Impact of radiologic variables on item responses of ODI, SRS22 and SF-36. in adult spinal deformity patients: differential item functioning (DIF) analysis results from a multi-center database.

PURPOSE: To determine if responses given to each question of the Scoliosis Research Society-22 (SRS22), Oswestry disability index (ODI) and Short Form-36 (SF-36) questionnaires are influenced by the radiological parameters. METHODS: Patients enrolled in a multi-centre prospectively collected adult spinal deformity database who had complete SRS22, ODI and SF-36 data at baseline and at one-year follow-up were analysed. The presence of a differential item function of each question within each score in relation to radiological parameters was analysed using a mixed Rasch model with the radiological threshold value(s) determined. RESULTS: Of those patients analysed (n = 1745; 1406 female, average age 51.0 ± 19.8 years), 944 were surgically and 801 were non-surgically treated. For the SRS22, questions (Q) 3, 5 and 18 were sensitive to almost all radiological parameters and the overall score was found sensitive to the Cobb angle. For the ODI, Q3, 6, 9 and 10 were not sensitive to any radiologic parameters whereas Q4 and 5 were sensitive to most. In contrast, only 3 of the SF-36 items were sensitive to radiological parameters. CONCLUSIONS: 78% of the SRS-22, 60% of the ODI and 8% of the questions in the SF-36 are sensitive to radiological parameters. Sagittal imbalance is independently associated with a poor overall outcome, but affects mental status and function more than pain and self-image. The assembly of questions responsive to radiological parameters may be useful in establishing a connection between changes in radiologic parameters and HRQL.

The Impact of Corrective Surgery on Health-Related Quality of Life Subclasses in Adult Scoliosis: Will Degree of Correction Prognosticate Degree of Improvement?

PURPOSE: Objectives in scoliosis corrective surgery include restoration of normal sagittal and coronal parameters to achieve patient satisfaction. HRQLs improvements remain limited after corrective surgery. The aim of this study was to evaluate the HRQL subclass variability specific to the sagittal and coronal correction in adult scoliosis surgery. METHODS: This multi-centre prospective analysis of consecutive adult spinal deformity (ASD) patients, from five European centres, only included multilevel instrumentation for scoliosis. d-(delta) values for each parameter represented pre to post-operative changes. Parameters included demographics, baseline, 1- and 2-year. HRQL outcomes (Oswestry disability index (ODI), Scoliosis Research Society (SRS)-22 and Short Form (SF36)), sagittal correction including relative spinopelvic alignment (dRSA) and coronal correction including major Cobb (dCobb) angles. RESULTS: A total of 353 patients reached 1-year and 2-year follow up. All HRQL total scores significantly improved postoperatively, including ODI, SRS-22 and SF36. HRQL subclasses which displayed persistent improvements correlated to dRSA included sex-life, self-image, fatigue, vitality, social functioning. The only HRQL subclass improvement that correlated with dCobb was self-image. CONCLUSION: Adult scoliosis surgery improves overall HRQL, having a minimal effect on each variable. Importantly, greater coronal deformity correction affects only greater self-image scores, whereas with greater sagittal correction there are many greater HRQL sub-class impacts. Correction and restoration of coronal balance is one of the surgical goals in adult scoliosis but the degree to which Cobb angle is corrected, apart from self-image, does not correlate with gains in sub-classes of HRQL. These results need to be taken into account when planning surgery.

Erratum to: Delayed post-operative tension pneumocephalus and pneumorrhachis.

Unfortunately, two author names were missed out in author group of the original publication.

Delayed post-operative tension pneumocephalus and pneumorrhachis.

INTRODUCTION: The incidence of pneumocephalus and pneumorrhachis after spinal surgery is unknown, with a paucity of literature on this complication. MATERIALS AND METHODS: We present the first published case of delayed onset tension pneumocephalus and pneumorrhachis associated with spinal surgery. RESULTS: This complication occurred from a cerebro-spinal fluid (CSF) leak after posterior instrumentation removal and was successfully treated with emergent wound debridement and the formation of a CSF fistula. CONCLUSIONS: This case illustrates that delayed post-operative tension pneumocephalus and pneumorrhachis can occur after spinal surgery in a patient with a CSF leak. It also illustrates that pneumocephalus and pneumorrhachis can be easily diagnosed with cross-sectional CT imaging. Furthermore, in a patient with rapid deterioration emergent surgical debridement may be necessary. Lastly, if the dural tear cannot be identified intra-operatively, the formalization of a CSF fistula should be considered.

Trends in fractures and fatalities of farmyard injuries in Ireland: a 10 year analysis.

The farming and agricultural sector remains one of Ireland's primary industries. Fatality rates remain higher than the European average. The aim of this study was to analyze the national trend in hospital in-patient admissions for farmyard related fractures and related fatalities in Ireland from 2005 to 2014. Relevant socioeconomic trends were used for comparison. There were 2,064 farm-related fractures and 187 fatalities recorded over the same period. Despite a decrease in incidence of farmyard fractures over 2005-2014, fatality rates have increased indicating the alarming continued occupational hazards and severity of sustained injuries.

Anterior spinal fusion (ALIF/OLIF/LLIF) with lumbosacral transitional vertebra: A systematic review and proposed treatment algorithm.

•Key anterior approaches differences in LSTV include vascular (aortic bifurcation/iliocaval confluence), muscular (psoas) and osseus anatomy (inter-crestal tangent/pubic symphysis), when compared to non-LSTV.•There are increased surgical deviations but not significantly greater complications for anterior approaches in LSTV.•Vascular awareness while accessing L45 will be in the presence of a more cephalad ABF and ICC with sacralized L5, and access to the deeper L56 level will be in the presence of a more caudal ABF and ICC in lumbarized S1.

A qualitative study exploring perceptions and experiences of patients and clinicians of palliative medicine outpatient clinics in different settings.

Palliative care exists in a variety of settings and palliative care teams form many guises within this. A Palliative Medicine Outpatient Clinic (PMOC) exists to meet the flexible provision of the needs and preferences of individuals within whatever care setting they reside. This explorative study used a qualitative methodology, capturing patients' actual experience of care in preference to their satisfaction, as this is a more accurate measure of how and what patients judge as important in their healthcare. The overall themes in this paper point to the 'value' that patients perceived from attending the PMOC and how important the clinics were to clinicians that provided the care. The clinic facilitates much more than symptom control and here lies the challenge in how we convert the very positive experience of individuals into a language of outcome measures that captures the 'essence' of our work in this fiscally driven health economy.

'Ready-access' CT imaging for an orthopaedic trauma clinic.

'Ready-Access' to CT imaging facilities in Orthopaedic Trauma Clinics is not a standard facility. This facility has been available at the regional trauma unit, in Merlin Park Hospital, Galway for the past four years. We reviewed the use of this facility over a 2-year period when 100 patients had CT scans as part of their trauma clinic assessment. The rate of CT scan per clinic was 0.6. The mean waiting time for a CT scan was 30 minutes. 20 (20%) new fractures were confirmed, 33 (33%) fractures were out-ruled, 25 (25%) fractures demonstrated additional information and 8 (8%) had additional fractures. 20 (20%) patients were discharged and 12 (12%) patients were admitted as a result of the CT scan. It adds little time and cost to CT scanning lists.

Impact of COVID-19 on the pain and disability of patients with adult spinal deformity.

PURPOSE: To evaluate the pain and functional effect of the COVID-19 pandemic on patients with ASD reflected by their response to SRS-22, ODI, and SF-36 questionnaires. METHODS: Patients who had stable pain and functional outcome scores over the preceding 2 years were enrolled in a local prospectively collected adult spinal deformity (ASD) database. A reanalysis of their SRS22, ODI and SF-36 data 14 days into confinement were compared to their last pre-confinement scores. RESULTS: 89 patients were included in this study (average age 60.7 years, 91% female) with an average time from last FU until confinement of 9.6 months. The ODI total score worsened by 5 points post-confinement with no difference seen in personal care, walking and social life. In contrast, the SRS-22 score showed small improvements in function/activity and satisfaction, but no significant differences for the other domains. Similarly, the SF-36 showed small improvements in physical function, physical and emotional role, vitality and PCS. CONCLUSION: The global COVID-19 pandemic and ensuing confinement had variable overall effects on ASD patients, without the expected marked worsening. In addition, this study illustrates that the SRS-22 questionnaire is less influenced by environmental and psychological factors than the ODI supporting its objectivity and accuracy in the evaluation of the QoL of ASD patients.

