Abstract

The current trend in kyphosis correction is for “every level” instrumentation to achieve intraoperative stability, correction, fusion and implant longevity.

We evaluate the medium term follow up of a low implant density (LID) construct.

All patients with adolescent kyphosis (idiopathic or Scheurmann's) on our deformity database were identified. Radiographs and records were analysed for neurological complications, correction and revision.

The constructs included were all pedicle screw anchors with multiple apical chevron osteotomies and a proximal and distal “box” of 6 to 8 screws. A four rod cantilever reduction manoeuvre with side to side connectors completed the construct. Kyphosis for any other cause was excluded. Follow up less than 12 months was excluded.

23 patients were identified with an average follow up 27 months (72 to 12 months) and a mean implant density of 1.1 (53.5% of “available” pedicles instrumented).

There was 1 false positive neurophysiological event without sequelae (4%).

There were no proximal junctional failures (0%).

There were no pseudarthroses or rod breakages (0%).

There was 1 loss of distal rod capture (early set screw failure) (4%). This was revised uneventfully.

There were 4 infections requiring debridement (early series).

Average initial correction was 44% (77.7 degrees to 43.5 degrees) with a 1% loss of correction at final follow up (43.5 to 44.0 degrees). The fulcrum bending correction index was 107% (based on fulcrum extension radiographs). 85% of curves had a fulcrum flexibility of less than 50%.

The average cost saving compared to “every level “instrumentation was £5700 per case.

This paper shows that a LID construct for kyphosis has technical outcomes as good as high density constructs. The obvious limitation of the study is the small number of patients in the cohort.

The infection rates have improved with changes to perioperative process in the later series of patients. We do not believe these are a consequence of the construct itself.

Introduction:

Shoulder balance after surgery is one main attribute of the cosmetic outcome. It has been difficult to assess on 2D images. The balance results from the interaction of rib cage, shoulder joint and scapular positions, spinal alignment and rotation, muscle size and co-ordination and pain interaction. Attempts have been made to predict shoulder balance from radiograph measurements. There is no consensus on this.

Aim:

To evaluate the effect of intraoperative manoeuvres on the rib hump.

Aim:

To evaluate the effect of a stiffer rod in normalising thoracic hypokyphosis in adolescent idiopathic scoliosis (AIS).

Introduction:

Scheuermann's kyphosis is a fixed round back deformity characterised by wedged vertebrae seen on radiograph. It is known patients presented with a negative sagittal balance before operation. Few studies investigated the outcome after operation, especially the change in the lumbar hyperlordosis.

Pedicle screw constructs (PSC) in scoliosis are a recently established and widely accepted method of managing scoliotic curves posteriorly. There is a perceived improved coronal and rotational correction when compared to other posterior only constructs. With continued use of this method, the authors and deformity surgeons in general have become aware of persistent thoracic hypokyphosis.

This review of 3 years of scoliosis cases using PSC looks at four different implant strategies utilised to manage this problem and our current practice. These strategies were:

All titanium 5.5 mm rod diameter (Expedium, Depuy spine)

All titanium 5.5 mm rod diameter with periapical washers (Expedium, Depuy spine)

All titanium 6.0 mm rod diameter (Pangea, Synthes)

Titanium pedicle screws with 5.5 mm diameter cobalt chrome rods (Expedium Depuy spine)

We have reviewed our outcomes with these strategies with respect to thoracic hypokyphosis. Strategy 1 had the highest rate of hypokyphosis on postoperative radiographs. Strategy 4 seems to have the best correction of coronal and sagittal plane abnormality post operatively. As a consequence, our current practice is the use of titanium pedicle screws and 5.5 mm diameter cobalt chrome rods when managing scoliosis with a pedicle screw construct.

Purpose of Study: To observe the efficiency of the combined motor-somatosensory monitoring and somatosensory-alone monitoring to identify the intra-operative neurologic changes.

Methods and Results: We retrospectively assessed 123 cases in our centre, who had complete neurophysiological report while undergoing corrective spinal deformity surgery with spinal monitoring, from 2004 to 2008. Combined motor-somatosensory, somatosensory-alone and motor-alone monitoring were applied in sixty five, fifty and eight operations, respectively. We also looked at the factors that could potentially affect the neuro-physiologic monitoring, such as preoperative neurological status, anaesthetic method, blood loss, competency level of the monitoring team and the reaction of the surgical team to a significant monitoring event. In total, there were only two cases of true positive event, defined as a significant intraoperative event and postoperative neurological deficit. Both of these cases had combined monitoring during their procedures. No case of false negative was observed. There were also five cases with a significant intraoperative event without post operative neurologic sequel (false positive). Four of these had combined monitoring, with complete normal sensory monitoring and abnormal motor monitoring, which prompted the operating team to the appropriate action.

Conclusion: Based on this observation, it is felt that the combined monitoring during spinal deformity correction procedures is superior to the sensory-alone monitoring for identifying the impending neurologic deficits. This is in accordance with the previous reports and recommendations.

