Although atlantoaxial rotatory fixation (AARF) is a common cause
of torticollis in children, the diagnosis may be delayed. The condition
is characterised by a lack of rotation at the atlantoaxial joint
which becomes fixed in a rotated and subluxed position. The management of
children with a delayed presentation of this condition is controversial.
This is a retrospective study of a group of such children. Children who were admitted to two institutions between 1988 and
2014 with a diagnosis of AARF were included. We identified 12 children
(four boys, eight girls), with a mean age of 7.3 years (1.5 to 13.4),
in whom the duration of symptoms on presentation was at least four weeks
(four to 39). All were treated with halo traction followed by a
period of cervical immobilisation in a halo vest or a Minerva jacket.
We describe a simple modification to the halo traction that allows
the child to move their head whilst maintaining traction. The mean follow-up
was 59.6 weeks (24 to 156).Aims
Patients and Methods
To address the natural history of severe post-tuberculous (TB)
kyphosis, with focus upon the long-term neurological outcome, occurrence
of restrictive lung disease, and the effect on life expectancy. This is a retrospective clinical review of prospectively collected
imaging data based at a single institute. A total of 24 patients
of Southern Chinese origin who presented with spinal TB with a mean
of 113° of kyphosis (65° to 159°) who fulfilled inclusion criteria
were reviewed. Plain radiographs were used to assess the degree
of spinal deformity. Myelography, CT and MRI were used when available
to assess the integrity of the spinal cord and canal. Patient demographics,
age of onset of spinal TB and interventions, types of surgical procedure,
intra- and post-operative complications, and neurological status
were assessed. Aims
Patients and Methods
Fractures of the odontoid peg are common spinal
injuries in the elderly. This study compares the survivorship of
a cohort of elderly patients with an isolated fracture of the odontoid
peg A total of 32 patients with an isolated odontoid fracture were
identified. The rate of mortality was 37.5% (n = 12) at one year.
The period of greatest mortality was within the first 12 weeks.
Time made a lesser contribution from then to one year, and there
was no impact of time on the rate of mortality thereafter. The rate
of mortality at one year was 41.2% for male patients (7 of 17) compared
with 33.3% for females (5 of 15). The rate of mortality at one year was 32% (225 of 702) for patients
with a fracture of the hip and 4% (9 of 221) for those with a fracture
of the wrist. There was no statistically significant difference
in the rate of mortality following a hip fracture and an odontoid
peg fracture (p = 0.95). However, the survivorship of the wrist
fracture group was much better than that of the odontoid peg fracture
group (p <
0.001). Thus, a fracture of the odontoid peg in the
elderly is not a benign injury and is associated with a high rate
of mortality, especially in the first three months after the injury. Cite this article:
In a multicentre, randomised study of adolescents undergoing
posterior spinal fusion for idiopathic scoliosis, we investigated
the effect of adding gelatine matrix with human thrombin to the
standard surgical methods of controlling blood loss. Patients in the intervention group (n = 30) were randomised to
receive a minimum of two and a maximum of four units of gelatine
matrix with thrombin in addition to conventional surgical methods
of achieving haemostasis. Only conventional surgical methods were
used in the control group (n = 30). We measured the intra-operative
and total blood loss (intra-operative blood loss plus post-operative
drain output).Aims
Patients and Methods
Back pain is a common symptom in children and
adolescents. Here we review the important causes, of which defects
and stress reactions of the pars interarticularis are the most common
identifiable problems. More serious pathology, including malignancy
and infection, needs to be excluded when there is associated systemic
illness. Clinical evaluation and management may be difficult and
always requires a thorough history and physical examination. Diagnostic
imaging is obtained when symptoms are persistent or severe. Imaging
is used to reassure the patient, relatives and carers, and to guide
management. Cite this article:
Multimodal infiltration of local anaesthetic provides effective
control of pain in patients undergoing total knee arthroplasty (TKA).
