Robert Dunsmuir

Vertebral osteomyelitis and discitis due to Gardnerella vaginalis

Gardnerella vaginalis is a facultative anaerobic Gram-variable pleomorphic rod that forms part of the normal vaginal flora. It is most commonly associated with infection of the genital tract in women, but recognition of extravaginal G. vaginalis infection is becoming more frequent. We describe an unusual case of G. vaginalis vertebral osteomyelitis and discitis in a 38-year-old woman with no apparent predisposing factors.

A survey of current controversies in scoliosis surgery in the United Kingdom.

Study Design. A 10-point questionnaire was constructed to identify the philosophy of surgeons on various aspects of scoliosis surgery, such as choice of implant, bone graft, autologous blood transfusion, cord monitoring, and computer-assisted surgery. Comparisons were then made with recommendations published in the spinal literature. Objective. To determine certain aspects of the current practice of scoliosis surgery in the United Kingdom. Summary of Background Data. Guidelines for good clinical practice in spinal deformity surgery are available in the United Kingdom but do not cover a number of controversial issues. Methods. Consultants and fellows attended the 2009 British Scoliosis Society meeting. Fifty questionnaires were completed by 45 consultants and 5 fellows. Results. All pedicle screw constructs favored by 25 of 50, hybrid 24 of 50 (1 undecided). Posterior construct of fewer than 10 levels, 20 of 50 would not cross-link, 11 of 50 used 1, and 19 of 20 used 2 or more. More than 10 levels 17 of 50 considered cross-links unnecessary, 4 of 50 used 1 and 29 of 50 used 2 or more. Eighty-eight percent preferred titanium alloy implants, whereas others used a mixture of stainless steel and cobalt chrome. When using bone graft, respondents used bone substitutes (24), iliac crest graft (14), allograft (12) and demineralized bone matrix (9) in addition to local bone. Ten of 50 would use recombinant bone morphogenetic protein (3 for revision cases only). Thirty-nine of 50 routinely used intraoperative cell salvage and 4 of 50 never used autologous blood. All used cord monitoring: sensory (19 of 50), motor (2 of 50), and combined (29 of 50). None used computer-aided surgery. Twenty-six operated alone, 12 operated in pairs, and 12 varied depending on type of case. Conclusion. This survey shows interesting variations in scoliosis surgery in the United Kingdom. It may reflect the conflicting evidence in the literature.

Unique combination of lumbosacral junction injury with open pelvic ring disruption and acetabulum fracture: case report.

Study Design. A case report of a complex spondylo-pelvic injury combining a traumatic spondylolysis and burst fracture of the fifth lumbar vertebra, with an open pelvic ring disruption and a fracture of the acetabulum. Objectives. To describe the mechanism, diagnostic approach, and rationale for treatment of this very rare and complex injury pattern, and finally to present the results of the treatment. Summary of Background Data. Traumatic spondylolysis of the fifth lumbar vertebra is a very uncommon type of injury, with few cases being reported in the literature. Combination of such an injury with pelvic ring and acetabular fractures has never been reported in the past. Methods. The patient was referred to our institution for definitive treatment after initial treatment at a local hospital involving laparotomy, defunctioning colostomy, and symphyseal plating. Accurate delineation of the complex injury pattern was established on computerized tomography with 3-dimensional multiplanar reconstruction, and magnetic resonance imaging of both the spine and pelvis. Definitive stabilization of the injury was made by posterior lumbopelvic segmental fixation with posterolateral fusion and open reduction and internal fixation of the acetabular fracture. Results. At 2 years after surgery, the patient was ambulatory, with an ankle-foot orthosis, and almost completely pain free. He was able to perform manual work. Conclusions. Complex associated injuries of the spondylo-pelvic junction and pelvis are always a challenge to treat because they demand careful assessment, stabilization of the patient, meticulous imaging, and a multidisciplinary approach.

Surgical treatment of tuberculous paraparesis in the third trimester: a report of two cases and review of the literature.

