Dror Ovadia

The Use of Three-Dimensional Computed Tomography in Evaluating Snapping Scapula Syndrome

This article evaluates imaging of the scapula and scapulothoracic joint in patients with snapping scapula syndrome. Between 1990 and 1996, a total of 20 patients (10 men and 10 women) with snapping scapula syndrome were evaluated. Diagnosis was based on patient complaints and physical examination findings. There were 26 affected scapulae (6 patients had bilateral presentation). Imaging of the scapula included plain radiography, computed tomography (CT), and 3-dimensional computed tomography (3-D CT) reconstruction. Plain radiography revealed bony incongruity between the anterior aspect of the scapula and the chest wall in 7 scapulae, CT revealed such incongruity in 19 scapulae, and 3-D CT revealed incongruity in all 26 scapulae. Treatment was conservative, consisting of nonsteroidal anti-inflammatory drugs, a physiotherapy program, and subscapular injection of a local anesthetic and steroids. In 5 patients who responded poorly to conservative treatment, the region responsible for the snapping was resected. Pain relief and resolution of the snapping were complete following surgery in 4 patients, while pain and crepitation persisted in the fifth. Three-dimensional CT is recommended as the main imaging modality in the evaluation of any patient with snapping scapula syndrome who is a candidate for surgical intervention.

Whiplash injury--a retrospective study on patients seeking compensation

The purpose of this cohort study is to evaluate the objective long-term findings and the final outcome of a population suffering from whiplash-associated disorders (WAD) after rear-end car collision and claiming legal compensation. Eight hundred and sixty-six patients after whiplash injury were followed up on average 32 months post-trauma. All patients had clinical examination and radiographs performed on the day of the accident and at follow up. MRI, CT scan, bone scan, electromyographic (EMG) tests were performed upon request of the treating physician and correlated by the authors with the clinical findings. Cervical pain was the most common complaint (96%). Radiating pain to one side of the upper limbs or the shoulder was also very common (36 and 24%, respectively). Chin to chest test was found to be a strong indicator in differentiating between the less severe (grades 1 and 2) to more severe (grades 3 and 4) WAD patients. In 10% of the patients with normal radiographic findings, degenerative changes were found at follow up. CT scan and MRI did not add to patient diagnosis, except for those patients suffering from degenerative changes and decreased range of motion (RoM). Based on our findings the initial radiograph taken in the emergency room was the best imaging modality and probably the only one needed routinely following whiplash injury. Although this is a special subgroup of patient seeking compensation, the overall prognosis is favorable in all grades of WAD injury and there is no need for further diagnostic expenditures.

Successful conservative treatment for neglected rotatory atlantoaxial dislocation.

Background: Rotatory atlantoaxial subluxation (RAS) is a rare condition that is often misdiagnosed and therefore incorrectly managed. We describe our experience and propose an algorithm for treating neglected RAS nonoperatively. Methods: All consecutive children with neglected (>6 wk) RAS were treated in our department between 2005 and 2010 by cervical traction using a Gleason traction device and nonsteroidal anti-inflammatory drugs and muscle relaxants. When reduction was not achieved, the Gleason device was replaced by a halo device without manipulative reduction, and weight was added as necessary until reduction was successful. Fixation of reduction was either by a sternooccipital mandibular immobilizer or a halo vest for 3 to 4 months. Results: All 5 children (4 boys and 1 girl, aged 4 to 11 y) were successfully treated for neglected RAS. The mean duration from symptom onset (eg, limited neck range of motion, discomfort) to treatment initiation was 11.6 weeks (range, 6 to 16 wk). Closed reduction was achieved by a Gleason or a noninvasive halo device within 1 to 2 weeks in 4 cases. The fifth case was reduced after 5 weeks of traction using a halo with a 5 kg weight. All children had symmetrical full range of motion, normal neurological examination, and were fully engaged in educational and sports activities without recurrent dislocations at final follow-up (mean, 30 mo; range, 18 to 49 mo). Conclusions: Conservative treatment by gradual and prolonged traction without manipulative reduction in neglected RAS might be a successful method. Reduction can often be achieved within 2 weeks of treatment onset. Level of Evidence: Level IV (retrospective case series).

Malignant bone and soft tissue tumors of the shoulder girdle a retrospective analysis of 30 operated cases

From 1988 to 1995, 30 patients (16 men) with malignant bone (n 23) and soft tissue (n 7) tumors of the shoulder girdle underwent surgery in our department. The mean age was 34 (6-80) years. 26 patients had primary and 4 had metastatic lesions. The average follow-up period was 3 (2-8) years, at the end of which 18 patients showed no evidence of disease, 2 were alive with disease, and 10 had died (9 because of tumor). 25 of the operations were limb-sparing procedures, while the other 5 were major amputations. Radical resection was performed in 4 patients, wide resection in 25 and marginal resection in 1. Local recurrence was observed in 2 patients. 10 patients with stage IIB tumors of the proximal humerus underwent extraarticular humeral and glenoid resection. Reconstruction was performed with either a modular or an improvised implant. Following surgery, those patients had a concave contour of the shoulder and poor abduction ability. Overall functional outcome was good in 18 patients, moderate in 11 and poor in 1. No correlation was found between functional outcome and reconstruction technique.

