Mike Hutton

Primary care perceptions of the prevalence, diagnosis and management of coccydynia: Results of a web-based survey of Devon general practitioners

Abstract Purpose The purpose of this study to take a snapshot opinion of general practitioner (GP) understanding of the prevalence, diagnosis, and management of coccydynia. Methodology We designed a simple 5-question survey to administer to our local GPs. The survey was sent to 107 GP practices in Devon whose details were provided by The Devon Access Referral Team. We received 150 electronic replies. We also submitted the survey to 50 GPs who attended a study day at our institution – and ensured they had not already completed the electronic format of the same work. Thus, we received 200 replies which we believe to be a representative sample of our local GPs opinion. Results Fifty-one percent of GPs correctly identified the prevalence of the condition. Thirty-nine percent believed the condition to be associated with an underlying psychological disorder. Fifty-two percent believed there was no proven treatment for the condition. Only twenty-two percent would consider referring the patient to any secondary care service that dealt with chronic spinal pain (pain clinic, rheumatology or spinal surgery) even if the symptoms persisted beyond 3 months duration. Seventy-three percent believed surgery was madness or had a less than 20% chance of relieving symptoms. Conclusion Coccydynia is a painful condition, causing significant distress for those suffering with the condition. Primary care physicians seem reluctant to recognize the problem as significant and reluctant to refer patients for treatment that may offer significant symptomatic relief. Education about the condition is required.

Catastrophic Cervical Spine Injuries in Contact Sports

Study Design Systematic review. Objectives To determine the incidence of catastrophic cervical spine injuries (CCSIs) among elite athletes participating in contact team sports and whether the incidence varies depending on the use of protective gear or by player position. Methods Electronic databases and reference lists of key articles published from January 1, 2000, to January 29, 2016, were searched. Results Fourteen studies were included that reported CCSI in rugby (n = 10), American football (n = 3), and Irish hurling (n = 1). Among Rugby Union players, incidence of CCSI was 4.1 per 100,000 player-hours. Among National Football League players, the CCSI rate was 0.6 per 100,000 player-exposures. At the collegiate level, the CCSI rate ranged from 1.1 to 4.7 per 100,000 player-years. Mixed populations of elite and recreational rugby players in four studies report a CCSI rate of 1.4 to 7.2 per 100,000 player-years. In this same population, the scrum accounted for 30 to 51% of total reported CCSIs in Rugby Union versus 0 to 4% in Rugby League. The tackle accounted for 29 to 39% of injuries in Rugby Union and 78 to 100% of injuries in Rugby League. Making a tackle was responsible for 29 to 80% of injuries in American football. Conclusion CCSIs are infrequent among elite athletes. There is insufficient evidence to determine the effect of protective gear (e.g., helmets, padding) on CCSI incidence. Scrum and tackle in rugby and tackling in American football account for the majority of CCSIs in each respective sport.

Erect radiographs to assess clinical instability in patients with blunt cervical spine trauma.

BACKGROUND Computed tomography (CT) and magnetic resonance imaging (MRI) are sensitive modalities for the assessment of the spine, but certain injuries remain poorly assessed with supine radiographs. We describe four cases in which cervical spine injuries were proven as unstable with erect radiographs after being previously evaluated with supine radiographs and CT scans. METHODS A retrospective review of medical records and images was used to identify four patients who presented to a teaching hospital from April to December 2010 with unstable cervical spine injuries that were only demonstrated on erect radiographs. RESULTS All four patients sustained either C4-C5 or C5-C6 injuries. Prior to diagnosis, each had been evaluated with supine radiographs that did not demonstrate instability. Computed tomography identified the osseous injuries that were present but did not provide suitable assessment of stability. Three patients successfully underwent anterior cervical discectomy and fusion. The fourth was managed with a Halo jacket because of major comorbidities. CONCLUSIONS Despite major advances in imaging, these cases highlight the importance of physiological loading and radiographs. The controlled use of erect radiographs to test for clinical instability in patients with cervical spine injuries should be considered except in cases in which instability is already evident on other imaging modalities and/or surgical treatment is already indicated.

Respiratory failure due to a displaced fracture of the odontoid

Fractures of the odontoid peg are relatively common in elderly people. Often they are minimally displaced and can be treated with a collar. However, a fracture which is displaced significantly may be difficult to manage. We describe the case of an 80-year-old man with a fracture of the odontoid peg which was completely displaced and caused respiratory distress. After initial closed reduction and application of a halo jacket, open and internal fixation was undertaken and relieved his symptoms. It is a safe and effective way to manage this injury.

Correction to: Can spinal surgery in England be saved from litigation: a review of 978 clinical negligence claims against the NHS

Unfortunately, the first author name was incorrectly published in the original publication. The complete correct name is given as below.

Do Growing Rods for Idiopathic Early Onset Scoliosis Improve Activity and Participation for Children

Objective To investigate whether growing rod surgery for children with progressive idiopathic early onset scoliosis (EOS) effects activity and participation, and investigate factors that may affect this. Study design Multicenter retrospective cohort study using prospectively collected data on 60 children with idiopathic EOS and significant scoliosis (defined as a Cobb angle >40°). Thirty underwent brace treatment, and 30, growth rod surgery. Questionnaire and radiographic data were recorded at 1 year. The validated Activities Scale for Kids performance version (ASKp) questionnaire was used to measure activity and participation. Results In the brace group, Cobb angle increased from 60° to 68°. There was no change in ASKp score. In the operative group, Cobb angle decreased from 67° to 45°. ASKp decreased from 91 to 88 (P < .01). Presence of spinal pain correlated with greater reduction in activity and participation scores in both groups, as did occurrence of complications in the operative group (P < .05). Both treatments permitted growth of the immature spine. Conclusions In children with significant idiopathic EOS (Cobb angle>40°), growth rod surgery was associated with a reduction in activity and participation and Cobb angle, whereas brace treatment was associated with an increase in Cobb angle and no change in activity and participation. Pain was the most important factor affecting activity and participation in both groups.