Background: Tuberculous paraplegia as a consequence of spinal infiltration in pregnancy is reported to be rare. Analysis of the current literature produces few case studies that report successful outcomes. Delay in diagnosis and treatment may ultimately result in an irreversible neurological deficit. The potential implications of progression are paraplegia and a significant associated morbidity to the fetus if delivered premature. Methods: Two cases of spinal tuberculosis in pregnancy are reported with description of clinical presentation, neuroradiographic findings and treatment. Results: Both patients made good recoveries after undergoing cesarean section followed by urgent spinal cord decompression and fixation for progression of neurology. On review at 2 years, neither patient had any permanent neurological deficit. Both children suffered no deleterious effects from treatment of the mothers. Conclusions: A treatment strategy to successfully treat this group of patients is recommended. Although there is a place for both chemotherapeutic and surgical intervention in the treatment of spinal tuberculosis, the authors suggest initiation of treatment with chemotherapy and close neurological monitoring of the patient, unless deterioration in neurological status mandates surgery. Furthermore, the use of steroids for fetal maturation should be used with caution.

Vertebral body versus iliac crest bone marrow as a source of multipotential stromal cells: Comparison of processing techniques, tri-lineage differentiation and application on a scaffold for spine fusion

The potential use of bone progenitors, multipotential stromal cells (MSCs) helping spine fusion is increasing, but convenient MSC sources and effective processing methods are critical factors yet to be optimised. The aim of this study was to test the effect of bone marrow processing on the MSC abundance and to compare the differentiation capabilities of vertebral body-bone marrow (VB-BM) MSCs versus iliac crest-bone marrow (IC-BM) MSCs. We assessed the effect of the red blood cell lysis (ammonium chloride, AC) and density-gradient centrifugation (Lymphoprep™, LMP), on the extracted VB-BM and IC-BM MSC numbers. The MSC abundance (indicated by colony counts and CD45lowCD271high cell numbers), phenotype, proliferation and tri-lineage differentiation of VB-BM MSCs were compared with donor-matched IC-BM MSCs. Importantly, the MSC attachment and osteogenesis were examined when VB-BM and IC-BM samples were loaded on a beta-tricalcium phosphate scaffold. In contrast to LMP, using AC yielded more colonies from IC-BM and VB-BM aspirates (p = 0.0019 & p = 0.0201 respectively). For IC-BM and VB-BM, the colony counts and CD45lowCD271high cell numbers were comparable (p = 0.5186, p = 0.2640 respectively). Furthermore, cultured VB-BM MSCs exhibited the same phenotype, proliferative and adipogenic potential, but a higher osteogenic and chondrogenic capabilities than IC-BM MSCs (p = 0.0010 and p = 0.0005 for calcium and glycosaminoglycan (GAG) levels, respectively). The gene expression data confirmed higher chondrogenesis for VB-BM MSCs than IC-BM MSCs, but osteogenic gene expression levels were comparable. When loaded on Vitoss™, both MSCs showed a similar degree of attachment and survival, but a better osteogenic ability was detected for VB-BM MSCs as measured by alkaline phosphatase activity (p = 0.0386). Collectively, the BM processing using AC had more MSC yield than using LMP. VB-BM MSCs have a comparable phenotype and proliferative capacity, but higher chondrogenesis and osteogenesis with or without using scaffold than donor-matched IC-BM MSCs. Given better accessibility, VB-BM could be an ideal MSC source for spinal bone fusion.

Vancomycin-Induced DRESS Syndrome: An Important Concern in Orthopedic Surgery

DRESS (drug reaction with eosinophilia and systemic symptoms) is a potentially serious complication when prolonged courses of antibiotics are given to patients, with an average onset of 2–6 weeks after commencement. There is a high mortality rate (1–10%). We report the case of a 62-year-old male who developed DRESS after seven weeks of antibiotic treatment with vancomycin for a deep spinal metalwork infection. We describe the typical rash and biochemical results, including eosinophilia, as well as the systemic signs seen in this case. The criteria for diagnosis of DRESS, including the RegiSCAR scoring system and commonly affected systems (renal, cardiac, and hepatic), are detailed, and we also discuss evidence for steroid treatment and considerations important in the use of this.

