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Orthopaedic Proceedings
Vol. 102-B, Issue SUPP_6 | Pages 114 - 114
1 Jul 2020
Thompson G Hardesty C Son-Hing J Ina J Tripi P Poe-Kochert C
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Intrathecal morphine (IM) is a common adjunct in paediatric spinal deformity surgery. We previously demonstrated with idiopathic scoliosis it provides safe and effective analgesia in the immediate postoperative period. This study represents our 25 year experience with IM in all diagnostic groups. Our prospective Pediatric Orthopaedic Spine Database (1993–2018) was reviewed to identify all patients undergoing spinal deformity surgery who received IM and who did not. Patients 21 years of age or less who had a posterior spinal fusion (PSF) with segmental spinal instrumentation (SSI), and received 9–19 mcg/kg (up to 1 mg) of IM were included. Early onset scoliosis surgical patients were excluded. We assessed demographics, pain scores, time to first dose of opioids, diagnoses, surgical time, paediatric intensive care unit (PICU) admission and IM complications (respiratory depression, pruritus, nausea/ vomiting). There were 986 patients who met inclusion criteria. This included 760 patients who received IM and 226 who did not. IM was not used for short procedures (< 3 hrs), respiratory concerns, unsuccessful access of intrathecal space, paraplegia, and anesthesiologist decision. Both groups followed the same strict perioperative care path. The patients were divided into 5 diagnostic groups (IM / non IM patients): idiopathic (578/28), neuromuscular (100/151), syndromic (36/17), and congenital scoliosis (32/21) and kyphosis (14/9). Females predominated over males (697/289). The first dose of opioids after surgery was delayed for a mean of 10.6 hrs in IM group compared to 2.3 hrs in the non-IM group (p=0.001). The postoperative pain scores were significantly lower in the IM groups in the Post Anesthesia Care Unite (p=0.001). Only 17 IM patients (2%) were admitted to the PICU for observation secondary to respiratory depression, none required re-intubation. None of the IM group were re-intubated. Forty-nine patients (6%) experienced pruritus in the IM group compared to 4 of 226 patients (2%) in the non IM group. There were 169 patients (22%) of the IM patients and 21 patients (9%) of the non IM had nausea and vomiting postoperatively. Three patients (0.39%) had a dural leak from the administration of IM but did not require surgical repair. There were no other perioperative complications related to the use of IM. There were no significant group differences. Pre-incision IM is a safe and effective adjunct for pain management in all diagnostic groups undergoing spinal surgery. The IM patients had lower pain scores and a longer time to first administration of post-operative opioids. Although there is an increased frequency of respiratory depression, pruritus, and nausea/vomiting in the IM group, there were no serious complications


Orthopaedic Proceedings
Vol. 101-B, Issue SUPP_3 | Pages 13 - 13
1 Apr 2019
Waliullah S Kumar V Rastogi D Srivastava RN
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Spinal tuberculosis is one of the most common presentations of skeletal tuberculosis. It is one of the major health issues of developing countries as it is associated with significant morbidity and mortality. Pott's paraplegia is a dreaded complication which can result in permanent neurological deficit, unless treated by timely intervention. We evaluated the efficacy of transpedicular decompression and functional recovery in patients of spinal tuberculosis with neurological deficit. A cohort of 23 patients (15 males and 8 female) with diagnosed spinal tuberculosis and having an average age of 37.5±8.4 years, satisfying our inclusion and exclusion criteria's and giving written informed consent were recruited in our study. All patients were managed by transpedicular decompression and fusion with posterior instrumentation. All the patients were followed up clinically, radiologically and hematologically. Patients were followed up at every six weeks for 4 months and thereafter at three monthly intervals to assess the long term outcomes and complications. Neurological evaluation was done by Frankel grading. Functional outcome was assessed by Visual Analog Score (VAS) and Owestry Disability Index score (ODI score). All the patients were followed for a minimum of 27 months. At the final follow-up, there was a statistically significant improvement in VAS score and ODI score. Out of 23 patients, all except three patients showed neurological recovery. We observed that transpedicular decompression is safe and effective approach for management of spinal tuberculosis as it allows adequate decompression of spinal cord while pedicular instrumentation provides stable spinal fixation and helps in early rehabilitation


Orthopaedic Proceedings
Vol. 97-B, Issue SUPP_16 | Pages 31 - 31
1 Dec 2015
Elafram R Boussetta R Jerbi I Bouchoucha S Saied W Nessib M
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Hydatid disease of the bone and soft tissue of the musculoskeletal system is uncommon. The dissemination mode leads to local malignancy with severe prognosis. Tunisia is an endemic area of the disease. Therefore we treated many patients affected the disease. We retrosectivelly reviwed 6 cases of bone hydatid cyst from 1990 to 2010. There were 3 males and 3 females. The mean age was 13 years. The localisation were 03 spinal, 2 in the proximal tibia and & localisation in trochanter. The diagnosis were histoligical in all patient. the mean delay for the diagnosis was 3 years. One patient with spinal localisation had neurological complication paraplegia. All the patient had surgical excision of the hydatid cyst. Ther ewere 3 cases with local recurrence. Because of the poor results with medical treatment, osseous hydatidosis must be treated by a radical operation with wide excision, adapted to each localization. In the main, the prognosis of osseous hydatidosis remains poor, especially with spinal and pelvic localizations, which are the most frequent ones. The prognosis and treatment of osseous hydatidosis belong in the same category as a locally malignant lesion


