary complications. With appropriate surgeon training and careful patient selection, this technique offers an acceptable alternative to the more traditional procedures. LEVEL OF EVIDENCE: Level II.

The "Skipped Segment Screw" Construct: An Alternative to Conventional Lateral Mass Fixation-Biomechanical Analysis in a Porcine Cervical Spine Model.

STUDY DESIGN: Cadaveric biomechanical study. PURPOSE: We compared the "skipped segment screw" (SSS) construct with the conventional "all segment screw" (ASS) construct for cervical spine fixation in six degrees of freedom in terms of the range of motion (ROM). OVERVIEW OF LITERATURE: Currently, no clear guidelines are available in the literature for the configuration of lateral mass (LM) screwrod fixation for cervical spine stabilization. Most surgeons tend to insert screws bilaterally at all segments from C3 to C6 with the assumption that implants at every level will provide maximum stability. METHODS: Six porcine cervical spine specimens were harvested from fresh 6-9-month-old pigs. Each specimen was sequentially tested in the following order: intact uninstrumented (UIS), SSS (LM screws in C3, C5, and C7 bilaterally), and ASS (LM screws in C3-C7 bilaterally). Biomechanical testing was performed with a force of 2 Nm in six degrees of freedom and 3D motion tracking was performed. RESULTS: The two-tailed paired t-test was used for statistical analysis. There was a significant decrease in ROM in instrumented specimens compared with that in UIS specimens in all six degrees of motion (p<0.05), whereas there was no significant difference in ROM between the different types of constructs (SSS and ASS). CONCLUSIONS: Because both configurations provide comparable stability under physiological loading, we provide a biomechanical basis for the use of SSS configuration owing to its potential clinical advantages, such as relatively less bulk of implants within a small operative field, relative ease of manipulating the rod into position, shorter surgical time, less blood loss, lower risk of screw-related complications, less implant-related costs, and most importantly, no compromise in the required stability needed until fusion.

'Munchausen syndrome': a forgotten diagnosis in the spine.

PURPOSE: To present the case of a patient with Munchausen's syndrome who underwent multiple surgeries in the spine before the diagnosis was made and, therefore, to highlight the importance of this obscure condition that can result in unnecessary surgical treatment. METHODS: A 44-year-old businesswoman presented with multiple episodes of low back pain and weakness in both lower limbs over past 11 years. Past history consisted of multiple hospitalizations, and three surgeries on her lumbar spine at different hospitals, with dramatic improvement in symptoms being reported each time after surgery. Clinical examination showed inconsistent and nonspecific neurological findings. Imaging studies like X-rays, magnetic resonance imaging, and all neurophysiological studies were within normal limits. RESULTS: Multi-disciplinary evaluation by a team of orthopedicians, neurologist and psychiatrist and rehabilitation specialists diagnosed it as 'Munchausen syndrome'. Only one report of this fictitious disease in spine was found in review of literature (Association AP, Diagnostic and statistical manual of mental disorders: DSM-IV-TR(®), 2003). CONCLUSIONS: A history of multiple surgical interventions at multiple hospitals, often followed by dramatic improvement and then relapse, should trigger a suspicion of Munchausen syndrome, particularly in the scenario of normal imaging studies. Diagnosing this rare condition in spine is key to avoid unnecessary surgery.

Plating, nailing, external fixation, and fibular strut grafting for non-union of humeral shaft fractures.

PURPOSE: To compare various treatment modalities (plating, Ilizarov external fixation, and non-vascular fibular cortical strut grafting) for non-union of humeral shaft fractures. METHODS: Records of 9 women and 26 men aged 24 to 71 (mean, 42) years who presented with non-union of humeral shaft fractures were reviewed. The humeral shaft fractures were secondary to low-energy trauma (n=22) or vehicular accidents (n=13) and involved the proximal (n=9), middle (n=15), and distal (n=11) regions. 13 of the fractures were open. Infection was evident in 8 of the non-unions. For non-unions with infection (n=8), a 2-stage procedure entailing temporary Ilizarov fixation followed by plating was used. For non-unions without infection (n=23), one-stage plating and cancellous bone grafting was used. For non-unions of osteoporotic bone (n=4), one-stage non-vascularised fibular strut grafting was used. Outcome was measured using the Disabilities of the Arm, Shoulder and Hand (DASH) scoring system. RESULTS: The 35 patients were followed up for a mean of 16 (range, 6-60) months. All achieved bone union except for one (who had persistent infection). Respectively for non-unions with infection, nonunions without infection, and non-unions of osteoporotic bone, the mean times to bone union were 6.5 (range, 4-10), 5 (range, 4-8), and 10 (range, 6-14) months, the mean improvement in DASH score was 30, 43, and 18, and malalignment was noted in 5, 2, and one patient. Three patients had a preoperative radial nerve palsy for which standard tendon transfer was performed 6 weeks after treatment for non-union. CONCLUSION: Compression plating achieved the best results. An external fixator may be used temporarily for infected non-unions. Fibular strut grafting may be used when non-unions warrant additional stability.