Alwyn Jones

Recurrence of kyphosis and its functional implications after surgical stabilization of dorsolumbar unstable burst fractures

BACKGROUND CONTEXT Treatment of unstable burst fractures in the dorsolumbar spine still remains controversial. Surgical stabilization has been aimed to prevent long-term back pain and progression of deformity. PURPOSE This study was aimed to analyze the degree of loss of correction of the angle of kyphosis with pedicle screw instrumentation in place and the components responsible for the recurrence of kyphosis after surgical stabilization of dorsolumbar A3 fractures and to assess the return of functional capacity in these patients. STUDY DESIGN Retrospective study. PATIENT SAMPLE This study involves 26 patients who had dorsolumbar unstable burst fractures (Arbeitsgemeinschaft für Osteosynthesefragen type A3). OUTCOME MEASURES Radiological assessment at injury, immediate postoperative period, and most recent follow-up along with functional assessment using short form 36 (SF-36) and return to work. METHODS All the patients had posterior pedicle screw instrumentation without fusion for unstable dorsolumbar burst compression (A3) fractures. The mean follow-up period was 25.5 months. All of them had their fractures stabilized with Universal Spinal System (Synthes, Welwyn Garden City, UK) Fracture System. Serial standing lateral radiographs were taken from the immediate postoperative period to the most recent follow-up. The angle of kyphosis; the heights of the discs above and below the fractured vertebra; and the heights of the vertebral bodies above, at, and below the fractured level were measured. The height at each level was measured in three segments (anterior, middle, and posterior). The values were normalized to avoid discrepancies while comparing radiographs. The difference in the height of each segment measured between the immediate postoperative period and the most recent follow-up was computed. RESULTS The mean angle of kyphosis was 6.3+/-8.9 in the immediate postoperative period and 15.7+/-6.7 at the most recent follow-up (p<.001). The mean patient function score from SF-36 was 52.3%, and the mean pain score was 44.9%. There was no relationship to the loss of correction angle of kyphosis to the patient function score (r=0.06, p=.76) and the pain score (r=0.11, p=.58). The correlation between the corresponding difference in the height of each segment and the degree of loss of correction of the angle of kyphosis showed positive correlation to the decrease in the anterior and middle segment heights at the fractured vertebral level. CONCLUSION There is a progressive loss of correction of the angle of kyphosis after posterior stabilization with instrumentation even without implant removal that mainly corresponds to the decrease in the anterior segment height of the fractured vertebral body.

Is return to professional rugby union likely after anterior cervical spinal surgery

We have examined the outcome in 19 professional rugby union players who underwent anterior cervical discectomy and fusion between 1998 and 2003. Through a retrospective review of the medical records and telephone interviews of all 19 players, we have attempted to determine the likelihood of improvement, return to professional sport and the long-term consequences. We have also attempted to relate the probability of symptoms in the neck and radicular pain in the arm to the position of play. Neck and radicular pain were improved in 17 patients, with 13 returning to rugby, the majority by six months after operation. Of these, 13 returned to their pre-operative standard of play, one to a lower level and five have not played rugby again. Two of those who returned to the game have subsequently suffered further symptoms in the neck, one of whom was obliged to retire. The majority of the players with problems in the neck were front row forwards. A return to playing rugby union after surgery and fusion of the anterior cervical spine is both likely and safe and need not end a career in the game.

Do magnetic growing rods have lower complication rates compared with conventional growing rods

BACKGROUND CONTEXT The main advantage cited for the use of the magnetic controlled growing rod (MCGR) system over the conventional growing rod (CGR) in early-onset scoliosis is avoiding repeated invasive surgical procedures for lengthening, thus reducing, complications. PURPOSE The study aimed to evaluate the complications of the MCGR system against the CGR system in our center. STUDY DESIGN/SETTING This is a retrospective case control series. PATIENT SAMPLE The sample includes patients with early-onset scoliosis treated with MCGR or CGR. OUTCOME MEASURES Complications and unplanned return to theater were the outcome measures. RESULTS Of the 37 patients (MCGR, N=10; CGR, N=27) in our cohort, 28 patients (76%) had at least one complication. Taking into account the follow-up period, MCGR had a higher complication rate than CGR group (0.32 complication per patient per year vs. 0.15 complication per patient per year). The use of MCGR was associated with a lower risk of deep infection (odds ratio [OR]: 0.22; p=.22) and superficial infection (OR: 0.07, p=.017) but increased risk of metalwork problems (OR: 4.67; p=.045) and unplanned return to theater (OR: 2.92; p=.05) compared with CGR. CONCLUSIONS Although MCGR has a lower rate of both deep and superficial infections when compared with CGR, it does not completely avoid repeated invasive surgical procedures as previously suggested. It does have a significant increased risk of metalwork problems and unplanned return to theater.

