Two patients had died by the time of follow-up (1 perioperative, 1 unrelated) leaving 41 patients (23 female, 18 male) for analysis. Mean age was 14.0 at surgery, mean follow-up of 2.6 years (0.25–5.3). GMFCS types 2–4 (8), 5 (31). Mean preoperative Cobb angle 78° and pelvic obliquity 18°. There were 34 posterior and 7 anterior and posterior instrumentations.
Diagnosis of infective discitis may be difficult as presentation is usually non-specific with little symptomatology and few signs in the early stages. This dilemma is further complicated by the fact there is a long latent period between the onset of symptoms and plain radiograph changes and a high index of suspicion must be maintained. We reviewed 30 cases referred to our unit for treatment between 1996 and 2001 with an emphasis on time to diagnosis. 90% of patients complained of some degree of back pain at initial presentation and 70% had symptoms of active infection. 60% had a history of recent sepsis and a further 23% had been extensively investigated for pyrexia of unknown origin (PUO). The mean time to diagnosis from first presentation to a member of the medical profession was 54 days (range 0–183 days). 35% of patients were diagnosed incidentally on a CT scan while investigating abdominal and chest symptoms or PUO so these diagnoses could potentially have been delayed further. 23% of patients required acute surgical treatment and in this sub-group the mean time to diagnosis was 61 days (range 14–91 days). 16% of patients died as a result of discitis. In this subgroup the mean time to diagnosis was 74 days (range 56–183 days). Many patients were extensively investigated for PUO or sepsis of unknown cause despite having persistent back pain. Although a small sample, delay in diagnosis seems to increase death rates. Many of these patients had first presented to their general practitioner or a physician for investigation, however discitis is rarely cited as a differential diagnosis of PUO in medical textbooks. A high index of suspicion must be maintained in patients with back pain, especially that of a non-mechanical nature. Discitis should be considered early in such patients especially those with evidence of infection. Discitis must always be included in the differential diagnosis of pyrexia of unknown origin.
Meticulous haemostasis not only improves the operative field facilitating spinal surgery, but also diminishes chances of post-operative neurological complications from a compressive haematoma. Since being introduced in the 1940’s, implantable haemostats have proven a useful adjunct in achieving haemostasis with relatively few complications. However, their use in spaces bounded by bony architecture can lead to compressive effects on neurological structures. We present three cases of post-operative cauda equina syndrome – two cases following surgery for lumbar disc herniation and one case following surgery for lumbar canal stenosis. In each case, implantable haemostats were utilised to control haemorrhage for complications during the surgery. All three patients underwent urgent exploration, which revealed cauda equina compression from clot organised around the haemostat. Neurological recovery was variable. We recommend careful attention to intra-operative haemostasis. Although haemostats can assist in achieving haemostasis, we caution against leaving them in situ.
The Charnley total hip replacement has had favourable long-term survival results. On the strength of these results orthopaedic companies have introduced “Charnley Copies” incorporating identical design parameters. The objective of the study was to determine whether the acetabular cups provided as DePuy Charnley copies by different manufacturers are identical with regards to their geometry. To analyze how any differences present may affect the motion characteristics of the arthroplasty. A jig was designed which allowed the measurements of: i) range of movement free from impingement, ii) the arc of movement during which the femoral neck is impinging on the cup, iii) point of subluxation and dislocation of the femoral head from the cup. The cups obtained for analysis where the Standard and Long Posterior Wall models of the DePuy Charnley, Aesculap ALFA, Corin Cenator and Avatar LFA. The Aesculap Plasma Symmetrical and Asymmetrical were analyzed for comparison. The Alfa has a greater free range of movement compared to the Charnley cup and the other copies. The Charnley cup, the Cenator and the LFA differed in their pattern of impingement. The Alfa had the earliest point of dislocation. Long Posterior Wall: The Avatar had the greatest free ROM. The Charnley and the Alfa dislocated in an anterior direction latest. The Avatar and Cenator dislocated latest in the posterior direction. Plasma Cup: Compared to the Charnley and its copies its free range of movement was greater, it had only one point of impingement and impinged through the smallest arc before dislocating. It did, however, dislocate easiest. Charnley copies are not identical. Differences in geometry exist and these alter important motion characteristics. Long term outcome may be affected. Surgeons should be aware of these differences when choosing implants.