Judith Sanchez-Raya

Does the lower instrumented vertebra have an effect on lumbar mobility, subjective perception of trunk flexibility, and quality of life in patients with idiopathic scoliosis treated by spinal fusion?

Study Design: Cross-sectional study in patients with idiopathic scoliosis treated with spinal fusion. Objectives: To measure lumbar spine mobility in the study population; determine low back pain intensity (LBPi), subjective perception of trunk flexibility (TF), and quality of life using validated outcome instruments; and investigate correlations of the lower instrumented vertebra (LIV) with TF, LBPi, and quality of life. Summary of Background Data: The loss of range of motion resulting from spinal fusion might lead to low back pain, trunk rigidity, and a negative impact on quality of life. Nonetheless, these outcomes have not been conclusively demonstrated because lumbar mobility and LIV have not been correlated with validated outcome instruments. Methods: Forty-one patients (mean age, 27 y) with idiopathic scoliosis treated by spinal fusion (mean time since surgery, 135 mo) were included. Patients were assigned to 3 groups according to LIV level: group 1 (fusion to T12, L1, or L2) 14 patients; group 2 (fusion to L3) 13 patients, and group 3 (fusion to L4, L5, or S1) 14 patients. At midterm follow-up, patients completed the Scoliosis Research Society (SRS)-22 Questionnaire and Quality of Life Profile for Spine Deformities to evaluate perceived TF, and rated LBPi with a numerical scale. Lumbar mobility was assessed using a dual digital inclinometer. Results: Group 3 (fusion to L4, L5, or S1) showed statistically significant differences relative to the other groups, with less lumbar mobility and poorer scores for the SRS subtotal (P=0.003) and SRS pain scale (P=0.01). Nevertheless, LBPi and TF were similar in the 3 groups. TF correlated with SRS-22 subtotal (r=−0.38, P=0.01) and pain scale (r=−0.42, P=0.007) scores, and with LBPi (r=0.43, P=0.005). Conclusions: LIV correlated moderately with lumbar mobility, health-related quality of life (SRS-22), and spinal pain (SRS-22 pain subscale), but not with intensity of pain in the lumbar area or perceived TF.

Increased infection risk after hip hemiarthroplasty in institutionalized patients with proximal femur fracture

In patients undergoing hip hemiarthroplasty (HHA) secondary to proximal femur fracture, acute periprosthetic joint infection (PJI) is one of the most important complications. We have detected an increased risk of PJI in chronic institutionalized patients (CIPs), and a higher number of early postoperative infections are caused by Gram-negative bacteria (GNB), not covered by the current prophylaxis (cefazolin in noninstitutionalized patients (NIPs) and cotrimoxazole in CIPs). We sought to compare infection characteristics between NIPs and CIPs, analyzing predisposing factors, causative pathogens, and antibiotic prophylaxis-related microbiological characteristics. We performed a retrospective review of our prospective institutional database to identify all patients consecutively admitted for HHA to treat proximal femur fracture at our centre between 2011 and 2013. PJI was diagnosed in 21 of 381 (5.51%) patients, with 10 of 105 (9.52%) in the CIP group and 11 of 276 (3.99%) in the NIP group, and statistical significance was achieved. GNB accounted for PJI in 14 (66.67%) patients. We detected a single case of methicillin-resistant Staphylococcus aureus (MRSA) infection in the NIP group. We confirm a higher risk of acute PJI among institutionalized patients, commonly caused by Gram-negative microorganisms, which are not covered by the current prophylaxis. New prophylactic strategies should be investigated in order to reduce this problem.

Functional results in young adults with spina bifida. A comparative study among two therapeutic periods