The Contribution of an Electronic Conductivity Device to the Safety of Pedicle Screw Insertion in Scoliosis Surgery

Study Design. Retrospective, controlled clinical study. Objective. To evaluate the contribution of an electronic conductivity device (ECD) to the safety of pedicle screw insertion in pediatric scoliosis surgery. Summary of Background Data. The implantation of pedicle screws in spinal deformity correction surgery has evolved into the currently predominant fixation technique. Methodologies for optimizing placement of pedicle screws are fluoroscopy, electromyography, and intraoperative image-based navigation. A hand-held ECD was recently introduced. Methods. Pedicle screw insertion was analyzed in 248 pediatric scoliosis patients (idiopathic, congenital, neuromuscular, syndromatic). Group I included 150 procedures without the aid of the ECD and group II included 98 ECD-aided procedures. The two groups were matched by age, sex, etiology, Cobb angle, and surgical criteria. Data on screw position and concomitant neuromonitoring alarms were compared. Group I consisted of patients operated with both the hybrid construct and pedicle screw instrumentation, while group II consisted of patients operated solely with pedicle screws. Both groups were operated on by a single surgeon with the same neurophysiologic methodology. Clinically relevant misplaced pedicle screws were established by intraoperative monitoring alarms concomitant with pedicle screw insertion. Results. A total of 1270 pedicle screw placements were analyzed in group I and compared with 1400 pedicle screw placements in group II. Neuromonitoring alarms concomitant with screw placement occurred in 10 procedures in group I (6.6%) compared with 3 in group II (3.0%). The contribution of the electronic device to reducing the number of neurophysiologic alarms was significant (P = 0.048, Fisher exact test). Nine of the 13 monitoring alarms (69%) were associated with implantation adjacent to the apex of the spinal curve. Conclusion. The use of an ECD significantly reduced the incidence of clinically relevant misplaced screws in a variety of scoliosis patients, thereby increasing the safety of pedicle screw implantation.

Whiplash injury: is there a role for electromyographic studies?

IntroductionThis retrospective study was undertaken to assess the value of carrying out baseline and follow-up electromyography (EMG) for patients with whiplash-associated disorders (WAD, grades I and II) after they had undergone rear-end car collisions, and to determine if there is any agreement with clinical and imaging (CT and MRI) findings.Materials and methodsWe carried out a retrospective review of 330 patients seeking compensation after rear-end car collisions. The treating physician referred all patients for EMG studies in the post-injury follow-up period and for additional CT scans and MRIs. All patients underwent physical and X-ray examination by the senior author (SD), and 75 patients with persistent radicular complaints were referred again for EMG studies. The results of the association between patient complaints, clinical examination, and EMG, CT and MRI studies are reported.ResultsWe sought but failed to find any correlations between 354 EMG results with those of 278 CT scans and 75 MRIs. Both subjective complaints and early vs late EMG abnormalities showed statistical agreement and persistency of findings only at disc level C7/D1.ConclusionsOur data indicate that follow-up EMG studies for patients with WAD do not contribute any useful information for patient management.

Floating tibia-talus complex--an ipsilateral dislocation of the knee and the subtalar joint in an elderly patient: a case report and review of the literature.

Knee dislocation is defined as a radiographically confirmed total loss of the tibiofemoral articulation. This rare injury is believed to be the result of a high-impact trauma. Knee dislocations are classified according the direction of tibial displacement with respect to the femur. Subtalar dislocation is the simultaneous dislocation of the distal articulations of the talus at both the talocalcaneal and talonavicular joints. These injuries are also quite rare and are mostly (80%-85%) classified as medial subtalar dislocations with the calcaneus lying medially, the head of the talus being prominent dorsolaterally and the navicular located medial and dorsal to the talar head. The authors report the case of an elderly patient who suffered ipsilateral anterior dislocation of his left knee and medial subtalar dislocation of his left foot. The authors believe this to be the first presentation in the English literature of an ipsilateral combination of these two injuries on the same limb.

T1-weighted MR imaging of bone marrow pattern in children with adolescent idiopathic scoliosis: a preliminary study

Purpose Distinct normal physiological patterns of fat conversion in vertebrae were described both for children and adults. Our aim was to evaluate the T1-weighted bone marrow pattern of the vertebral bodies in various sites along the scoliotic spine of children with adolescent idiopathic scoliosis (AIS). Methods We retrospectively evaluated spine MRI studies of children with AIS. Scoliosis radiographs were assessed for type of curvature according to the Lenke classification. A paediatric neuroradiologist assessed the T1-weighted signal of vertebral bodies in comparison with the adjacent disc and distinct patterns of fatty conversion within the apical and stable vertebral bodies. Statistical assessment was performed. Results MRI study of the spines of 75 children with AIS were assessed, 59 (79%) of whom were female, with an age range of nine to 19 years. The relative overall T1-weighted signal intensity of the vertebral body bone marrow relative to the intervertebral disc was hyperintense in 76% and isointense in 24%. Fatty conversion grade of the stable vertebra was higher than the apex vertebra (p = 0.0001). A significant tendency to have more advanced fat conversion patterns in the apex vertebra up to age 13.5 years old compared with adolescents above that (p = 0.015) was seen. Conclusion This preliminary study suggests a different pattern of bone marrow conversion in AIS from the normal physiologic pattern described in the literature. Whether these changes are secondary to the biomechanics of the curved spine or may suggest that bone marrow maturation rate and content have a role in the pathogenesis of AIS remains to be further researched. Level of Evidence Level III (Diagnostic Study)