Surgical management of severe cervical kyphosis with myelopathy in osteogenesis imperfecta: a case report.

Study Design. A case of a 9-year-old child with Osteogenesis Imperfecta and severe cervical kyphosis associated with wedged vertebrae and progressive neurological deterioration is presented. Objective. To highlight the difficulties in surgical management of this condition and to discuss the appropriate surgical approach. Summary of Background Data. This case demonstrates an unusual case of Osteogenesis Imperfecta with associated wedged vertebrae causing a quadriparesis. Surgical decompression and stabilization can be performed with resolution of symptoms even in this age group with the appropriate approach and implants. Methods. A 9-year-old girl presented with progressive cervical kyphosis and quadriparesis. At the age of 3 years, she underwent posterior cervical fusion (C1–C6) for instability. Radiological and laboratory investigations confirmed the diagnosis of Osteogenesis Imperfecta, and radiographs of the cervical spine revealed a kyphotic deformity of 120°. Magnetic resonance imaging and computerized tomography scans showed anterior cord compression attributable to wedged vertebrae at C3 and C4. Magnetic resonance imaging-angiography was performed before surgery to identify the anatomic position of the vertebral arteries. A modified anterolateral approach to the upper cervical spine was performed, and anterior C3 and C4 corpectomies with interbody cage and plate fixation were carried out. Results. After surgery the patient made a full neurological recovery, and significant correction of the deformity was achieved and maintained at follow-up. Conclusions. Cervical kyphotic deformity in Osteogenesis Imperfecta is uncommon. Association of this condition with wedged vertebrae is rare. Surgical decompression of the upper cervical spine is a challenging problem in the presence of this deformity. Which surgical approach to use is controversial. There are difficulties exposing wedged vertebrae by a standard anterior approach, and hence we have used a modified anterolateral approach to address this surgical problem, because a posterolateral approach was impossible with the intervening vertebral arteries. Spinal stabilization in children with Osteogenesis Imperfecta and poor bone stock is a challenge. We have used a small diameter MOSS cage (“Harms mesh cage”) with maxillofacial plate and screws to achieve stabilization and fusion.

Anterior screw fixation for a pediatric odontoid nonunion: a case report.

Study Design. A case of an odontoid nonunion in a child treated with anterior screw fixation. Objectives. To demonstrate that an anterior screw procedure can be performed with an odontoid nonunion with resultant fusion to maintain range of motion. Methods. A 15-year-old boy presented with pain in his neck following a rugby football injury. Admission plain radiographs and computed tomography scan demonstrated an odontoid nonunion. Radiographs of a previous cervical spine injury 2 years before demonstrated a missed odontoid fracture. Results. The child was initially treated conservatively with halo vest immobilization, which did not result in healing. Direct anterior screw fixation was performed and the fracture united 5 months following surgery. Discussion. The nonunion was asymptomatic for 2 years until the second injury when it became clinically symptomatic. It did not respond to conservative treatment and was unstable on screening requiring operative intervention. Conclusions. Very few cases have been reported of pediatric odontoid nonunions. If the fracture pattern allows, then direct anterior screw fixation should be considered in order to maintain range of motion at the atlantoaxial articulation.

Avulsion of the L4 spinous process: an unusual injury in a professional rugby player: case report.

Study Design. A case of L4 spinous process avulsion following a hyperflexion injury treated with surgical excision. Objective. To show that single photon emission computerized tomography is essential for the diagnosis and that excision can provide a successful outcome. Summary of Background Data. The avulsion resulted from a forced hyperflexion injury at the L4/5 area, where the interspinous ligament provides a high resistance to flexion. Methods. A 29-year-old international rugby football player injured his low back during a match. Plain radiography and magnetic resonance imaging did not reveal the injury. Single photon emission computerized tomography and computerized tomography showed the lesion. Results. Initial conservative therapy failed to control the symptoms, and, therefore, late excision was performed with pain-free return to contact sports at 3 months. Conclusions. Few cases of interspinous process avulsions have been described, and, to our knowledge, this is the first reported case of rugby football player who had a successful outcome with late surgical excision.