Thromboembolism prophylaxis practices in orthopaedic arthroplasty patients.

Thromboembolic events are a post-operative complication of arthroplasty surgery for up to 3 months. The incidence however, is not fully known. Some form of prophylaxis should be provided to all arthroplasty patients. Clinicians are wary of side effects, compliance profile and the associated cost. The objective of this study is to investigate practice patterns and their relevance to 3 risk groups. Ninety questionnaires were sent to orthopaedic surgeons with 3 hypothetical clinical scenarios and 10 prophylaxis regimes for thromboembolism across different risk groups. The response rate was 81/90 (90%). The most popular options in all 3 cases were early mobilisation, thrombo-embolism deterrant (TED) stockings and low molecular weight heparin (LMWH) (51/81, 62% of all cases). An inconsistent relationship exists between preferred practice and relevant guidelines. Preferred practice does not correlate with each level of risk.

Validation of a Simplified SRS-Schwab Classification Using a Sagittal Modifier.

STUDY DESIGN: Multicenter, prospective study of consecutive adult spinal deformity (ASD) patients. OBJECTIVE: To Validate Schwab's classification accuracy for surgical indication, and to evaluate a simplified sagittal modifier. SUMMARY OF BACKGROUND DATA: The SRS-Schwab Radiologic Classification based on clinical impact parameters, offers 27 different sagittal classification possibilities regarding sagittal vertical alignment (SVA), pelvic tilt (PT), and pelvic incidence-lumbar lordosis (PI-LL). The high number of classification possibilities makes it complex to use. METHODS: Inclusion criteria were ASD patients, presenting at least 1 criteria: Cobb ≥ 20°, SVA ≥ 5 cm, thoracic kyphosis ≥ 60°, or PT ≥ 25°. A total of 1,004 patients (410 nonoperative and 594 operative) were classified regarding SVA, PT, and PI-LL (0, +, ++), and 27 possibilities were identified. Categories were formed by adding the number of + signs, considering PT, SVA, and PI-LL. Three specific categories were identified: Aligned: 0 +; Moderate deformity: 1 to 3+; and Severe deformity: 4 to 6+. A χ-square test was performed for surgical indication (operated or not) and an analysis of variance was performed to evaluate the relationship between categories and Oswestry Disability Index (ODI). Probability <.05 was considered significant. RESULTS: Significant differences for HRQoL scores and surgical indication were found in the 27 sagittal parameter possibilities. For nonoperative patients, 230 (56.1%) were classified as aligned, 145 (35.4%) as moderate, and 35 (8.5%) as severe. For operative patients, there were 200 (33.7%), 215 (36.2%), and 179 (30.1%) in each respective subgroup. For HRQoL scores and surgical indication, no significant differences were found within each category, but significant differences were found when comparing the subgroups. CONCLUSIONS: Despite the correlation between SRS-Schwab classification and surgical indication, it is complex to use, with a total of 27 possibilities regarding sagittal modifiers. This simplification into three categories offers more readability, without losing any significant information, and could replace Schwab sagittal modifiers. In association with other parameters, they could be used for decision-making. LEVEL OF EVIDENCE: Level II.

Cervical spine fracture through a cervical disc replacement.

INTRODUCTION: We report a rare case of cervical spine trauma through a cervical disc replacement and adjacent multilevel disc fusions. Cervical disc replacement (CDR) is a viable option for the surgical treatment of degenerative disc disease however long term follow up data regarding this operative technique is poor specifically relating to traumatic complications. We know of no previous reports of bilateral cervical pedicle fractures occurring adjacent to CDR and anterior cervical spine instrumentation. PRESENTATION OF CASE: A 46 year-old with a history of C6C7 CDR and C4-6 anterior cervical decompression and fusion was an unrestrained driver involved in a road traffic accident and suffered bilateral C7 pedicle fractures and a right C6C7 facet joint fracture-subluxation without neurological deficit. Reduction and fixation via a posterior approach achieved a satisfactory alignment and the patient made an uneventful recovery. DISCUSSION: A significant force coupled with cervical fixation resulted in a bilateral pedicle fracture of the cervical spine with preserved neurological function. CONCLUSION: The protective role of the CDR has not been previously demonstrated but may have played a role in this case. The authors believe the challenges encountered in the treatment of this patient provide valuable lessons in the management of complex cervical spine trauma in the setting of previous instrumentation.

