Study Design:
Efficacy study.
Objectives:
To elucidate the limitations of radiography in patients with spinal ankylosing disorders (SAD) with an emphasis on thoracolumbar injuries, which have been ...less focused upon.
Methods:
We searched our hospital’s emergency room database for patients who underwent a total spine computed tomography (CT) following a diagnosis of SAD on radiographs following a minor fall. A high-quality presentation containing 50 randomly situated anteroposterior + lateral radiographs was created. Of these, 24 contained a hyperextension type fracture diagnosed by CT. Twelve physicians—4 spine surgeons, 4 senior orthopedic residents and 4 junior orthopedic residents were requested to identify the pathologic radiographs and note the fracture level.
Results:
Fracture diagnosis stood at 65% for the best reader. When examining the different subgroups, the mean rate of diagnosis for spine surgeons was 55% and for orthopedic residents 32%. Mean diagnosis of thoracic fractures was 26%, of lumbar fractures was 55%, and for the entire thoracolumbar spine was 40%. The interobserver agreement (kappa coefficient) was found to be 0.37 for the entire group and 0.39 for spine surgeons. This finding was statistically significant.
Conclusions:
The simple radiograph is an inefficient modality for diagnosis of hyperextension type thoracolumbar fractures in patients with SAD. The poor interobserver agreement rate further amplifies this finding. Advanced imaging is recommended in these patients.
The treatment of patients with spinal ankylosing disorders (SAD) continues to pose a unique challenge for the practitioner. This population is especially susceptible to vertebral column fractures, ...specifically unstable extension type fractures even from minor trauma. An increase in geriatric patients with unstable extension type vertebral fractures may be especially anticipated due to change in patient demographics including an increase in age and prevalence of associated comorbidities. In the geriatric population, studies have shown that early surgery for other injuries such as hip fractures may reduce patient complications and mortality. These studies have changed patient care protocols in many medical centers worldwide.
In this study, we aim to assess the relationship between the timing of surgery for vertebral fractures in this population and patient complications, rehospitalization rates, length of hospital stays and mortality.
Retrospective cohort study.
Patients included were those diagnosed with thoracolumbar extension type fractures and a SAD, over 65 years old, following minor trauma and with no prior spinal instrumentation.
Patient complications, surgical site infections, rehospitalization rates, length of hospital stays and perioperative mortality.
We searched our department's database for all patients that met our inclusion criteria. Difference in patient outcomes that underwent early surgery of less than 72 hours from diagnosis as opposed to those that underwent later surgery was assessed.
A total of 85 patients were diagnosed with extension type thoracolumbar fractures at our institution between 2016-2020. Of these, 47 met the inclusion criteria for this study. Nineteen patients underwent surgery less than 72 hours from diagnosis and 28 more than 72 hours from diagnosis. No difference was found in age and Elixhauser comorbidity scores between the groups. A statistically significant difference in perioperative patient complications between the early and the late groups (p=0.0003) was found. There was no statistically significant difference between the groups when comparing surgical site infections, length of hospital stay, rehospitalization within a month and perioperative mortality.
Time to surgery may affect complication rates in patients of the elderly population with spinal ankylosing disorders presenting with unstable hyperextension type thoracolumbar fractures. Early surgery in this patient population should be considered.
This abstract does not discuss or include any applicable devices or drugs.
•This study evaluates the effect of early surgery on elderly patients which present with unstable extension type fractures following minor trauma.•Delay of surgery (>72 hours) in geriatric patients ...presenting with an unstable extension type thoracolumbar fracture may cause an increase in medical complications and mortality at 6 months.
The management of trauma patients with ankylosing spinal disorders has become an issue of increasing interest. Geriatric patients frequently sustain unstable extension type vertebral fractures with ankylosed spines. In this population, studies have shown that early surgery for other injuries such as hip fractures may reduce patient complications and mortality. These studies have changed patient care protocols in many medical centers worldwide.
We aim to assess the relationship between the timing of surgery for unstable vertebral fractures in ankylosed spines in the geriatric population and patient outcomes.
Retrospective clinical study conducted in a tertiary hospital.