There is little information about the added benefits of posterior
capsular infiltration (PCI) using different combinations of local
anaesthetic agents. Our aim was to investigate the effectiveness
of the control of pain using multimodal infiltration with and without
infiltration of the posterior capsule of the knee. In a double-blind, randomised controlled trial of patients scheduled
for unilateral primary TKA, 86 were assigned to be treated with
multimodal infiltration with (Group I) or without (Group II) PCI.
Routine associated analgesia included the use of bupivacaine, morphine,
ketorolac and epinephrine. All patients had spinal anaesthesia and patient-controlled
analgesia (PCA) post-operatively. A visual analogue scale (VAS)
for pain and the use of morphine were recorded 24 hours post-operatively.
Side effects of the infiltration, blood loss, and length of stay
in hospital were recorded.Aims
Patients and Methods
Nerve palsy is a well-described complication
following total hip arthroplasty, but is highly distressing and
disabling. A nerve palsy may cause difficulty with the post-operative
rehabilitation, and overall mobility of the patient. Nerve palsy
may result from compression and tension to the affected nerve(s)
during the course of the operation via surgical manipulation and
retractor placement, tension from limb lengthening or compression
from post-operative hematoma. In the literature, hip dysplasia,
lengthening of the leg, the use of an uncemented femoral component, and
female gender are associated with a greater risk of nerve palsy.
We examined our experience at a high-volume, tertiary care referral
centre, and found an overall incidence of 0.3% out of 39 056 primary
hip arthroplasties. Risk factors found to be associated with the
incidence of nerve palsy at our institution included the presence
of spinal stenosis or lumbar disc disease, age younger than 50,
and smoking. If a nerve palsy is diagnosed, imaging is mandatory
and surgical evacuation or compressive haematomas may be beneficial.
As palsies are slow to recover, supportive care such as bracing,
therapy, and reassurance are the mainstays of treatment. Cite this article:
Segmental vessel ligation during anterior spinal surgery has been associated with paraplegia. However, the incidence and risk factors for this devastating complication are debated. We reviewed 346 consecutive paediatric and adolescent patients ranging in age from three to 18 years who underwent surgery for anterior spinal deformity through a thoracic or thoracoabdominal approach, during which 2651 segmental vessels were ligated. There were 173 patients with idiopathic scoliosis, 80 with congenital scoliosis or kyphosis, 43 with neuromuscular and 31 with syndromic scoliosis, 12 with a scoliosis associated with intraspinal abnormalities, and seven with a kyphosis. There was only one neurological complication, which occurred in a patient with a 127° congenital thoracic scoliosis due to a unilateral unsegmented bar with contralateral hemivertebrae at the same level associated with a thoracic diastematomyelia and tethered cord. This patient was operated upon early in the series, when intra-operative spinal cord monitoring was not available. Intra-operative spinal cord monitoring with the use of somatosensory evoked potentials alone or with motor evoked potentials was performed in 331 patients. This showed no evidence of signal change after ligation of the segmental vessels. In our experience, unilateral segmental vessel ligation carries no risk of neurological damage to the spinal cord unless performed in patients with complex congenital spinal deformities occurring primarily in the thoracic spine and associated with intraspinal anomalies at the same level, where the vascular supply to the cord may be abnormal.
The results of hip and knee replacement surgery
are generally regarded as positive for patients. Nonetheless, they are
both major operations and have recognised complications. We present
a review of relevant claims made to the National Health Service
Litigation Authority. Between 1995 and 2010 there were 1004 claims
to a value of £41.5 million following hip replacement surgery and
523 claims to a value of £21 million for knee replacement. The most common
complaint after hip surgery was related to residual neurological
deficit, whereas after knee replacement it was related to infection.
