Abstract

Our previous rat study demonstrated an ex vivo-created “Biomimetic Hematoma” (BH) that mimics the intrinsic structural properties of normal fracture hematoma, consistently and efficiently enhanced the healing of large bone defects at extremely low doses of rhBMP-2 (0.33 μg). The aim of this study was to determine if an extremely low dose of rhBMP-2 delivered within BH can efficiently heal large bone defects in goats.

Goat 2.5 cm tibial defects were stabilized with circular fixators, and divided into groups (n=2-3): 2.1 mg rhBMP-2 delivered on an absorbable collagen sponge (ACS); 52.5 μg rhBMP-2 delivered within BH; and an empty group. BH was created using autologous blood with a mixture of calcium and thrombin at specific concentrations. Healing was monitored with X-rays. After 8 weeks, femurs were assessed using microCT.

Using 2.1 mg on ACS was sufficient to heal 2.5 cm bone defects. Empty defects resulted in a nonunion after 8 weeks. Radiographic evaluation showed earlier and more robust callus formation with 97.5 % (52.5 μg) less of rhBMP-2 delivered within the BH, and all tibias were fully bridged at 3 weeks. The bone mineral density was significantly higher in defects treated with BH than with ACS. Defects in the BH group had smaller amounts of intramedullary and cortical trabeculation compared to the ACS group, indicating advanced remodeling.

The results confirm that the delivery of rhBMP-2 within the BH was much more efficient than on an ACS. Not only did the large bone defects heal consistently with a 40x lower dose of rhBMP-2, but the quality of the defect regeneration was also superior in the BH group. These findings should significantly influence how rhBMP-2 is delivered clinically to maximize the regenerative capacity of bone healing while minimizing the dose required, thereby reducing the risk of adverse effects.

Electrical stimulators are commonly used to accelerate fracture healing, resolve nonunions or delayed unions, and to promote spinal fusion. The efficacy of electrical stimulator treatment, however, remains uncertain. We conducted a meta-analysis of randomised sham-controlled trials to establish the effectiveness of electrical stimulation for bone healing.

We searched MEDLINE, EMBASE, CINAHL and Cochrane Central to identify all randomised sham-controlled trials evaluating electrical stimulators in patients with acute fractures, non-union, delayed union, osteotomy healing or spinal fusion, published up to February 2015. Our outcomes were radiographic nonunion, patient-reported pain and self-reported function. Two reviewers independently assessed eligibility and risk of bias, performed data extraction, and rated overall confidence in the effect estimates according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

Fifteen randomised trials met our inclusion criteria. Electrical stimulation reduced the relative risk of radiographic nonunion or persistent nonunion by 35% (95%CI 19% to 47%; 15 trials; 1247 patients; number needed to treat = 7; p < 0.01; moderate certainty). Electrical stimulation also showed a significant reduction in patient-reported pain (Mean Difference (MD) on the 100-millimeter visual analogue scale = −7.67; 95% CI −13.92 to −1.43; 4 trials; 195 patients; p = 0.02; moderate certainty). Limited functional outcome data showed no difference with electrical stimulation (MD −0.88; 95% CI −6.63 to 4.87; 2 trials; 316 patients; p = 0.76; low certainty).

Patients treated with electrical stimulation as an adjunct for bone healing have a reduced risk of radiographic nonunion or persistent nonunion and less pain; functional outcome data are limited and requires increased focus in future trials.

The hook screw method is a direct repair technique that permits ‘restitutio ad integrum’ for a functional segment. The surgical method of treating spondylolysis and grade 1 spondylolisthesis by spondylytic hook screw reduction and bone grafting in 34 patients is reported. Of these patients, 32 showed good to excellent results.

Arthritis may cause mild to moderate pain at rest, joint stiffness and varus or valgus deformity. This may prevent a person from working or prevent them from sitting cross-legged, squatting, climbing the stairs or walking distances. The role of osteotomy have been studied. One hundred cases were performed over a 5 year period and the results were evaluated.

There were 44 men and 56 women. The majority were sedentary workers. The majority of the patients had symptoms for between 1 and 2 years. Pain was mostly located on the medial side and there was no pre-operative feeling of instability. The pre-operative range of movement was between 90–120 degrees in 68% of cases.

In 20 cases, a dome osteotomy was performed. In 80 cases a wedge osteotomy: 75 cases were valgus osteotomy and 5 cases by varus osteotomy. All patients benefited from surgery as regards the relief of pain. Very old and obese patients showed poor results after surgery due to their inability to do the required physiotherapy. The patients having a shorter duration of symptoms showed greater radiographic improvement than those with a longer duration of symptoms.

The patients with 1–10 of postoperative valgus alignment obtained the most pain relief and a good range of motion. Over correction and failure to achieve valgus showed poor results. Overall, 52 % of patients showed good results, 35 % fair and 13% poor results.

Introduction: The ideal regimen for safe and effective post operative pain relief inspinal surgery remains elusive. Numerous studies have been conducted comparing epidural with patient controlled analgesia with no firm conclusion as to which is best.

Aims: To determine the efficacy of acute pain relief between surgical placed epidural catheter and patient controlled analgesia for lumbar spinal surgery.

Method: A 42 month retrospective survey of 82 spinal surgery patients case notes and anaesthetic charts performed by a consultant spinal surgeon and his registrar from 2002 to 2005. There were 34 epidural and 48 PCA patients. Visual analogue Score (0–10) at 6 hourly intervals up to 36 hours, complications and age of patient were looked at. Exclusion criteria for epidural were dural tear, history of hypotension, unexplained neurological symptoms, and bleeding disorders and surgeon choice. Epidural infusion consisted of bupivacaine 0.1% with 5mls loading dose and 10mls/ hour infusion and PCA consisted of morphine sulphate 2mg/ml with a 1ml loading dose and 5 minute lockout interval.All patients were on standard analgesia which included oromorph 5mg four hourly orally and paracetamol 1gram six hourly as required orally. No radiographic evidence of epidural catheter placement was performed. Post-operative complications which included hypotension, nausea, vomiting, and drowsiness were monitored.

Results: The average age for the epidural group was 46.9 and PCA group 49.8. The most striking finding was that the average pain score at each six hourly interval waslower in the epidural group. This was significant in the first 18 hours post-operatively.However, 3 complications occurred in the epidural group which included hypotension. In addition, 3 epidural infusions were stopped and changed to PCA most likely due to improper placement of catheter. There were no complications with the PCA group.

Conclusion: This observational study demonstrates clinically and statistically that in the acute post-operative phase and up to 36 hours that epidural analgesia for lumbar spine surgery is more effective than PCA. From this survey, the risk of epidural was higher, although no serious complications occurred. Surgeon placement of catheter is also important in the effective delivery of epidural pain relief. The lower efficacy of the PCA may have been due to poor patient understanding of the concept of PCA and thereforeits

Prospective Study Design. 198 consecutive patients with back pain leg pain with MRI scan showing disc prolapse were operated from June 2001 to January 2004. In 22 patients it was found that the cause of nerve root compression was a localised venous plexus and the disc was intact.

Objectives: To emphasize the fact that the clinical presentation of a localised venous plexus of epidural veins in the lumbar spine can resemble that of an acute disc prolapse.

Summary of Background data: After reporting 6 cases of this type in Spine Volume 28 Number 1 we designed a prospective study of all discetomies done in our institution. Our outcome suggests that the finding of enlarged epidural veins during lumbar spine disc decompression is relatively common, but it is only recently that they have been implicated as the cause of the presenting symptoms.

Methods and Results: 198 patients presented with severe low back pain accompanied by sciatica, which had begun acutely. Physical examination in most of these patients showed the presence of neurological signs in the affected leg. The diagnosis of possible disc prolapse with nerve compression was demonstrated by MRI scan. However , at surgery, in 22 patients the intervertebral disc appeared to be relatively normal without any bulge and intact annulus, but a large venous structure in the form of plexus of epidural vein compressing the nerve root was found in the spinal canal.. The configuration of this venous plexus matched the MRI findings. The symptoms were relieved by decompression of the spinal canal and ablation of the veins.

