John Thometz

Progression of scoliosis after skeletal maturity in institutionalized adults who have cerebral palsy.

To study the natural history of scoliosis in institutionalized adults who have cerebral palsy, we reviewed retrospectively the cases of fifty-one patients. The patients were followed for at least four years (mean, 16.3 years; range, four to forty years) after they had reached skeletal maturity. The individuals in whom the curve eventually progressed the most had had the largest curves at the time of skeletal maturity. The rate of progression was 0.8 degree each year in the patients in whom the curve was less than 50 degrees at the time of skeletal maturity and 1.4 degrees in those in whom the curve was more than 50 degrees (p less than 0.04). The patients who had the largest curves at the time of skeletal maturity had spastic quadriplegia and either a thoracolumbar or a lumbar curve, and they were bedridden.

Threaded K-wire spinous process fixation of the axis for modified gallie fusion in children and adolescents

A retrospective analysis of a technique for achieving atlantoaxial arthrodesis was performed. Fourteen patients underwent a modified Gallie technique, and all patients achieved successful arthrodesis with minimal restriction in rotation of the neck postoperatively. No patients showed neurologic deterioration. Fixation of a threaded K-wire to the spinous process of the axis improved the stability of the wiring technique, and we have been very successful in achieving atlantoaxial arthrodesis in the pediatric population.

The effect on gait of lengthening of the medial hamstrings in cerebral palsy.

The purpose of this study was to analyze the effect of lengthening of the medial hamstrings on the gait of patients who had spastic cerebral palsy. Thirty-one patients had preoperative and postoperative gait analyses. Standard parameters, such as velocity, cadence, and stride length, were evaluated, as were motion graphs of the hip, knee, and ankle. There was little difference between the preoperative and postoperative mean values for velocity, cadence, and stride length, which were expressed as percentages of normal for the patients age. The contours of the postoperative motion graphs of the knees changed very little compared with those of the preoperative graphs; when a graph showed restricted motion preoperatively, it did so postoperatively. Although extension of the knee in stance phase improved postoperatively, the improvement was accompanied by decreased flexion of the knee during swing phase. When spasticity of both the hamstrings and the quadriceps was noted on the preoperative electromyogram, motion of the knee in the sagittal plane was markedly restricted.

Gabapentin use in pediatric spinal fusion patients: a randomized, double-blind, controlled trial.

BACKGROUND: Gabapentin has opioid-sparing effects in adult surgical patients, but no reported studies have involved children and adolescents. In a double-blind, randomized, controlled trial, we examined whether gabapentin decreases postoperative opioid consumption for pediatric spinal fusion patients with idiopathic scoliosis. METHODS: Patients, aged 9 to 18 years, received preoperative gabapentin (15 mg/kg, treatment) or placebo. Anesthesia was standardized. After surgery, all patients received standardized patient-controlled analgesia opioid and continued on either gabapentin (5 mg/kg) or placebo 3 times per day for 5 days. Opioid use was calculated in mg/kg/time intervals. Pain scores and opioid side effects were recorded. RESULTS: Data from 59 patients (30 placebo and 29 gabapentin) did not differ in demographics. Total morphine consumption (mg/kg/h ± SD) was significantly lower in the gabapentin group in the recovery room (0.044 ± 0.017 vs 0.064 ± 0.031, P = 0.003), postoperative day 1 (0.046 ± 0.016 vs 0.055 ± 0.017, P = 0.051), and postoperative day 2 (0.036 ± 0.016 vs 0.047 ± 0.019, P = 0.018). In addition, gabapentin significantly reduced first pain scores in the recovery room (2.5 ± 2.8 vs 6.0 ± 2.4, P < 0.001) and the morning after surgery (3.2 ± 2.6 vs 5.0 ± 2.2, P < 0.05), but otherwise pain scores were not significantly different. There were no differences in opioid-related side effects over the course of the study. CONCLUSION: Perioperative oral gabapentin reduced the amount of morphine used for postoperative pain after spinal fusion surgery, but not overall opioid-related side effects. Initial pain scores were lower in the treatment group. Perioperative use of gabapentin seems to be an effective adjunct to improve pain control in the early stages of recovery in children and adolescents undergoing spinal fusion.

Relationship between Quantec measurement and Cobb angle in patients with idiopathic scoliosis.

The Quantec Spinal Imaging System (QSIS) is a raster stereography used to measure three-dimensional trunk images. The Q angle, a coronal plane measurement generated by the Quantec Spinal Imaging System (QSIS), was compared with the Cobb angle in assessment of scoliosis curve magnitude. One hundred forty-nine patients with idiopathic scoliosis were evaluated using both the Quantec system and plane radiographs. The Cobb and Q angles demonstrated significant correlation in the thoracic region (r = 0.65, p < 0.05), lumbar region (r = 0.63, p < 0.05), and in the thoracolumbar region (r = 0.70, p < 0.05). The difference between the Q and Cobb angles was small when the Cobb angle was <21 degrees with less than 6 degrees of axial surface rotation, as measured by the QSIS method. For smaller curves with minimal rotation, there is close correlation between the Cobb angle and the Quantec angle.

Functional classification of patients with idiopathic scoliosis assessed by the Quantec system: a discriminant functional analysis to determine patient curve magnitude.