Background At least 75–85% of children born with Spina Bifida (SB) are expected to reach their early adult years. The growing adult SB population encounters a variety of complications including neurological, neurosurgical, cognitive, psychosocial, renal/urological, bowel management, mobility, musculoskeletal/orthopedic, sexual function, skin, and others. Materials and methods We compared two cohorts of adult patients with the diagnosis of Myelomeningocele, Meningocele, and Sacral anomalies associated with Meningocele, regularly controlled in our multidisciplinary SB Unit and treated in two different therapeutical periods. The first series included patients born before 1974 whereas the patients in the second series were born between 1982 and 1989. We collected the data from the medical history, radiographic records and also performed an interview with each patient included in this study. We collected information concerning two aspects: medical and social variables. The medical data included diagnosis, functional neurological level, shunted hydrocephalus, vertebral malformations, intelligence quotient (IQ), urological and faecal incontinence, reeducation of incontinence, orthosis and type of gait. The social data included level of education, employment, marital status and driving licence. We developed a questionnaire with 15 secondary conditions associated with SB which had to be filled in order of importance by all patients with normal or borderline IQ as per Wechsler Scale. Results A total of 206 patients were included in this study: 104 patients in the first series and 102 in the second one. Both series were homogeneous in relation to gender, functional neurological level and diagnosis. We found differences statistically significant in both series in relation to shunted hydrocephalus (p=0.001), spinal deformity (p=0.043), urinary re-education and collection method (p= 0.000), faecal re-education method (p=0.000), gait orthosis (p= 0.045), and educational level (p=0.000) reflecting an improvement in the second series. We found no differences in both series in relation to IQ, incontinence, ambulation, work incorporation, marital status and driving license. Regarding the personal questionnaire, there were statistically significant differences in the perception of both samples in relation to pressure ulcers (p=0.022), urinary incontinence (p=0.001), faecal incontinence (p=0.014), urinary infection (p=0.019), IQ (p=0.012), and sexual activity (p=0.000). Conclusions Management of the musculoskeletal, bowel, bladder, renal, neurological systems, and other issues in SB patients have changed and improved in the last years, regarding not only diagnostic and therapeutic procedures but also a coordinated interdisciplinary team approach that has lead these patients to reach adulthood in better conditions.

Current situation of young adults in a multidisciplinary spina bifida unit

Results A total of 100 patients were included in this study: 57 male and 43 female. The mean age was 21.3 (± 2.3, range 18–25) years. Myelomeningocele represented 91% of the sample. Regarding functional neurological level, 70% of patients belonged to lumbar (medium and low) or sacral. Hydrocephalus was present in 92% of them and 65% required the placement of a shunt. A total of 48% of the sample had a normal IQ. The 59% of the cases had some type of spinal deformity. 57 patients reached community ambulation whereas 24 were wheelchair-dependent. All patients except one case of meningocele were urine incontinent. Faecal and urinary re-education was achieved in 77.5% and 75.3% of our patients respectively. On the social aspect, the majority of our patients were single, had no children, were living with their parents and had a low educational level and work incorporation.

Responsiveness of Image Perception Outcome Scales After Surgical Treatment of Idiopathic Scoliosis: A Comparison Between the Trunk Appearance Perception Scale (TAPS) and Scoliosis Research Society–22 (SRS-22) Questionnaire