Conclusion: Lumbar spine venous plexi of epidural veins can cause nerve root compression and the MRI image of a localised plexus of epidural veins can closely resemble that of a prolapsed intervertebral disc. Could this be the cause of failed back syndrome in patients who have already undergone decompression and discetomy? Wenger et al show success rate of 92.5% to 94.7% after discetomy but still there is an failure rate of 7.5 to 5.3% leading to failed back syndrome. The incidence of symptomatic lumbar epidural varices is said to be low. Zimmerman et al quoted their incidence as 0.067% and Hanley et al 5%. Our study shows an incidence of 11.11%.

Traumatic rotatory atlanto-axial dislocation and subluxations are rare injuries. The diagnosis is often missed or delayed because of subtle clinical signs. Head tilt makes the interpretation of plain radiographs difficult. Delayed diagnosis often results in chronic instability necessitating surgical stabilization. A hitherto undescribed clinical sign was evaluated which should lead to increased awareness and avoid delay in the diagnosis.

Why a new clinical sign?

Easily missed injury

Methods: This study was carried out between 1997 to 2003. The test was applied to 59 patients presenting in Accident and Emergency. All this patients had head tilt even after the application of a hard cervical collar. All the 59 patients had CT scans to confirm or exclude the diagnosis of Rotatory atlanto axial dislocation/subluxation.

Results: The new clinical sign was found to be positive in all the fourteen patients with atlanto- axial rotatory dislocations/subluxations which was confirmed by CT scan. The test was also found to be positive in 5 patients with unilateral facet joint dislocation. The sensivity of the test in our study was 100%. The specificity was 89%, positive predictive value 0.73, negative predictive value 0.9 (90%).

Conclusion: This new clinical sign may help in early recognition of the injury and also act as an effective screen to indicate which patient needs a CT scan to confirm the diagnosis. This can also be applied in places where the CT scan facilities are not readily available especially in the developing nations.

Purpose of the study: To establish the difference between AO plate osteosynthesis and Elastic Stable Intramedullary Nailing and the long-term outcome.

Design: Prospective randomised study.

Material: During 2000 and 2002 prospective randomised study was carried out where children with diaphysial fracture of long bone was either treated with osteosynthesis with AO plate or ESIN. 32 children had AO plate osteosynthesis and 34 children had ESIN procedure.

Methods: In our series of patients managed with ESIN Nailing 24 had forearm fracture 6 had femur fracture 2 had humeral and 2 had tibial fracture. The other group with AO plate osteosynthesis had 25-forearm fracture 1 humeral fracture 4 tibial fractures and 2 femoral fractures.

Results: The group treated with AO plate osteosynthesis 2 had rotational deformity and rest did well. The recovery period after removal of metal work was longer.

The group treated with ESIN procedure 1 patient fell down and bend the C-Nail, which was straightened in situ, and the fracture healed with slight curvature of the femur, which corrected slowly with growth. The forearm fractures did not have any rotational deformity. The recovery period post removal of the ESIN was very short.

Conclusion: We find that ESIN is a superior procedure for diaphysial fractures of long bone in children and AO plating should only be done in cases where ESIN is not possible.

Background context: Cauda equina following a prosthetic Disc nucleus replacement has never been reported.

Purpose: To describe a case of Cauda equina following migration of the Prosthetic disc nucleus and possible cause.

Study design: Case report and review of literature.

Patient Sample: Case report.

Outcome measures: 2 patients. Report of presenting symptoms and review of radiographs.

Method/description: A 24-year-old man presented with progressively worsening pain radiating down his right leg and low back pain. His MRI scan showed a disc bulge at L4/5 for which we underwent decompression and discetomy. 4 months later he presented again with same symptoms. MRI imaging showed a disc prolapse at L4/5. He underwent a revision decompression discectomy and a prosthetic disc nucleus replacement. On the 4th postoperative day he complained of urinary retention and was unable to move his right ankle with loss of sphincter tone. The plain radiographs showed that the prosthetic disc nucleus had migrated posteriorly. He was immediately taken to theatre, which showed posterior migration of the prosthetic disc nucleus compressing the theca and displacing the nerve root. The prosthetic disc nucleus was removed from the space relieving the tension of the nerve root and the theca.

Conclusions: Migration of Prosthetic disc nucleus can lead to cauda equina and this needs to be explained to the patient as possible risk factor. The angle of the vertebrae has to be measured before selecting a patient. If angle below 5 degree it is a high risk patient.