Vascular complications resulted in the highest costs per case in
each group. Although there has been a large increase in the number of operations
performed, there has not been a corresponding relative increase
in litigation. The reasons for litigation have remained largely
unchanged over time after hip replacement. In the case of knee replacement,
although there has been a reduction in claims for infection, there
has been an increase in claims for technical errors. There has also
been a rise in claims for non-specified dissatisfaction. This information
is of value to surgeons and can be used to minimise the potential
mismatch between patient expectation, informed consent and outcome. Cite this article:
Although vertebroplasty is very effective for relieving acute pain from an osteoporotic vertebral compression fracture, not all patients who undergo vertebroplasty receive the same degree of benefit from the procedure. In order to identify the ideal candidate for vertebroplasty, pre-operative prognostic demographic or clinico-radiological factors need to be identified. The objective of this study was to identify the pre-operative prognostic factors related to the effect of vertebroplasty on acute pain control using a cohort of surgically and non-surgically managed patients. Patients with single-level acute osteoporotic vertebral compression fracture at thoracolumbar junction (T10 to L2) were followed. If the patients were not satisfied with acute pain reduction after a three-week conservative treatment, vertebroplasty was recommended. Pain assessment was carried out at the time of diagnosis, as well as three, four, six, and 12 weeks after the diagnosis. The effect of vertebroplasty, compared with conservative treatment, on back pain (visual analogue score, VAS) was analysed with the use of analysis-of-covariance models that adjusted for pre-operative VAS scores.Objectives
Patients and Methods
The April 2014 Spine Roundup360 looks at: medical treatment for ankylosing spondylitis; unilateral TLIF effective; peg fractures akin to neck of femur fractures; sleep apnoea and spinal surgery; scoliosis in osteogenesis imperfect; paediatric atlanto-occipital dislocation; back pain and obesity: chicken or egg?; BMP associated with lumbar plexus deficit; and just how common is back pain?
Identifying cervical spine injuries in confused or comatose patients
with multiple injuries provides a diagnostic challenge. Our aim
was to investigate the protocols which are used for the clearance
of the cervical spine in these patients in English hospitals. All hospitals in England with an Emergency Department were asked
about the protocols which they use for assessing the cervical spine.
All 22 Major Trauma Centres (MTCs) and 141 of 156 non-MTCs responded
(response rate 91.5%).Aim
Patients and Methods
We analysed the influence of the timing of surgery (<
48 hours, group 1, 21 patients vs >
48 hours, group 2, 14 patients) on the neurological outcome and restoration of mobility in 35 incomplete tetra- and paraplegic patients with metastatic spinal-cord compression. Pain and neurological symptoms were assessed using the American Spinal Injury Association impairment scale. More improvement was found in group 1 than in group 2 when comparing the pre-operative findings with those both immediately post-operatively (p = 0.021) and those at follow-up at four to six weeks (p = 0.010). In group 1 the number of pre-operatively mobile patients increased from 17 (81%) to 19 patients (90%) whereas the number of mobile patients in group 2 changed from nine (64%) to ten (71%). These results suggest that early surgical treatment in patients with metastatic spinal-cord compression gives a better neurological outcome even in a palliative situation.
High-pressure injection injuries occur infrequently but are usually work-related and involve the non-dominant hand. The neck is a very rare site for such an injury. We describe the management of a 36-year-old man with a high-pressure grease-gun injection injury to his neck causing a cervical spinal cord injury. He developed severe motor and sensory changes which were relieved by surgical removal of the grease through anterior and posterior approaches.
We present a review of claims made to the NHS
Litigation Authority (NHSLA) by patients with conditions affecting the
shoulder and elbow, and identify areas of dissatisfaction and potential
improvement. Between 1995 and 2012, the NHSLA recorded 811 claims
related to the shoulder and elbow, 581 of which were settled. This
comprised 364 shoulder (64%), and 217 elbow (36%) claims. A total
of £18.2 million was paid out in settled claims. Overall diagnosis,
mismanagement and intra-operative nerve injury were the most common
reasons for litigation. The highest cost paid out resulted from
claims dealing with incorrect, missed or delayed diagnosis, with
just under £6 million paid out overall. Fractures and dislocations
around the shoulder and elbow were common injuries in this category.
All 11 claims following wrong-site surgery that were settled led
to successful payouts. This study highlights the diagnoses and procedures that need
to be treated with particular vigilance. Having an awareness of
the areas that lead to litigation in shoulder and elbow surgery
will help to reduce inadvertent risks to patients and prevent dissatisfaction
and possible litigation. Cite this article:
