Quantitative microbiology of pressure sores in different stages of healing.

The quantitative microbiology of 25 pressure sores in different stages of healing was examined in 25 patients with spinal cord injury. When grossly necrotic tissue was present (stage 1), 5.8 isolates per patient with a density of 6.4 log10/g was recovered, with comparable findings for aerobes and anaerobes. In the absence of necrotic tissue but with the presence of undermining (stage 2), 1.5 aerobic and 0.2 anaerobic isolates were recovered per patient with a mean density of 2.7 and 0.1 log10/g of tissue for aerobic and anaerobic isolates, respectively. The lesions were almost sterile in patients with no necrotic tissue and no undermining (stage 3). Foul smell was always associated with the presence of anaerobes in deep tissue cultures, however, six patients with nonfoul-smelling lesions yielded anaerobes. A 75% quantitative concordance was seen between swab and biopsy culture results. The quantitative concordance between peripheral and central biopsy culture results was 63%, showing variability in results from different sampling areas. No relationship was observed between the density of microorganisms and the eventual outcome of the myocutaneous flap procedure.

Occipito-cervico-thoracic spine fusion in a patient with occipito-cervical dislocation and survival.

A 16-year-old man with occipito-cervical dislocation and survival was treated at Rancho Los Amigos Medical Center. The patient had ligamentous instability between the occiput and the cervical spine. His neurologic level was complete at the C1 level, and he was dependent on a mechanical respirator. Sternocleidomastoid and other neck musculature were not functional. A fusion of the occiput to cervical spine and cervical spine to thoracic spine was performed to obviate the need for external neck support. The patient went on to fuse and is now independently mobile with a tongue-switch driven wheelchair with a respirator trailer 2 years after injury. The patient has no need for external support as a result of his fusion.

The effect of surgical intervention on rehabilitation time in patients with thoracolumbar and lumbar spinal cord injuries.

One hundred forty-seven patients with unstable low thoracic and lumbar fractures were examined. All patients had significant neurologic injuries. Ninety-one patients exhibited incomplete lesions whereas fifty-six had complete lesions. Age, sex, cause of injury, fracture location, fracture mechanism, and complications were recorded and analyzed. The average follow-up was 25 months (range 2-148). Incomplete neurologic lesions demonstrated a significant increase in ASIA motor points if both decompression and stabilization were performed at the same operative sitting. When decompression was performed before stabilization a decrease in improvement was noted. Patients with complete lesions demonstrated a significant reduction in rehabilitation time if stabilization was augmented with sublaminar wires rather than Drummond wires or Harrington rods alone.

Pedicle screw fixation for arthrodesis of the lumbosacral spine in the elderly. An outcome study.

STUDY DESIGN: An analysis of the outcome and effectiveness of instrumented arthrodesis of the lumbosacral spine in elderly patients conducted using a review of records, assessment of fusion via plain radiographs, and a two-part questionnaire. OBJECTIVE: To ascertain the outcome and efficacy of instrumented arthrodesis of the lumbosacral spine in patients 60 years of age and older. BACKGROUND DATA: From 1987 to 1991, 38 patients of at least 60 years of age underwent instrumented arthrodesis of the lumbosacral spine using the Wiltse or Selby pedicle screw fixation system (Advanced Spine Fixation Systems, Inc., Irvine, CA). Patients were considered for surgery only after attempts at conservative management, including physical therapy, medication, injection blocks, and home exercises, had proven unsuccessful. METHODS: Follow-up examinations were performed 3 months, 6 months, 1 year, and 2 years after surgery. Fusion was assessed using plain radiographs, including flexion-extension films. Inpatient and outpatient records were reviewed, and a two-part questionnaire was used to establish the effect of surgery on function and lifestyle. Thirty patients responded to the questionnaire. Follow-up observation of the patients ranged from 25 to 56 months. The mean age was 73.8 years (range, 60-90 years). RESULTS: The mean co-morbidity was 1.7. Based on the authors' method of evaluation of fusion, the fusion rate was 92%. Fifty-seven percent of the patients reported excellent or good results, 26% reported fair results, and 17% reported poor results. Functional gains of 50% or more were reported by 71% of the respondents. Female patients had significantly more complications than male patients, but reported comparable outcomes. CONCLUSION: Despite the increase in age, co-morbidity, and associated risk of perioperative complications inherent in this population, an outcome comparable with that of younger patients is reported.

Superior entrapment of the clavicle.

Three degrees of acromioclavicular separation are commonly recognized. A Type III separation with entrapment of the clavicle on the top of the acromion is frequently not recognized while in its acute phase and amenable to closed reduction. The sign of this type of acromioclavicular separation is an apparent Type III in which one cannot manipulate the clavicle. The acute case is treated by local anesthesia, manipulation, and splinting. The chronic case is treated by excision of the outer end of the clavicle. In 1979 we treated three acute and one chronic superior entrapment of the clavicle on the acromion. During this time interval 67 acromioclavicular separations of Grade I, II, and III were treated. This amounted to 6% of our acromioclavicular separations treated during 1979.

Perioperative risk factors for wound infections after lower back fusions.

Although reduced by technology, antibiotics and surgical technique, spinal infection from surgery remains a recognizable risk. The rate of infection in spinal surgery is reviewed. Identification of risk factors are important in preoperative planning. Preoperative risk factors for postoperative spinal infection include obesity and smoking. Attention to sterility and efficient technique can reduce potential wound contamination intraoperatively. Excessive wound drainage and seroma formation should warn of a potential wound infection.

Cost of medical care for postoperative spinal infections.

The movement towards managed care has raised the awareness of health care costs in today's society. The additional expense involved in treating patients with deep postoperative spinal infections after lower back fusion increases the total cost of care more than four times. Three areas of greatest increase in cost are room and board, pharmacy and laboratory charges. Decreasing the expense of this complication can best be effected through use of home nursing care, choice, and duration of antibiotic treatment and prudent laboratory testing.

Classification of thoracolumbar fractures and posterior instrumentation for treatment of thoracolumbar fractures.

In treating thoracolumbar injuries, an accurate diagnosis of the structural injury to the spine is critical. I recommend the Allen classification, but all classifications assist in obtaining an accurate understanding of the spine dynamics resulting from the injury. It is essential to remember that the majority of thoracolumbar injuries result from high-energy trauma. It is incumbent upon the spinal surgeon to ensure that multisystem trauma and life-threatening injuries, with the exception of a deteriorating neurologic injury, are cared for before embarking on spinal surgery. Even treatment of these injuries may have to be delayed if cardiovascular or abdominal hemorrhagic injuries take precedence. A critically important piece of information is the neurologic diagnosis. I recommend the ASIA Motor Index as the gold standard for diagnosing injuries and prognosticating outcome. Accurate neurologic diagnosis must be obtained prior to surgery. Finally, I recommend a firm understanding and a good working relationship with the device system used for fixation. Other instructional course authors agree that whether the anterior or the posterior approach is used, familiarity with the device nuances, by not only the surgeon but also the operating team, is very helpful in achieving a successful uncomplicated implantation. If all of the above recommendations are followed, successful outcome and optimal patient recovery can be anticipated in most cases.

Evaluation of continuous intraspinal narcotic analgesia for chronic pain from benign causes.

Intraspinal narcotic analgesia (INA) has been used for chronic pain from nonmalignant causes with moderate success. To ascertain the efficacy of the morphine pump, we reviewed the 2-year results of continuous INA in 18 patients with failed back syndrome or arachnoiditis and intractable, debilitating pain that was unrelieved by conventional means. All patients underwent a trial screening of single-dose intrathecal narcotics with good pain relief. After 2 years, 8 pumps were still functioning, 8 patients had the pump removed or turned off, and 2 patients were lost to follow-up. Our patients averaged 1.4 additional procedures or hospitalizations after initial pump insertion. Overall, only 4 patients had objective evidence of benefit from INA, for a success rate of 25%. Results of this review suggest INA should not be used for the long-term management of chronic pain from nonmalignant causes.

Compression arthrodesis of finger joints.

Compression arthrodesis is useful for treatment of finger and thumb joints in arthrosis, scleroderma, hypermobile joints, paralytic deformities, and rheumatoid arthritis. A dorsal incision exposes the joint. Its surfaces are prepared in a ball-and-socket arrangement using a high-speed burr. A longitudinal pin 1.1 mm in diameter is passed distally and then retrograde to determine the angle of fusion and to prevent migration of bone ends as the longitudinal compression is applied. Transverse pins 1.5 mm in diameter are put in one-third of the distance from the joint. A Charnley clamp, as modified by Micks and Hager, is applied and tightened. At 6 weeks, the arthrodesis is checked for solidity and, if stable, X-rays are examined for new bone. When solid, the joints should be protected by external splinting for an additional 2 weeks to be sure that the fusion is complete. Compression arthrodesis was obtained in 49 of 54 joints. Solid fusion was usually attained within 6 weeks, without loss of mobility of other joints.

Proximal row carpectomy with muscle transfers for spastic paralysis.

Fourteen patients with spastic paralysis from various causes (eight with cerebral palsy) who needed minimal two handed activities to assist in self-care and who desired improvement in appearance were treated by proximal row carpectomy. In twelve transfer of flexor carpi ulnaris to extensor carpi radialis brevis was done, and in two the extensors of the wrist were shortened. Various other procedures were done in some patients. Prolonged splinting was carried out. Better extension of the wrist was obtained and supination improved more when the transfer was subcutaneous around the ulnar border than when through the interosseus membrane. Less tendency for the carpus to displace ulnarward was seen when the distal half of the scaphoid was not removed. Strength of grasp and pinch improved, but ability to release objects was diminished due to the more dorsiflexed position of the wrist. Subjective use for two handed activities was improved and the patients were satisfied with the appearance.

Thigh compartment syndrome secondary to intertrochanteric hip fracture in a quadriplegic patient: case report.

Compartment syndromes in the thigh are rare and the diagnosis may be difficult in the light of subtle early physical findings in the patient with spinal cord injury. Clinical awareness of the impending compartment syndrome is important to provide timely proper treatment and avoid disabling deformities. A compartment syndrome should not be ignored in the paraplegic, because the potential for late fibrosis and contractures may limit the independence of such patients. Greater awareness and index of suspicion are needed to successfully recognize and promptly treat the compartment syndrome in this patient population.

Spinal disease in the aged.

Treatment of the diseased spine in the elderly is a difficult challenge for the practitioner. Spinal surgery for this population requires specialized surgical skills. Patient evaluation, nonoperative treatment, surgical indications, surgical techniques, and postoperative management involve unique considerations. The patient's functional expectations, general medical condition, and proposed benefits from surgery must be addressed before any surgical intervention. Spinal surgery for the aged requires the orthopaedic surgeon to consider this patient as more than just an older individual and demands that the entire perioperative milieu be examined and its issues resolved. The projected data on aging of the United States population make this issue increasingly important.

Surgical stabilization of the cervical spine. A comparative analysis of anterior and posterior spine fusions.

Two hundred twenty-two cervical spine stabilization procedures in 212 patients are reviewed. In 114 posterior cervical fusions, 88 anterior fusions, and ten combined procedures, no deaths occurred. Surgical complication rates were similar, but more severe complications were noted with anterior cervical fusions, including tracheoesophageal problems and transient neurologic loss. Six cases of graft dislodgement requiring reoperation also occurred. In long-term follow-up evaluations, 36 anterior fusion patients developed progressive kyphotic deformity averaging 22 degrees between surgery and the time solid fusion was obtained. Degenerative changes above and below the fusion mass were detected in 36 of 59 patients treated by anterior surgery. Posterior cervical fusion patients were noted to have no significant late change in alignment, and degenerative changes were infrequent. However, 73 of 98 patients had significant extension of fusion mass beyond the originally intended levels of stabilization. Because anterior cervical spine fusion was associated with significant complications of graft dislodgement and tracheoesophageal trauma, as well as postsurgical progressive deformity, the authors recommend posterior wiring and fusion as the procedure of choice to treat cervical spine instability and permit halo-free postsurgical rehabilitation. When anterior neural decompression and fusion is necessary, concomitant posterior wiring and fusion or halo vest immobilization may be necessary to maintain reduction and prevent kyphotic angulation, because posterior ligamentous disruption is not always grossly evident on radiographic examination.

The effect of surgical decompression on neurologic outcome after lumbar fractures.

From 1980 until 1989, 69 patients with lumbar fractures resulting in incomplete paraparesis were admitted to the authors' medical center for treatment. Thirty had anterior vertebrectomy, including 18 who had posterior instrumentation and four who had anterior instrumentation. Twenty-two patients were treated with a posterolateral decompression and fusion, including four who also required an anterior decompression. Nineteen of the remaining 21 patients required posterior spine instrumentation and fusion only. The American Spinal Injury Association (ASIA) motor index score was determined for each patient pre- and postoperatively and used to compare these three treatment groups. Average follow-up period for the patients was 19 months. The improvement in ASIA motor score for all patients treated with decompression averaged 10 and similar improvement was obtained in those who were treated with posterior decompression (10.2 points). The average improvement in those who had vertebrectomy was 9.9 points. For those who had fusion without decompression, average improvement was 4.2 points. Comparing those patients who were surgically decompressed, either anteriorly or posteriorly, with those patients who only underwent fusion, the difference in neurologic improvement was statistically significant. Neurologic outcome after lumbar fractures is improved by surgical decompression. The neurologic outcome results were similar after anterior and posterior decompression.

Cervical spine fusions for trauma. A long-term radiographic and clinical evaluation.