Recommendations for Lengthening of Magnetically Controlled Growing Rods in Children With Pacemakers.

Purpose of the Study: Pacemakers are currently identified as a contraindication for the use of magnetic growth rods (MGRs). This arises from concern that magnetic fields generated by the MGR external remote controller (ERC) during lengthening procedures may induce pacemaker dysfunction. We investigated (1) whether MGR lengthening affects pacemaker function, and (2) if the magnetic field of a pacemaker affects MGR lengthening. Methods: MGRs were tested in conjunction with an magnetic resonance imaging-compatible pacemaker, which was connected to a virtual patient under continuous cardiac monitoring. To determine whether pacemaker function was affected during MGR lengthening, the electrocardiogram trace was monitored for arrhythmias, whereas an ERC was applied to lengthen the MGRs at varying distances from the pacemaker. To investigate if MGR lengthening was affected by the presence of a pacemaker, at the start and end of the experiment, the ability of the rods to fully elongate and shorten was tested to check for conservation of function. Results: When the pacemaker was in normal mode, <16 cm away from the activated ERC during MGR lengthening, pacemaker function was affected by the ERC’s magnetic forces. At this distance, prophylactically switching the pacemaker to tonic mode before lengthening prevented occurrence of inappropriate pacing discharges. No deleterious effect of the pacemaker’s magnetic field on the MGR lengthening mechanism was identified. Conclusions: Magnetic resonance imaging-compatible pacemakers appear safe for concomitant use with MGRs, provided a pacemaker technician prophylactically switches the pacemaker to tonic function before outpatient lengthening procedures. Clinical Relevance: This experiment was designed to provide the first safety information on MGR lengthening in children with pacemakers. Although currently a rare clinical scenario, with increasing use of MGRs, this clinical scenario may arise more frequently in the future.

Incomplete cauda equina syndrome secondary to haemorrhage within a Tarlov cyst

Sacral perineural (Tarlov) cysts are benign, cerebrospinal fluid containing lesions of the spinal nerve root sheath. They are usually asymptomatic; however, a small proportion have the potential to cause compression of nerve roots and/or the cauda equina. We report a case of a 61-year-old man who presented with acute onset back pain associated with bilateral radiculopathy. Between referral and consultation, the patient developed urinary dysfunction which resolved spontaneously. MRI revealed haemorrhage within a Tarlov cyst, resulting in compression of the cauda equina. Due to the considerable clinical improvement at the time of consultation, surgical decompression of the cyst was not considered to be indicated. An interval MRI scan 8 weeks later demonstrated that the haemorrhage within the perineural cyst had spontaneously resolved and the patient remained asymptomatic at 5-year follow-up.

Alternative technique in atypical spinal decompression: the use of the ultrasonic scalpel in paediatric achondroplasia.

Spinal stenosis can be a very disabling condition. Surgical decompression carries a risk of dural tear and neural injury, which is increased in patients with severe stenosis or an atypical anatomy. We present an unusual case of symptomatic stenosis secondary to achondroplasia presenting in a paediatric patient, and highlight a new surgical technique used to minimise the risk of dural and neural injury during decompression.

Are MAGEC Rods a Contraindication to MRI: An In-Vitro Study Evaluating the Effect of MRI on Rod Growth, Temperature, and Image Interpretation

Introduction The management of early-onset pediatric deformity has been revolutionized by the development of adjustable growing rods. These rods contain a rare-earth magnet that rotates when triggered by an externally applied magnetic field resulting in rod elongation. This patient group includes those with underlying neuromuscular conditions who occasionally require further MRI of the neuraxis during development and, given the magnetic properties of the rod, they are conventionally contraindicated for this imaging modality once implanted. We have investigated the behavior of the MAGEC (Ellipse Technology) rod to determine whether MRI adversely affects the elongation properties of the rod or indeed directly causes any detrimental consequences, including rod elongation, shortening, heating, or significant artifact to outline implications for this patient group. Materials and Methods We designed an in-vitro experiment using two MAGEC rods secured in an MRI compatible restraint system to investigate MRI behavior of magnetic growing rods during scanning. We used a 1.5T Philips MRI and a restraint system designed to secure the rods within this environment. Repeated gradient echo multiscan sequence MRI of the neuraxis was performed to evaluate whether the rods elongated, contracted, or rotated during scanning, while we used MRI compatible heat-sensors attached to the outer housing of the rods to assess temperature changes. We also assessed the ability of the rods to lengthen after completion of the MRI and a phantom model to evaluate the amount of artifact induced by the rare-earth magnet. Results During repeated MRI of the neuraxis, the MAGEC rod mechanism was not triggered; however, the rods did rotate to bring the internal rare-earth magnet in line with the surrounding electromagnetic field, while only small forces were generated causing rod movement within the restraint system. The ability of the rods to lengthen after MRI was not enhanced or impaired and no significant heating effect on the external rod housing was demonstrated. The assessment of imaging with a phantom model did reveal a significant degree of artifact up to 30 cm because of the presence of the magnet within the electromagnetic field and, therefore, only MRI of the head and cervical spine could be interpreted with normal placement of MAGEC rods within the pediatric patient. Conclusion This study demonstrated that there are no detrimental effects of MRI on the MAGEC rod. In addition, while the degree of the artifact demonstrated prohibits imaging of the thoracolumbar spine, the MRI images of the head and cervical spine remain unimpaired. Finally, we did not demonstrate any significant force acting on the rod by the electromagnetic field that would cause implant dislodgement or loosening during MRI.