Simultaneous bilateral total hip arthroplasties in nonagenarians.

Total hip arthroplasty (THA) is an effective and durable treatment option for hip osteoarthritis (OA). As life expectancy continues to increase, so too will the demand for joint arthroplasty in the 10th decade of life, frequently in cases involving osteoarthritis of both hips. Simultaneous bilateral total hip arthroplasty (SBTHA) is a valuable therapeutic option in appropriately selected patients with bilateral degenerative hip disease, although its use in the very elderly is poorly reported on in the literature. A case of bilateral hip OA successfully treated with SBTHA in a nonagenarian is presented and the literature is reviewed.

Effect of sulfhydryl reagents and protease inhibitors on sodium dodecyl sulfate-heat induced dissociation of Ricinus communis agglutinin.

Ricinus communis agglutinin dissociated to lower molecular weight forms when heated in sodium dodecyl sulfate in the absence of reducing agents, while ricin was little affected by such treatment. The data suggest that strong noncovalent bonds hold together two A-B heterodimers in the Ricinus communis agglutinin tetramer. Protease inhibitors such as diisopropylfluorophosphate, phenylmethansefulonyl fluoride, and EDTA, did not prevent the sodium dodecyl sulfate-heat induced dissociation; however, sulfhydryl specific reagents (N-ethylmaleimide, 5,5'-dithiobis (2-nitrobenzoic acid) and p-chloromercuribenzoate) were effective. Titration of the lectins in sodium dodecyl sulfate indicated that ricin contains one sulfhydryl and Ricinus communis agglutinin four sulfhydryl groups, none of which react in the presence of 8 M urea. The sulfhydryl groups that could be titrated in the intact proteins in sodium dodecyl sulfate were on the A chains.

The contribution of I-Abm12 to the production of autoantibodies to dsDNA.

The development of IgG autoantibodies to dsDNA in NZBxNZW F1 (NZB/W) and NZBxSWR F1 (SNF1) mice have been linked to specific alleles of MHC class II genes contributed by the NZW and SWR parents respectively. Recently, our laboratory has shown that the introduction of the bm12 mutation into NZB mice (NZB.H-2bm12) results in mice which are phenotypically similar to NZB/W F1 mice and, in particular, develop IgG anti-dsDNA antibodies. A variety of immune abnormalities have been described in autoimmune NZB (H-2d) mice. It is, however, unclear at present, whether all these abnormalities are due to the influence or effect of a single set of linked genes or due to multiple genes. It was reasoned that NZB.H-2bm12 mice provide a unique opportunity to examine this issue. Specifically, we bred a series of five different F1 colonies of mice: (a) NZB.H-2bm12/b F1; (b) NZB.H-2bm12/d F1; (c) NZB-H-2b/d F1; (d) NZB-H-2bm12 x B6.C-2bm12 F1 (NZB/B6.H-2bm12 F1); and (e) NZB x B6.C-H-2bm12 F1 (NZB/B6.H-2d/bm12 F1) mice. All groups of mice were serially followed for the appearance of IgM and IgG anti-ssDNA and anti-dsDNA antibodies, splenic CFU-B, spontaneous secretion of IgM, FMF analysis, proteinuria and survival. We report herein that H-2bm12 genes have a dominant influence on the appearance of IgG anti-dsDNA antibodies. In contrast, antibodies to ssDNA, IgM secreting cells, CFU-B and Ly-1 B cells are linked to genes from the NZB background. Finally, we particularly note an absence of IgG antibodies to dsDNA in NZB-H-2b/d F1 mice.

Ionic binding characteristics of monoclonal autoantibodies to DNA from NZB.H-2bm12 mice.

NZB (H-2d) mice are well known for the production of IgM autoantibodies to ssDNA. However, an F1 cross between NZB and either NZW or SWR mice is required to produce IgG nephritogenic antibodies to dsDNA and glomerulonephritis. The contribution of parental class II loci in the hybrid mice is clearly important to the development of anti-dsDNA antibodies. In contrast, NZB mice congenic with the Iabm12 mutation develop IgG autoantibodies to dsDNA despite being homozygous for Ia. As a part of our effort to examine the mechanisms of disease development in NZB.H-2bm12 mice, we have generated a panel of monoclonal antibodies against nucleic acids. A subgroup of these antibodies exhibited strong electrostatic interaction with nucleic acids as evidenced by inhibition of their binding by a moderate increase in ionic strength. Interestingly, the effect of salt was either all or none; e.g., antibodies were either markedly inhibited or virtually unaffected. The importance of this ionic interaction was highlighted by analysis of DNA binding of antibodies from serum and nephritic kidneys of NZB.H-2bm12 mice. Antibodies specific for ssDNA, which are common in NZB mice and not associated with nephritic lupus, are largely unaffected by salt. However, serum and kidney eluted IgG antibodies specific for dsDNA were markedly inhibited by salt. We postulate that B cell clones whose antibodies exhibit electrostatic interaction with DNA are preferentially expanded during the course of lupus in NZB.H-2bm12 mice and that such antibodies contribute significantly to glomerulonephritis.

Operationalizing a comprehensive neurobehavioral plan.

The formulation and implementation of a workable and effective plan of care for the complex rehabilitation patient are nursing challenges. Even more challenging, however, is putting the plan into operation over a 24-hour period. Staffing variations, patients' circadian rhythms, and visiting hours are only a few of the factors that require consideration when formulating a viable plan of care. The purpose of this article is to discuss strategies that have been effective in providing consistent, safe, therapeutic care for the patient population on a 39-bed neurobehavioral unit that treats mostly individuals with traumatic brain injuries.

Potential triggers for the holistic assessment of people with severe chronic obstructive pulmonary disease: analysis of multiperspective, serial qualitative interviews.

OBJECTIVES: This study explores the narrative accounts of chronic obstructive pulmonary disease (COPD) to identify events that potentially could act as triggers for provision of supportive and palliative care. Trigger events must have meaning for the patient/carer, be visible to professionals, and have value in provoking useful actions. METHODS: A purposive sample of people with severe COPD, and their informal and professional carers, was recruited from primary/secondary care in Scotland. Indepth participant-led interviews allowed people to tell their illness story. Events occurring throughout the individual's account of the COPD journey were identified, and analysed thematically with regard to the meaning, visibility and use as potential triggers. RESULTS: Events identified from 92 transcripts (21 patients, 13 family carers, 18 professionals) punctuated the disease trajectory and crossed multiprofessional boundaries of care. These reflected advancing disease (increasing carer burden, becoming housebound, appointment frequency, increasing burden of disease, shifting priorities of care) or were an intervention addressing the consequences of advancing disease (requesting disabled parking, home adaptations, hospital admissions). Despite being meaningful in terms of increasing disability, many were invisible to professionals. Others were isolated events symptomatic of wider, ongoing disability which could potentially have use as triggers. CONCLUSIONS: Meaningful events can be identified within the story of COPD which reflect wider needs, are clearly visible to alert professionals, and be of use in terms of potentially guiding supportive interventions. To achieve this level of usefulness, services will need to promote health and social care integration with clear processes to facilitate holistic assessment when a trigger is detected.

Cementing techniques for the tibial component in primary total knee replacement.

The optimum cementing technique for the tibial component in cemented primary total knee replacement (TKR) remains controversial. The technique of cementing, the volume of cement and the penetration are largely dependent on the operator, and hence large variations can occur. Clinical, experimental and computational studies have been performed, with conflicting results. Early implant migration is an indication of loosening. Aseptic loosening is the most common cause of failure in primary TKR and is the product of several factors. Sufficient penetration of cement has been shown to increase implant stability. This review discusses the relevant literature regarding all aspects of the cementing of the tibial component at primary TKR.