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_19 | Pages 1 - 1
1 Dec 2014
Horn A Dix-Peek S
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Purpose of study:. The question of prolonged bracing following injury in patients diagnosed with SCIWORA remains controversial. Proponents of the ‘Segmental Spinal Instability’ hypothesis claim that there is occult ligamentous injury leading to instability and a risk of recurrent injury. Published reports of recurrent SCIWORA involve patients with minor, transient neurological symptoms and normal MRI findings. The contradicting ‘differential stretch hypothesis’ is based on the premise that the spinal column will deform elastically, exceeding the elastic deforming potential of the more fragile spinal cord, but will return to its baseline stability. The purpose of this study is to evaluate the need for bracing in patients with SCIWORA based on MRI evidence of instability. Methods:. A retrospective chart review was performed for a series of eleven patients with documented SCIWORA that presented to Red Cross Children's Hospital over the past 8 years. Details regarding mode of injury, age at presentation, neurological deficit at presentation, MRI findings and long term prognosis were documented. MRI's were reviewed by the authors as well as a consultant radiologist. Results:. There were 9 males and 2 females. The average age was 4.5 years. All patients were victims of motor vehicle accidents and had multiple injuries. Five patients had cervical, five thoracic and one had both cervical and thoracic injuries. There were 1 monoplegia, 4 hemiplegias, 3 paraplegias and 3 triplegias. None of the MRIs performed on these patients demonstrated ligamentous or bony injury. Patients with only T2 changes demonstrated progressive neurological recovery within a few months following injury. There were no recurrences and none of the patients were braced following the diagnosis of SCIWORA. Conclusion:. Our results from this small series support the ‘differential stretch hypothesis’ and we maintain that patient's with SCIWORA does not demonstrate spinal instability and therefore does not require bracing following injury


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXI | Pages 147 - 147
1 May 2012
R. J S. KG R. G P. A R. BS
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Introduction. Neurological involvement occurs in 10-30% cases of caries spine. Surgical debridement and stabilisation is needed to decompress the cord and prevent progression of deformity. This prospective study was undertaken to determine the efficacy of operative treatment in the management and neurological recovery in patients with caries spine with neural deficit. Material & methods. 20 patients, 14 male, 6 female, were included and followed up for 1 year after surgery. The mean age was 39.45 years. 10 patients had complete paraplegia and 9 patients had paraparesis. 1 patient with cervical involvement had quadriplegia. Anterior decompression and stabilisation was done in all the cases. Objective of surgery was adequate debridement of diseased foci, decompression of cord and stabilisation of spine with correction of deformity. In 19 (95%) patients there with thoraco-lumbar involvement. This was addressed with a titanium mesh cage filled with impacted bone graft and supplemented with 2 Moss Miami screws and a rod construct. In the cervical spine, cervical spine locking plate was used for stabilisation after decompression and bone grafting (tricortical iliac crest graft). Results. Fifteen patients had complete and 5 patients had incomplete neurologic recovery. Neurological recovery started as early as first post-op week (range 3 days to 12 weeks). The ASIA motor score improved from 60.80 (60.80 +/− 20.206) before surgery to 73.55 (73.55 +/− 13.828) at 1 month and 95.30 (95.30+/−11.934) at 6 months after surgery. The ASIA sensory score improved from 173.30 (173.30 +/− 50.689), to 186.85 (186.65 +/− 37.452) at one month and 218.45 (218.45 +/−11.843) at 6 months. All 8 patients with bladder and bowel involvement recovered normal bladder and bowel functions at 6 months. There was no recurrence of infection. Bony fusion was achieved in all patients and there were no implant failures. Conclusion. Anterior debridement, decompression, stabilisation and anti-tubercular chemotherapy resulted in neurological recovery in the majority of the patients


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XLI | Pages 83 - 83
1 Sep 2012
Damree S Quan G
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The optimal management of patients with the diagnosis of a spinal epidural abscess (SEA) remains controversial. The purpose of this study was to describe the clinical characteristics of patients presenting with spontaneous SEA and to correlate presentation and treatment with clinical and neurological outcome. A retrospective review of the medical records and radiology of patients with a diagnosis of SEA, treated between September 2003 and December 2010, at a tertiary referral hospital was performed. A total of 46 patients were identified including 27 males and 19 females. Mean age was 61 years (range, 30 – 86 years). At presentation, all patients had axial pain and 67% had a neurological deficit, out of which one third had paraplegia or quadriplegia. 32% patients were febrile. Diabetes was the most common risk factor (30%) followed by malignancy (17%), intravenous drug use (6%) and alcoholism (2%). Organisms were cultured in 44 patients with Methicillin Sensitive Staphylococcus Aureus most common (68%), followed by Methicillin Resistant Staphylococcus Aureus (14%). The epidural abscess was located in the lumbar spine in 24 patients, thoracic spine in 11 patients and cervical spine in 11 patients. 61% of patients had a concurrent source of septic focus on presentation, including psoas abscess (24%), facet joint septic arthritis (15%), pneumonia (11%), infective endocarditis (7%) and urosepsis (4%). 26% of patients were treated non-operatively, with computed tomography-guided aspiration and/or intravenous antibiotics based on cultures, whereas 74% underwent surgical decompression with or without fusion in combination with antibiotics. The mean inpatient hospital stay was 42 days (range, 2 – 742 days) and 34% of patients required an average of 40 days of Intensive Care Unit admission. At time discharge from hospital, of the patients managed nonoperatively, 33% had improved neurological function, 17% had worsened neurological function, 17% died and data was unavailable in 33%. Of the patients treated with surgery, 74% had improved neurological function, 6% remained unchanged, 6% had worsened neurologic function, 6% died and data was unavailable in 9% at time of discharge. SEA remains a severe condition associated with multiple septic foci and significant morbidity. Surgical decompression combined with antibiotics is associated with superior neurologic recovery compared with non-operative management, however a significant proportion of patients still deteriorate or die. Early diagnosis and management may prevent or reduce permanent neurologic deficit