Patients included were those diagnosed with isolated thoracolumbar extension type fractures and a spinal ankylosing disorder over 65 years old following minor trauma and with no additional injuries or neurological deficit.
Primary outcome measures included postoperative medical complications and mortality at 1 and 6 months. Secondary outcome measures included rehospitalization rates, length of stay, and surgical site infections.
We searched our department's database for all that met our inclusion criteria who underwent surgery. The difference in patient outcomes that underwent early surgery defined as less than 72 hours from diagnosis as opposed to those that underwent later surgery was assessed.
A total of 82 patients underwent surgery following a diagnosis of an extension type thoracolumbar fracture at our institution between 2015 and 2021. Of these, 50 met inclusion criteria. Nineteen patients underwent surgery less than 72 hours from diagnosis and 31 more than 72 hours from diagnosis. No difference was found in age, functional status, and Elixhauser comorbidity scores between the groups. A statistically significant difference in perioperative patient complications between the early and the late groups (p=.005) was found. Mortality at six-months was significantly different between the groups as well (p=.035). There was no statistically significant difference between the groups when comparing surgical site infections, length of hospital stay, rehospitalization within a month, and perioperative mortality.
Time to surgery affects complication rates and six-month mortality in geriatric patients with spinal ankylosing disorders presenting with an isolated unstable hyperextension type thoracolumbar fracture. Early surgery of less than 72 hours from presentation in this patient population is recommended.
To compare the reduction quality, surgery time, and early postoperative complications between the 2 following surgical approaches: the ilioinguinal and the anterior intrapelvic (AIP or modified ...Rives-Stoppa).
Retrospective study.
Comparison of 122 patients operated in our center between 1996 and 2003 with the ilioinguinal approach and 103 cases operated between 2004 and 2011 with the AIP approach.
Level 1 trauma center, acetabular fracture surgery referral center.
The patients' demographics, fracture type, fracture reduction quality, surgery time, and postoperative complications were compared.
Anatomic reduction was achieved in 84 patients (68.9%) treated by the ilioinguinal approach and in 85 patients (82.5%) treated by the AIP approach (P = 0.018). In both the columns, acetabular fracture type anatomic reduction was achieved in 54.2% of the ilioinguinal group and 79.4% of the AIP group (P = 0.018). In the ilioinguinal group, surgery time decreased as the number of surgeries increased (P = 0.021), whereas a similar trend was not found in the AIP group. Fracture type distribution and complication rates were similar for both the groups.
The AIP approach is a safe alternative that offers better exposure and possibly improved reduction quality of acetabular fractures compared with the ilioinguinal approach. We believe that the major advantage of the AIP approach is that it enables reduction of the posterior column and the quadrilateral plate from the contralateral side and enables application of a buttress plate below the pelvic brim.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Aim
We aimed to evaluate the risk of developing adolescent scoliosis among recipients of recombinant human growth hormone (rhGH).
Methods
This registry‐based cohort study included 1314 individuals ...who initiated rhGH treatment since 2013, treated during 10–18 years of age for at least 6 months. This group was matched to a comparison group of 6570 individuals not treated with rhGH. Demographic and clinical information was extracted from the electronic database. The results are presented using hazard ratios (HR) and 95% confidence intervals (CI).
Results
During a median follow‐up of 4.2 years, 59 (4.5%) rhGH recipients and 141 individuals (2.1%) from the comparison group were diagnosed with adolescent scoliosis. The age at diagnosis did not differ between the groups (14.7 versus 14.3 years, p = 0.095). Patients treated with rhGH were more likely diagnosed with scoliosis (HR 2.12, 95% CI 1.55–2.88, p < 0.001). Among males, the risk was about three times greater in the treated versus the comparison group (HR 3.15, 95% CI 2.12–4.68, p < 0.001), while in females the risk was not increased (HR 1.12, 95% CI 0.72–2.04, p = 0.469).
Conclusions
Recombinant human growth hormone treatment was associated with an increased risk to be diagnosed with adolescent scoliosis in males. Scoliosis development should be monitored appropriately in rhGH recipients.
Proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) are a well-recognized, yet incompletely defined, complication of adult spinal deformity surgery. There is no standardized ...definition for PJK, but most studies describe PJK as an increase in the proximal junctional angle (PJA) of greater than 10°–20°. “Soft landing” is a novel strategy for PJK reduction by creating a gradual transition from a rigid segmental construct to the native spine at the top of the construct while reducing junctional stress at those levels.
To determine if the “soft landing" strategy, when applied in adult spinal deformity, will decrease the rate of PJF.
Retrospective consecutive series.
Thirty-six consecutive series of adult spinal deformity patients at a single institution.
Rate of proximal junctional failure (PJF).
In this study, “soft landing” was used in a 36 consecutive series of adult spinal deformity patients at a single institution. Patient demographics, including age, sex, indication for surgery, revision surgery, surgical approach and use of osteotomies and vertebroplasty were collected. The PJA, global sagittal alignment (TPA, SVA) and spinopelvic parameters (PI,PT,SS) were measured preoperatively and at last follow-up using 36-inch radiographs. Data on change in PJA and need for revision surgery were collected. Univariate and multivariate analyses were performed to identify factors associated with change in PJA and proximal junctional failure (PJF), defined as PJK requiring surgical correction.
A total of 36 consecutive patients were included: The mean age of the cohort was 60 years, and 92% of patients were women. Over half of these cases (58%) were revision surgeries, with 67% involving a combined anterior or lateral and posterior approach. The mean change in PJA was 11.4°; 22 patients had a change of less than 10°. Thirteen patients had a change in PJA of 10°–20°, and 1 patient had a change in PJA of greater than 20°. Reoperation was performed in 8 cases (22%); however, only 2 (∼6%) were for PJF.
Our study demonstrates the “soft landing" strategy decreases the rate of PJF, with only 6% of cases requiring reoperation for a structural failure.
This abstract does not discuss or include any applicable devices or drugs.
This was a retrospective case series.
The objective of this study was to discuss the treatment challenges in scoliosis patients with Rett syndrome (RTT) in a national referral centre for RTT. We ...describe structural characteristics of curves, age of onset, genetic mutation, ambulation status, and treatment through RTT progression. Based on this unique experience, we aimed to suggest guidelines for scoliosis treatment in RTT patients.
RTT is a neurodevelopmental disorder associated with a mutation in the methyl-CpG binding protein 2 (MECP2) gene, primarily in females with significant features of growth failure, gastrointestinal and pulmonary dysfunction, ataxia, seizures, and intellectual disability. Scoliosis is the most common orthopedic manifestation of RTT and is present in 64%-75% of patients. No clear guidelines for scoliosis treatment in RTT are available, and typically patients are treated according to guidelines of another neuromuscular scoliosis.
Clinical and radiographic data were gathered, including MECP2 mutation type, scoliosis characteristics, preoperative treatment, surgical treatment, functional status, and postoperative follow-up.
Our cohort included 102 patients with RTT. They were 36 who presented with scoliosis; 18 were treated surgically. C-curve was found in 17 patients and S-type in 19. Scoliosis treatment onset was 8.76 years in the C-type group and 13.88 years in the S-type group. The average curve at the time of surgery was 52.42 degrees. The average time until surgery was 2.44 years. Seventeen patients underwent posterior spinal fusion, and 1 patient underwent posterior spinal fusion+anterior spinal fusion with an average correction of 40 degrees. The most common mutation was R255X nucleotide (30% of cases). The most severe curves had mutations R168X and R270X nucleotides.
We advise early monitoring for patients with RTT and scoliosis due to early and rapid progression. Common mutations found were R255X, R168X, R270X, and T158M. We recommend surgical treatment in every curve above 45 degrees, independently of age.
Symptomatic pseudoarthrosis after transforaminal lumbar interbody fusion (TLIF) could result in sagittal malalignment. Revision posterior surgery with TLIF cage removal poses a challenge ...intraoperatively. The authors have proposed salvage anterior approach for cage removal and have discussed unique experience with the correction in their deformity patients.