STUDY DESIGN Retrospective study of prospectively collected longitudinal data. OBJECTIVES To analyze the Trunk Appearance Perception Scales (TAPSs) responsiveness to surgical treatment of idiopathic scoliosis (IS). TAPS is a drawing-based instrument to assess trunk deformity in IS. It shows appropriate metric properties, such as internal consistency and discriminant validity. However, no data on responsiveness to surgical treatment is available. METHODS A total of 109 patients (85.3% females) with IS were included (mean age at surgery 18 years). In all the cases, surgery consisted of posterior spine fusion and instrumentation. The magnitude of the largest curve (MLC) was 63.8° before surgery and 26.3° (correction 58.3%) at a mean follow-up of 20.8 months. Internal and external responsiveness were analyzed on the basis of effect size (ES), standardized response mean (SRM), minimum detectable change (MDC), and correlation between percentage of MLC correction and outcome measure change. Data for TAPS were compared to those of SRS-22 Image domain. RESULTS TAPS showed somewhat larger internal responsiveness (ES 1.96, SRM 1.73, 86.2% of patients exceeding MDC) than SRS-22 Image scale (ES 1.44, SRM 1.29, 73.4% of patients exceeding MDC). No correlation was found between the percentage of MLC correction and baseline to follow-up change in TAPS or SRS-22 Image scores. CONCLUSION The TAPS instrument shows adequate responsiveness to surgical treatment of idiopathic scoliosis and is somewhat larger than SRS-22 Image domain data. The lack of correlation between radiologic correction and clinical improvement indicates that the two outcomes must be independently collected. These data on responsiveness complete the TAPS validation process. TAPS is a valid, reliable, and responsive instrument to evaluate the outcome of surgical treatment of idiopathic scoliosis. LEVEL OF EVIDENCE Level IV.STUDY DESIGN Retrospective study of prospectively collected longitudinal data. OBJECTIVES To analyze the Trunk Appearance Perception Scales (TAPSs) responsiveness to surgical treatment of idiopathic scoliosis (IS). SUMMARY OF BACKGROUND DATA TAPS is a drawing-based instrument to assess trunk deformity in IS. It shows appropriate metric properties, such as internal consistency and discriminant validity. However, no data on responsiveness to surgical treatment is available. METHODS A total of 109 patients (85.3% females) with IS were included (mean age at surgery 18 years). In all the cases, surgery consisted of posterior spine fusion and instrumentation. The magnitude of the largest curve (MLC) was 63.8° before surgery and 26.3° (correction 58.3%) at a mean follow-up of 20.8 months. Internal and external responsiveness were analyzed on the basis of effect size (ES), standardized response mean (SRM), minimum detectable change (MDC), and correlation between percentage of MLC correction and outcome measure change. Data for TAPS were compared to those of SRS-22 Image domain. RESULTS TAPS showed somewhat larger internal responsiveness (ES 1.96, SRM 1.73, 86.2% of patients exceeding MDC) than SRS-22 Image scale (ES 1.44, SRM 1.29, 73.4% of patients exceeding MDC). No correlation was found between the percentage of MLC correction and baseline to follow-up change in TAPS or SRS-22 Image scores. CONCLUSION The TAPS instrument shows adequate responsiveness to surgical treatment of idiopathic scoliosis and is somewhat larger than SRS-22 Image domain data. The lack of correlation between radiologic correction and clinical improvement indicates that the two outcomes must be independently collected. These data on responsiveness complete the TAPS validation process. TAPS is a valid, reliable, and responsive instrument to evaluate the outcome of surgical treatment of idiopathic scoliosis. LEVEL OF EVIDENCE Level IV.

Prosthetic Limb Options for Below and Above Knee Amputations: Making the Correct Choice for the Right Patient

Purpose of ReviewThis review focuses on the options that are available for people who have had below and above knee amputations.Recent FindingsProsthetic limbs have evolved, with substantial technological advancements in the past two decades. However, the most sophisticated device is not the most appropriate for everyone. Osseointegration appears to have become an established treatment option for a selected group of patients with limb amputation. However, there is sufficient evidence to fully inform patients as to the possible risks and complications compared with the benefits. The active prostheses clinical research is limited to prototypes and low number of subjects, although test results show the potential to restore the functional performance of an amputee.SummaryThis review article highlights the prosthetic options that are available for people who have had below and above knee amputations. The development of osseointegration and active prostheses is a challenging task and thus should remain subject to future research including extended clinical evaluations.

Degree of suitability of information (DSI) for children with idiopathic scoliosis and their parents

Background As parents and their children increasingly use Internet website to obtain information about Adolescent Idiopathic Scoliosis (AIS), a growing need to evaluate the content quality of websites is emerging. Bettany-Saltikov et al. and MacCulloch et al. have suggested some suitable requirements that websites on scoliosis should include. From these suggestions, we have created an instrument to quantify this suitability.

Poster 226: Comparative Study of the Functional Results in Young Adults With Spina Bifida During Two Therapeutic Periods. A Case Series