Ninety-six successful cervical spine fusions performed for trauma, with a minimum of 5 years' follow-up, were retrospectively reviewed. Radiographic degenerative changes adjacent to fusion masses were assessed and correlated with clinical symptoms. The type of fusion, fusion extension, and final kyphosis of the involved segments were also analyzed. Twenty-eight patients had fusion masses aligned in 20 degrees or more of kyphosis. There was a significant increase in complaints of cervical pain in patients with neck fusions equal to or exceeding 20 degrees of kyphosis (P < 0.01). Evidence of mild degenerative changes adjacent to fusion masses was common, but did not correlate with symptoms.

Spinal cord injury from civilian gunshot wounds: the Rancho experience 1980-88.

We performed a retrospective review of the medical records of 316 patients with spinal cord injury (SCI) secondary to gunshot wounds (GSW) admitted to Rancho Los Amigos Medical Center for rehabilitation between 1980 and 1988. There were 289 male and 27 female patients whose mean age was 25.9 years (range, 11-56 years). Of these, 238 were paraplegic (103 incomplete, 135 complete), and 78 were quadriplegic (45 incomplete, 33 complete). Forty were shot by handguns of known caliber and four by shotguns; in 272 cases, the type of weapon was unknown. A total of 230 cases sustained a single bullet wound, and 86 had multiple bullet wounds. The length of acute hospitalization, but not rehabilitation hospital stay, increased with the number of associated injuries. Rehabilitation and, hence, total length of stay was significantly less (mean, 100 and 130 days, respectively) for SCI/GSW victims than for SCI victims of motor vehicle accidents, falls, or diving accidents. The methods of calculating costs for admission were based upon Rancho Los Amigos Medical Center financial statistics. This hospital has charged for a daily occupancy fee. The fee is based upon an average of all charges for all patients. No additional fees are charged for special tests or procedures. In 1980, the average daily admission hospitalization charge was $785. In 1990, the last quoted hospital charge was $1,125. This is for the basic spinal cord injury rehabilitative stay. In general, at Rancho Los Amigos, patients are admitted for rehabilitation when all acute medical and surgical problems have been cleared and the patient is ready to participate in rehabilitation evaluation and therapy programs.(ABSTRACT TRUNCATED AT 250 WORDS)

Outcome after Wiltse pedicle screw removal.

Thirty-five patients were retrospectively reviewed after hardware removal after previous posterior lumbar spinal fusion by using Wiltse pedicle screw fixation. Pseudarthrosis was intraoperatively confirmed in 10 patients. Thirty of 35 patients were reviewed at an average of 17.5 months (range, 6-57 months). Of 30 patients, 30 had persistent back pain that limited activities and lumbar motion. Patients found to have pseudarthroses were significantly more likely to have less pain, use fewer narcotic medications, and have an improved quality of life after reoperation than patients found to have solid fusions. Postsurgical assessment of fusion is difficult, with instrumentation making exploration the most reliable method determining the state of arthrodesis. Accurate preoperative assessment of the fusion mass is the most important factor in deciding whether or not to reoperate on patients after Wiltse pedicle screw arthrodesis of the lumbar spine.

Nonoperative management of upper thoracic spine fractures.

We attempted to determine if nonsurgical treatment could be successful in treating instability of upper thoracic spine fractures, which may receive some stabilization and splinting from the ribs. From 1966 to 1989, the records of all patients treated at Rancho Los Amigos Medical Center for fractures from T-1 to T-8 were reviewed. Penetrating injuries and malignant lesions were excluded. A total of 118 patients were admitted during this period; 49 patients had nonsurgical treatment. Complications included 1 patient with neurologic worsening, brace-related skin necrosis in 8 cases, and deep venous thrombosis in 12 patients. No failure of arthrodesis was noted. Rib fractures did not adversely affect late stability. We conclude that orthotic treatment of thoracic spine instability from T-1 to T-8 can be successful, especially in cases where early surgery is not possible.

Assessment of pseudarthrosis in pedicle screw fusion: a prospective study comparing plain radiographs, flexion/extension radiographs, CT scanning, and bone scintigraphy with operative findings.

Twenty-five consecutive patients who had previously undergone lumbar fusion using stainless steel pedicle screw instrumentation and complained of persistent, severe pain were identified for prospective study. All patients had been scheduled for hardware removal and fusion inspection. Studies to rule out pseudarthrosis included plain radiography, flexion and extension radiography, computed tomography, and bone scintigraphy. Each preoperative radiographic study was then evaluated in a blinded fashion by a single independent radiologist and was determined to show fusion or pseudarthrosis. Each patient then underwent surgery, at which time the pedicle screw instrumentation was removed and the fusion was inspected. Using surgical inspection as absolute evidence of fusion or pseudarthrosis, statistical analysis was undertaken to evaluate the predictive value of the radiographic studies singly and in combination. No statistically significant correlation was found.