All patients with symptoms of clinical deformity or symptomatic pseudoarthrosis operated from January of 2012 to February of 2018 were included in the study. TLIF cage removal followed by anterior lumbar interbody fusion (ALIF) surgery was performed in all patients. Radiographic sagittal parameters including thoracic kyphosis (TK; T4-T12), sagittal vertical axis (SVA), T1 pelvic angle (TPA), lumbar lordosis (LL), the mismatch between pelvic incidence (PI) and LL (PI-LL), sacral slope (SS), pelvic tilt (PT), and PI were analyzed.
6 patients (mean age of 57 years, 83% female) underwent TLIF retrieval through anterior approach and ALIF with hyperlordotic cages (HLCs), followed by posterior spinal fusion surgery. Described technique entails use of tailored instruments with sequential gentle distraction of end plates with TLIF spreader could facilitate in the cage removal. Mean number of interbody levels fused pre as well as post were 1.5. The radiographic sagittal parameters from preoperative versus postoperative standing were as follows: T4-T12 TK, 16° vs. 37.6°; LL, -25° vs. -47.6°; PT, 36° vs. 26°; PI-LL, 35° vs. 12.4°; SVA, 12° vs. 5.6°; and TPA, 44° vs. 25°, with p<.001. Mean number of instrumented level fused were 8.1. Using linear regression analysis, change from pre-to postoperative standing in LL predicted pre-to postoperative change in SVA and TPA for global correction (R= -0.30 and -0.80, respectively).
Anterior approach is a suitable technique for TLIF cage removal while preserving the end plates for subsequent optimal interbody fusion at the index level in symptomatic pseudoarthrosis patients or those with clinical deformity. ALIF with HLCs with or without Ponte osteotomy can restore segmental and overall sagittal alignment.
Purpose
In adolescent idiopathic scoliosis (AIS), the rib prominence is a major cosmetic concern which can be improved using thoracoplasties. We sought to determine if the use of deep drains helps ...minimize the development of pleural effusions after thoracoplasties.
Methods
Retrospective study of 45 patients with AIS undergoing posterior spinal fusion (PSF) and thoracoplasties.
Results
Thirty six out of 45 patients (80.0%) required placement of a deep surgical drain, and 16 out of 45 (35.6%) developed pleural effusions after PSF with concomitant thoracoplasty. Of the 16 patients who developed pleural effusion, 12 of 36 (33.3%) required a placement of a deep drain (
p
> 0.05). Of the total 45 patients in this cohort, 3 patients (6.7%) required chest tubes, and 4 patients (8.9%) developed surgical site infections (SSIs). We found that deep drains were associated with a lower incidence of SSI (2.8% vs 33.3%;
p
= 0.021). Patients who had a pleural effusion had longer ICU stays (
p
= 0.037) and longer requirements of nasal oxygen (
p
= 0.025).
Discussion
The presence of a pleural effusion in patients with AIS undergoing PSF with thoracoplasty was associated with longer oxygen requirements and length of hospital ICU admission. Thirty six percent of patients with thoracoplasties developed pleural effusions, but deep subfascial drains did not significantly decrease the incidence of pleural effusions.
Background: Studying a specific illness could lead medical students to an incorrect interpretation of certain physical symptoms, so that symptoms which were previously considered normal are now ...regarded as a true sign of an illness.
Aim: To examine the appraisal of self-health state, the existing fear of morbidity and the level of health-related anxiety among medical students throughout medical school.
Methods: Anonymous questionnaires were distributed to first through sixth year medical students at the Tel-Aviv University Medical School. The questionnaires were distributed to all the students who were present on the study days.
Results: We observed a significant rise in the emotional-distress process with entering the clinical years followed by a significant decrease later on. Similar pattern was seen in health anxiety and in preoccupation with and fear of illness and death. While the perceptual-cognitive process increased gradually, there was no change in interference with life scores.
Conclusion: "Medical student's disease" should be regarded as a phenomenon depending on the years of learning. By breaking it down into its components, one can better characterize it and predict its onset. By defining it as a normal process, one can assist in guiding medical students to reduce their level of anxiety and distress.
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