Study Design: An analysis of patients admitted with cervical trauma, comparing: those managed with rigid collars until definitive management; rigid collar usage overnight; and no rigid collar usage from outset.

Objectives: To determine the safety of omitting a rigid collar following cervical trauma, whilst awaiting definitive management.

Summary of Background Data: The use of a rigid collar can result in pain, occipital sores, as well as raised intracranial pressure in head injured patients.

Subjects: Fifty one patients with proven cervical fractures were analysed. Three groups of patients were identified with respect to their initial management after admission to the ward until definitive management: 1) Hard collar, sandbags and bed rest 2) Hard collar in situ overnight and then sandbags and bed rest. 3) Sandbags and bed rest. All patients had full spinal care and precautions, with rigid collars used for any transfers. The spectrum of injury severity was similar throughout all 3 groups.

Outcome measures: Loss of alignment, neurological compromise and complications related to the rigid collar.

Results: There was no loss of reduction or progression of neurological deficit in any group. There were compliance issues in the rigid collar group. Two patients developed occipital skin problems following rigid collar use. All groups proceeded to definitive management successfully.

Conclusion: No significant adverse events were noted in any group. Management without a rigid collar depends on good nursing care. It is more comfortable for the patient and avoids the potential problems encountered with rigid collar use. In compliant patients not requiring immediate definitive management the omission of the rigid collar did not result in loss of reduction or neurological compromise. We feel such collars should be for transport and extrication only.

Objective: To establish the anatomy of the iliolumbar vein.

Design: Prosections of human cadavers were examined.

Subjects: Sixteen iliolumbar veins in eight cadavers. Outcome measures: Width, length, pattern of drainage, tributaries, distance from IVC to the iho lumbar vein, structures drained and immediate relations. The risk of avulsion on great vessel retraction to expose the L4/L5 disc.

Results: Two variants encountered; a single vein an average 3.74cms from the IVC (11/16), or two stems, an average of 2.98cms to the proximal and 6.04cms to the distal (5/16). All 16 veins tore on great vessel retraction. In all veins the obturator nerve was found to cross superficially an average 2.76cms lateral to the mouth, in four cases, the actual distance was less than 1.5cms. In 15 veins the lumbosacral trunk crossed deep, in one superficial. The average distance from the mouth was 2.5 cms, in three veins the actual distance was 1cm or less.

Conclusion: This study confirms variability in the vein with vulnerability to avulsion on retraction of the great vessels. The close relationship with the obturator nerve and lumbosacral trunk further emphasise the need for proper exposure of the vein prior to ligature and safe surgical exposure of the anterior lumbar spine. Other findings are also presented.

We carried out a cadaver study of 16 iliolumbar veins in order to define the surgical anatomy. Two variants were found; a single vein at a mean distance of 3.74 cm from the inferior vena cava (11 of 16) and two separate draining veins at a mean distance from the vena cava of 2.98 cm for the proximal and 6.24 cm for the distal stem (5 of 16). Consistently, the proximal vein tore on attempted medial retraction of the great vessels. The mean length of the vein was 1.6 cm and its mean width 1.07 cm. Three stems were shorter than 0.5 cm. Two or more tributaries usually drained the iliacus and psoas muscles, and the fifth lumbar vertebral body. The obturator nerve crossed all veins superficially at a mean of 2.76 cm lateral to the mouth. In four of these, this distance was less than 1.5 cm. Usually, the lumbosacral trunk crossed deep, at a mean distance of 2.5 cm lateral to the mouth, but in three veins, this distance was 1 cm or less.

Our findings emphasise the need for proper dissection of the iliolumbar vein before ligature during exposure of the anterior lumbar spine.

Residual pain after total hip due to a number of causes both local to and replacement may be distant from the hip. We describe pain related to the psoas muscle after total hip replacement in nine patients. All presented with characteristic symptoms. We describe the key features and management. Gratifying results were achieved with treatment. This diagnosis should be considered when assessing patients with pain after total hip replacement.

Residual pain after THR can have a number of causes. Unless there was a major intraoperative inadequacy or early deep infection provided the patient indicates the greater part of the preoperative arthritic pain has been relieved and if other major clinical and radiological features are satisfactory remaining discomfort is all too easily attributed to a muscular origin with reassurances it will settle down! The senior authors attention was drawn to intrusive groin pain by a patient who had an otherwise uneventful bilateral (same sitting) THR. Right groin pain remained particularily marked on moving the leg getting in and out of her car on the drivers side.Clinical assessment Xray & CT scan & CT guided diagnostic injection suggested the symptoms were due to Psoas irritation perhaps due to a cement prominence underneath a proud edge of a flanged Charnley acetabular component. Through a direct anterior exposure this was shown to be so. There was evidence of Psoas Bursitis with a granular appearance.Symptoms were relieved by removing the flange and cement prominence and performing a partial psoas bursectomy and partial psoas tenotomy. Six similar cases are described. How to avoid or treat this annoying minor complication of a generally successful operation by attention to detail is discussed