Purpose of study: To assess whether a plane x-ray at five months is needed in a DDH screening program.

Method: Between 1990 and 2004 we operated selective hip screening, including ultrasound. Hips screened as normal had an X-ray at 5 months, initially instituted to cover the ultrasound learning curve. These were reported by a consultant radiologist and referred if thought abnormal. For the purposes of this study the notes, scans and X-rays of all patients referred at 5 months were reviewed.

Results: In Nottingham there were approximately 108,500 births between 1990 and 2004. Of these 11,425 were referred for ultrasound scan. 53 were referred to orthopaedics following the x-ray at 5 months. 47 of these had a complete data set. Of these 47 children, 30 (64%) were watched, 9 (19%) had arthrograms only, 5 (11%) had adductor tenotomy and application of a hip spica. One (2%) child had Pavlik harness treatment and 2 (4%) had a femoral osteotomy.

Graf’s alpha angles and percentage cover were reviewed from the original ultrasounds, many of which were of poor quality. This demonstrated that there was less than 50% cover for 14/30 (47%) who were watched, for 6/9 (78%) who had arthrograms, for 1/1 (100%) treated by harness, for 4/5 (80%) treated with adductor tenotomy and hip spica and for 2/2 (100%) requiring surgery. Alpha angles less than 60 degrees did not predict the need for intervention. There were no late cases from the group that had X-rays classed as normal at 5 months.

Conclusions: The importance of measuring head cover was established and is now routine in the hip instability clinic. It was clear that a large population had received unnecessary X-rays. X-rays are now only performed if US at 6 weeks reveals a low alpha angle or less than 50% cover.

Introduction: Although the ultrasound diagnosis of neural tube defects has been described extensively, anomalies of the fetal vertebral bodies have received little attention. This study aims to document the incidence of congenital hemivertebrae, the association with defects of other organ systems and discuss the outcome.

Methods: All fetuses with ultrasonographically detected vertebral anomalies presenting to the above institution over a four year period were included in the study. Those with open neural tube defects were excluded. The level and Cobb angle (where possible) were estimated from the 18 week scan. Associated congenital anomalies were noted. Radiographs were taken soon after birth and checked for accuracy of original diagnosis and patients were monitored for curve progression.

Results: Fourteen fetuses with congenital hemivertebrae were found from a total of 12,000 routine antenatal scans. Maternal age ranged from 22–32 years (mean 26.8 years) with an average term of 36.3 weeks (range 29–40). Only two fetuses were born prematurely: one at 33 weeks as part of a twin gestation (only one of the twins had an isolated hemivertebrae) and the other at 29 weeks via emergency caesarian section for fetal distress. This pregnancy was complicated by the oligohydramnios sequence (Potter syndrome). Ten of 14 fetuses had an isolated hemivertebrae. Two had VATER association (oesophageal and anal atresia) and two had multiple mosaic type congenital scoliosis, one of which had associated rib and abdominal wall malformation. All pregnancies resulted in live births. All except one child remain well at latest follow-up (average 25 months). The infant born at 29 weeks has had multiple complications of prematurity. Vertebral anomalies appeared in the thoracic spine in five, the lumbar spine in eight and the sacrum in one resulting in scoliosis in 13 and kyphosis in one. The average antenatal Cobb angle was 30°. The average postnatal Cobb angle was 32° (range 18–42). Accuracy of localisation (level and type) was good with only one error due to inability to see the S1 hemivertebrae. Six of the 14 had surgery before the age of 24 months, with the youngest aged three months. In this group the average pre-operative Cobb angle was 35° (range 25–42°). Three patients had anterior and posterior fusion in-situ without instrumentation. Three patients had hemivertebrectomy with correction and posterior instrumentation of the spine.

Conclusion: In general sonographically detected isolated fetal hemivertebrae carry a good prognosis. If associated with the oligohydramnios syndrome the fetus is at high risk. Ultrasound appears accurate in the diagnosis of both the level and type of congenital malformation. The value of early surgical management needs continued assessment.

Objective: To assess the clinical and radiological outcome of isolated hemivertebrae and multiple vertebral anomalies in the very young.

Design: A cohort of patients with congenital scoliosis were identified on antenatal ultrasound and followed prospectively from twenty weeks in-utero (IU) for a mean of two years (range IU – five years).

Subjects: Twenty fetuses with congenital hemivertebrae were identified from 16, 000 routine antenatal scans over a five-year period. Each was X-rayed at six weeks and investigated for renal and cardiac abnormalities.

Outcome Measures: Clinical assessment included trunk balance, neurological abnormality and associated congenital abnormalities. Radiological assessment of curve magnitude and curve progression was performed using the Cobb method. The potential for progression (based on site, degree of incarceration, growth potential and presence of a congenital bar) was assessed. In all cases a clinical and radiological assessment was made at maximal follow-up.

Results: One of the twenty fetuses aborted spontaneously at 23 weeks, three remain in-utero, leaving 16 live births. Thirteen of 20 had an isolated hemivertebra, and seven of twenty had multiple vertebral abnormalities. Two fetuses had renal agenesis, two had VATER’s syndrome and one had rib and abdominal wall abnormalities. The mean antenatal Cobb angle was 30°. IU curve progression was noted in three. Seven of the 16 live births required surgery based on curve magnitude, curve progression, truncal imbalance and the potential for progression. Surgery included anterior and posterior convex hemi-epiphyseodesis in two, and hemivertebra excision with fusion in five. The mean pre-operative Cobb angle was 36° (range 25–42) reducing to a mean of 21° (range 0–45) at maximal follow-up.

Conclusions: Multiple vertebral abnormalities were more commonly associated with renal and cardiac abnormalities. If associated with the oligohyramnios sequence the fetus appeared to be at high risk. In general US detected isolated fetal hemivertebrae carry a good prognosis, nevertheless 38% of these cases at our institution underwent surgery within the first two years of life.

Forty-two consecutive patients with suspected lumbar disc protrusions were studied prospectively to compare the diagnostic accuracy of low-field strength MRI with that of radiculography. Thirty patients subsequently underwent surgical exploration at 33 levels and the operative findings were compared to both methods of diagnostic imaging. All patients had MRI studies, whilst 29 patients also had radiculography. Both studies were evaluated without prior knowledge of the clinical signs, operative findings or the results of other imaging techniques. MRI predicted the correct diagnosis in 29 of the 33 levels explored, an accuracy of 88%. All discs proven to be abnormal demonstrated a reduced signal from the nucleus pulposus. There were two false positive results and two doubtful cases but no false negatives. Radiculography predicted the correct diagnosis in 24 of 32 levels explored, an accuracy of 75%. There were two false positive results, five doubtfuls and one false negative. The overall accuracy when both tests were considered rose to 94%. Of the remaining 12 patients all except one showed good correlation between the MRI and radiculographic findings. These results indicate that low field strength MRI is slightly better than radiculography in diagnosing lumbar disc protrusions.