Study Design. A stepwise discriminant analysis was used to define a spinal deformity score based on three-dimensional measurements by the Quantec spinal image system (raster stereophotograph). Objective. To provide functional classification of spinal deformity in patients with mild idiopathic scoliosis without using radiographs. Summary of Background Data. Most studies classify the degree of spinal deformity in terms of coronal plane radiograph without analyzing transverse rotation. To the authors’ knowledge, no studies investigating classification of spinal deformity in idiopathic scoliosis using Quantec system measurements have been documented. Methods. In this study, 129 patients with a single curve and 119 patients with a double curve were divided into three groups according to Cobb angle: Group 1 (less than 10°), Group 2 (10–20°), and Group 3 (greater than 20°). Results. The patients were assigned to the group with the highest scores after application of a stepwise discriminant analysis. The accuracy of the classification system by functional scores for the patients with a single curve was 85% for Group 1, 63.5% for Group 2, and 71.7% for Group 3. The accuracy of classification by functional scores for the patients with a double curve was 87.1% for Group 2 and 76.1% for Group 3. Conclusion. The back surface image study is a method for providing a quantitative assessment of mild spinal deformity, allowing evaluation of patients by integrated three-dimensional parameters with no reference to radiographs.

Screening for adolescent idiopathic scoliosis: an information statement by the scoliosis research society international task force

BackgroundRoutine screening of scoliosis is a controversial subject and screening efforts vary greatly around the world.MethodsConsensus was sought among an international group of experts (seven spine surgeons and one clinical epidemiologist) using a modified Delphi approach. The consensus achieved was based on careful analysis of a recent critical review of the literature on scoliosis screening, performed using a conceptual framework of analysis focusing on five main dimensions: technical, clinical, program, cost and treatment effectiveness.FindingsA consensus was obtained in all five dimensions of analysis, resulting in 10 statements and recommendations. In summary, there is scientific evidence to support the value of scoliosis screening with respect to technical efficacy, clinical, program and treatment effectiveness, but there insufficient evidence to make a statement with respect to cost effectiveness. Scoliosis screening should be aimed at identifying suspected cases of scoliosis that will be referred for diagnostic evaluation and confirmed, or ruled out, with a clinically significant scoliosis. The scoliometer is currently the best tool available for scoliosis screening and there is moderate evidence to recommend referral with values between 5 degrees and 7 degrees. There is moderate evidence that scoliosis screening allows for detection and referral of patients at an earlier stage of the clinical course, and there is low evidence suggesting that scoliosis patients detected by screening are less likely to need surgery than those who did not have screening. There is strong evidence to support treatment by bracing.InterpretationThis information statement by an expert panel supports scoliosis screening in 4 of the 5 domains studied, using a framework of analysis which includes all of the World Health Organisation criteria for a valid screening procedure.

Severe osteomyelitis caused by Myceliophthora thermophila after a pitchfork injury

BackgroundTraumatic injuries occurring in agricultural settings are often associated with infections caused by unusual organisms. Such agents may be difficult to isolate, identify, and treat effectively.Case reportA 4-year-old boy developed an extensive infection of his knee and distal femur following a barnyard pitchfork injury. Ultimately the primary infecting agent was determined to be Myceliophthora thermophila, a thermophilic melanized hyphomycete, rarely associated with human infection, found in animal excreta. Because of resistance to standard antifungal agents including amphotericin B and caspofungin, therapy was instituted with a prolonged course of terbinafine and voriconazole. Voriconazole blood levels demonstrated that the patient required a drug dosage (13.4 mg/kg) several fold greater than that recommended for adults in order to attain therapeutic blood levels.ConclusionUnusual pathogens should be sought following traumatic farm injuries. Pharmacokinetic studies may be of critical importance when utilizing antifungal therapy with agents for which little information exists regarding drug metabolism in children.

Long-Term Follow-Up of the Flexor Carpi Ulnaris Transfer in Spastic Hemiplegic Children

A retrospective study was performed on 25 patients with cerebral palsy who underwent transfer of the flexor carpi ulnaris to the radial wrist extendors. The mean age at the time of surgery was 8 years 1 month. The mean follow-up was 8 years 7 months. At follow-up, the mean active wrist dorsiflexion was 44.2°, palmar flexion was 19.0°, supination was 40.2°, and pronation was 53.4°. According to a modification of Greens evaluation system, there were six excellent, nine good, five fair, and five poor results. Two patients required further surgery to correct a supination, dorsiflexion contracture. We found the transfer to be quite effective in improving wrist dorsiflexion, although there was often a significant loss of active palmar flexion postoperatively. The patient therefore should have good digital extension (with the wrist extended passively above neutral) to be considered for the transfer.

Deformity of the calcaneocuboid joint in patients who have talipes equinovarus.

A retrospective analysis was done of the records and radiographs of 100 club feet (in sixty-six patients) that had been consecutively treated with an operation. Twenty-six feet (26 per cent) had had a Grade-II deformity of the calcaneocuboid joint, as determined with a radiographic classification that had been developed on the basis of the degree of medial displacement of the cuboid. When the calcaneocuboid joint is in normal alignment, the central point of the cuboid ossification center lies on the mid-longitudinal axis of the calcaneus; when there is a Grade-I deformity, the mid-point of the cuboid ossification center lies lateral to the medial tangent but medial to the longitudinal axis of the calcaneus; and when there is a Grade-II deformity, the central point of the cuboid lies on or medial to the medial tangent of the calcaneus. Although a Grade-I deformity of the calcaneocuboid joint need not be corrected, a Grade-II deformity should be treated with release of the calcaneocuboid joint, which in this series was performed in conjunction with a complete subtalar release (including a talonavicular release). Sixteen of the twenty-six feet that had a Grade-II deformity had a complete release of the calcaneocuboid joint at the time of the operation; the release was not done in the remaining ten feet, some of which were operated on early in the series, before the importance of the deformity at the calcaneocuboid joint had been recognized.(ABSTRACT TRUNCATED AT 250 WORDS)