Disclosures: R. L. Kriel, Medtronic Inc, Research grants Objective: Using a dog model, assess the safety and tolerance of intravenous (IV) baclofen. Design: Prospective, crossover, non-blinded after approval from IACUC. Setting: University veterinary science laboratory. Participants: 6 adult hound-mix dogs, 19-25 kg. Interventions: The first 2 dogs received an oral baclofen dose of 10 mg. After a 1-day washout, the same dogs received a 10-mg dose as an IV bolus (2 mg/mL concentration) over 5 minutes. The oral tablet was crushed, suspended in 5 mL of water and administered into the posterior pharynx. The dogs were not sedated. The subsequent 4 dogs were entered into a dose escalation study to determine limits of clinical tolerance and to correlate clinical observation with blood level. The same clinical observation scales were used. Boluses of 0.5, 1.0 and 1.5 mg/kg were given followed by constant infusion of baclofen (rates of 0.1, 0.2 and 0.4 mg/kg/h). Main Outcome Measures: Vital signs, modified Glasgow Coma Scale for Dogs, Discomfort and Behavior Scale. Blood samples were obtained during the observation period for determination of baclofen levels. Results: The boluses of 0.5 mg/kg and 1.0 mg/kg were tolerated with little or no clinical effect, however within 30 minutes of beginning the constant infusion of 0.2 mg/kg/h after the second bolus (1.0 mg/kg) dogs became progressively sedated and ataxic. At the highest dosages, vomiting, profuse salivation, and stupor occurred. At that time infusions were stopped and the dogs were allowed to recover while receiving IV hydration. They recovered to their baseline status within 3-6 hours. Oral bioavailability in the first 2 dogs was 0.66 and 0.69. Half-lives after intravenous administration were 3.32 and 3.58 hours indicating that baclofen was accumulating during infusions. Conclusions: IV baclofen bolus doses of 0.5 and 1.0 mg/kg were tolerated. Definite, but reversible, toxicity occurred at higher plasma baclofen concentrations.

Poster 98: Are Low-Trauma Wrist Fractures Predictive of Osteoporosis? A Case Series

Disclosures: G. A. Sowa, None. Objective: Mechanical loading has been shown to affect intervertebral disk matrix homeostasis. We have previously demonstrated that compression results in a time and magnitude dependent alteration in expression of genes involved in matrix homeostasis in vitro. The current study extends this work into an animal model to characterize the effects of chronic cyclic compression on intervertebral disk collagen homeostasis in vivo. Design: Controlled laboratory animal study. Setting: Laboratory. Participants: NA. Interventions: Cyclic axial compression was applied in vivo to a functional spine unit in New Zealand white rabbits via a novel custom designed loading apparatus at 2.5 MPa at 0.5 Hz (low frequency) and 5.0 Hz (high frequency) for 2 h/d, 5 d/wk. Main Outcome Measures: Serum was collected after 18, 24, 28, 34, and 38 weeks of loading and analyzed for CTX-II (a marker of collagen II breakdown). After sacrifice, the annulus fibrosis (AF) and nucleus pulposus (NP) were harvested from the loaded segments. Gene expression analysis was used to compare collagen II expression to unloaded controls. Results: Serum CTX-II levels were higher in the high-frequency animals than low frequency or control animals at all time points. Low-frequency animals demonstrated elevation of CTX-II levels over controls only after 38 weeks of loading. In the AF, gene expression of collagen II was decreased compared with control at 10 weeks in the low-frequency group but elevated in both low and high frequency groups after 30 weeks of loading and in all NP samples. Conclusions: Collagen remodeling appears to become more apparent after increased durations of loading as demonstrated by time dependent increases in collagen II gene expression in the annulus and increased collagen II breakdown, as indicated by increased CTX-II levels. Future histological evaluation will be required to determine the significance of these molecular changes on overall matrix structure.

Measuring health outcome in young adults with spina bifida

boyfriend/girlfriend (p=0.017), and not having some of the conditions of the personal questionnaire such as obesity (p=0.008), urinary infections (p=0.004), and scoliosis (p=0.014). A higher score in the HRQL was associated with a better faecal reeducation (p=0.046), gait level (p=0.043), use of gait aids (p=0.017), family economic level (p=0.020), mobility, self-care, and usual activities. A lower score in the HRQL was related to had undergone spine surgery (p=0.016), having anxiety/ depression (p=0.000), and having some of the conditions of the personal questionnaire such us pressure ulcers (p=0.010), and low self-esteem (p=0.024). In the regression model, determinant factors of having worse quality of life measured with EQ VAS were anxiety/depression, obesity, having boyfriend/girlfriend, and urinary infection. Determinant factors of having worse quality of life measured with HRQL were self-care, anxiety/depression, IQ and low self-esteem. Conclusions Almost two thirds of the series referred no problems in the health outcome. The determinants factors related to young SB patients personal perception of quality of life are not those related to disability.