Keith Synnott

Cauda equina syndrome: assessing the readability and quality of patient information on the Internet.

Study Design. A readability and quality control Internet-based study using recognized quality scoring systems. Objective. To assess the readability and quality of Internet information relating to cauda equina syndrome accessed through common search engines. Summary of Background Data. Access to health-related Internet information has increased dramatically during the past decade. A significant proportion of this information has been demonstrated to be set at too high a level for general comprehension. Despite this, searching for health-related information is now the third most popular online activity. Methods. A total of 125 cauda equina syndrome Web sites were analyzed from the 5 most popular Internet search engines: Google, Bing, Yahoo, Ask, and AOL. Web site authorship was classified: academic, physician, medico-legal, commercial, or discussion/social media. Readability of each Web site was assessed using the Flesch Reading Ease score, the Flesch-Kincaid grade level, and the Gunning Fog Index. Quality was calculated using the DISCERN instrument and The Journal of the American Medical Association benchmark criteria. The presence of HON-code certification was also assessed. Results. Fifty-two individual Web sites were identified and assessed. The majority of Web sites were academic or physician compiled (53.8%; 28/52); however, a significant minority of Web sites were medico-legal related (19.2%; 10/52). Just 13.5% (7/52) of Web sites were at or below the recommended sixth-grade readability level. HON-code certified Web sites achieved significantly greater DISCERN (P = 0.0006) and The Journal of the American Medical Association (P = 0.0002) scores. Conclusion. Internet information relating to cauda equina syndrome is of variable quality and largely set at an inappropriate readability level. Given this variability in quality, health care providers should direct patients to known sources of reliable, readable online information. Identification of reliable sources may be aided by known markers of quality such as HON-code certification. Level of Evidence: N/A

Foot drop--an unusual presentation of exertional compartment syndrome.

INTRODUCTION We report the case of a 67-year-old male presenting to our service with a foot drop after a short history of increasingly symptomatic exertional compartment syndrome. Magnetic resonance imaging (MRI) was supportive of the diagnosis, and the diagnosis confirmed with compartment pressure measurement. This is an atypical presentation and highlights the need to consider exertional compartment syndrome in those outside the ‘‘elite athlete’’ demographic.

The Evaluation of the Inverted Supinator Reflex in Asymptomatic Patients

Study Design. A prospective study was undertaken over a 6-month period to determine the incidence of the inverted supinator reflex in asymptomatic, neurologically normal individuals. Objective. The objective of our study is to assess asymptomatic patients for the presence of the inverted radial reflex and to determine its clinical relevance. Summary of Background Data. The inverted radial reflex sign is commonly used in clinical practice to assess cervical myelopathy. It is unknown whether the sign correlates with the presence or severity of myelopathy, and no consensus exists regarding the significance of a positive sign in asymptomatic individuals. Methods. Patients attending the Trauma Clinic at our institution were invited to participate. Each patient was examined neurologically and specifically for the presence or absence of the Babinski test, Hoffmans sign, the finger escape sign, static and dynamic Rombergs test, and the inverted supinator reflex. Patients were excluded if they had any history of neck pain, any history of neurosurgical procedure or spinal surgery, any known neurologic disorder or deficit, or if there was any outstanding medicolegal case. Results. We examined 277 patients in 6-month period. The male to female ratio was 1.1:1. The mean age was 27 years (range, 16–78). The incidence of the inverted supinator reflex was 27.6% (75/271). Of the 75 positive patients, the inverted supinator reflex was present bilaterally in 39% (29/75). Nine of 75 patients (10%) had an associated positive Hoffmans sign but had no other signs suggestive of myelopathy. The proportion of patients with a positive inverted supinator reflex reduced with increasing age (Pearson correlation coefficient > 0.80). Conclusion. This study demonstrates that an isolated, inverted supinator reflex may be a variation of normal clinical examination. We believe that an isolated inverted supinator reflex, in the absence of other clinical findings, is not a reliable sign of cervical myelopathy; however, it must be interpreted with caution in the older patient.

Internet use in an orthopaedic outpatient population

BackgroundOver 60% of people nationally now have internet access. We aimed to assess the level of access to the internet within our practice population and gauge the level of internet use by these patients. MethodsThis was a questionnaire-based study. Patients attending a mixture of trauma and elective outpatient clinics were invited to complete a questionnaire collecting basic demographic details and history of information seeking. ResultsTwo-hundred and nintey-two patients completed the questionnaire (146 men, 146 women). Seventeen were incomplete and excluded from final analysis. Multiple logistic regression found younger age (O.R. 2.22 in 20-35 age group), possession of health insurance (O.R. 2.65) and higher levels of education (O.R. 8.22 for tertiary education) all were significantly associated with a higher level of access to the internet. Among patients with internet access, a second regression analysis showed that a positive history of surgery (O.R. 2.82) and possession of a trade qualification (O.R. 5.15) were the best predictors of internet use to research a patient’s orthopaedic condition. ConclusionsOur study was consistent with previous studies showing that younger and better educated patients had greater access to the internet. We believe there is a niche for increased information provision for those patients who require surgery, but we must be aware that access is not available to everyone in the community.

Segmental fracture of the lumbar spine.

Study Design. A case report is presented. Objective. To describe a rare, previously undescribed pattern of spinal injury. Summary of Background Data. This seems to be a unique injury with no previously described injuries matching the fracture pattern observed. Methods. This is a case report based on the experience of the authors. The discussion includes a short literature review based on pubmed searches. Results. We report the case of a 26-year-old female cyclist involved in a road traffic accident with a truck resulting in complete disruption of the lumbar spine. The cyclist was caught on the inside of a truck turning left and seems to have passed under the rear wheels. She was brought to the local emergency department where, after appropriate resuscitation, trauma survey revealed spinal deformity with complete neurologic deficit below T12 and fractured pubic rami, soft tissue injuries to the perineum and multiple abrasions. Plain radiology showed a segmental fracture dislocation of her lumbar vertebrae, extending from the L1 superior endplate through to L4–L5 disc space. The entire segment was displaced in both anteroposterior and lateral planes. Computed tomography confirmed these injuries and ruled out significant visceral injury. She was transferred to the national spinal unit (author unit), where she underwent reduction and fixation with rods and screws from T9–S1, using one cross-link. After her immediate postoperative recovery, she was referred to the national rehabilitation unit. Conclusion. Although so-called “en bloc” lumbar fractures have been previously described, the authors were unable to find any injury of this degree in the literature. This rare injury seems to show a pattern of spinal injury previously undescribed.

Persistence of Axial Rotation in Idiopathic Scoliosis Due to the Structural Changes of the Intervertebral Disc

There is some research about the morphological changes, spinal instability and causal factors influencing the mechanism of idiopathic scoliosis, however, there remains some controversy about its aetiology and pathogenesis [1,2] and complementary research is required to better identify the causal factors and pathologic mechanism(s) involved in the initiation and development of idiopathic scoliotic deformities of spine. In this study, a validated three-dimensional, anatomically accurate, mathematical model of the mid-thoracic motion segment (T7-T8), which consists of all bony element, soft tissues and articular contact surfaces is utilized, enabling investigation the influence of collagen deficiency in the initiation and progression of idiopathic scoliosis deformity. Alteration in the structure of the intervertebral disc is applied to the model and the resulting geometrical changes together with the coupling behaviour are computed.