Benefits of the use of blood conservation in scoliosis surgery

AIM To investigate whether autologous blood transfusion (ABT) drains and intra-operative cell salvage reduced donor blood transfusion requirements during scoliosis surgery. METHODS Retrospective data collection on transfusion requirements of patients undergoing scoliosis surgery is between January 2006 and March 2010. There were three distinct phases of transfusion practice over this time: Group A received “traditional treatment” with allogeneic red cell transfusion (ARCT) in response to an intra- or post-operative anaemia (Hb < 8 g/dL or a symptomatic anaemia); Group B received intra-operative cell salvage in addition to “traditional treatment”. In group C, ABT wound drains were used together with both intra-operative cell salvage and “traditional treatment”. RESULTS Data from 97 procedures on 77 patients, there was no difference in mean preoperative haemoglobin levels between the groups (A: 13.1 g/dL; B: 13.49 g/dL; C: 13.66 g/dL). Allogeneic red cell transfusion was required for 22 of the 37 procedures (59%) in group A, 17 of 30 (57%) in group B and 16 of 30 (53%) in group C. There was an overall 6% reduction in the proportion of patients requiring an ARCT between groups A and C but this was not statistically significant (χ2 = 0.398). Patients in group C received fewer units (mean 2.19) than group B (mean 2.94) (P = 0.984) and significantly fewer than those in group A (mean 3.82) (P = 0.0322). Mean length of inpatient stay was lower in group C (8.65 d) than in groups B (12.83) or A (12.62). CONCLUSION When used alongside measures to minimise blood loss during surgery, ABT drains and intra-operative cell salvage leads to a reduced need for donor blood transfusion in patients undergoing scoliosis surgery.

Innate Lymphoid Cells are Present at Healthy Patients Spinal Enthesis, Providing a Potential Mechanism for Spondyloarthropathy Pathogenesis

Background The pathogenesis of murine spondyloarthropathy (SpA) has been intimately linked to the presence of Interleukin(IL)-23 responsive, innate like lymphocytes at different anatomical regions including spinal enthesis. Human SpAs are associated with Single nucleotide polymorphisms (SNPs) in genes related to the IL-23 pathway and drugs that block IL-12/23 have shown efficacy. We hypothesized that the normal human enthesis has a population of resident innate lymphoid cells (ILCs) that could be involved in governing entheseal immune homeostasis. In particularly entheseal resident type 3 ILCs (ILC3s) may be critical, since ILC3s in other tissues have been shown to produce inflammatory cytokines in response to IL-23. Methods Normal spinal enthesis were harvested from healthy patients undergoing spinal surgery and enzymatically digested prior to fluorescence activated cell sorting (FACS). Cellular immunophenotyping and cell sorting was performed on enthesis samples harvested from 6 patients; ILC3s, were identified as lineage (CD3- TCRγδ- TCRαβ- CD19- CD14- CD11c- CD1a- CD303- FcεRI- CD34- CD123-) and cellular surface marker CRTH2 negative with positive expression of CD45, CD127, CD117. ILC2s, which have been linked to fibrotic reactions, were identified as lineage negative with positive expression of CD45, CD127 and CRTH2. The expression of RORγt transcript was tested in sorted populations by RTqPCR. Anterior cruciate ligament (femoral enthesis) was obtained from subjects with knee OA and injured enthesis undergoing repair were also collected and analyzed by immunohistochemistry (IHC). Results All sorted samples contained ILC3s, median proportion 0.09% (range 0.015–0.63). Transcript analysis confirmed the expression of RORγt, transcript, an ILC3 related transcription factor, in sorted ILC3 populations, with ILC3s expressing 51-fold greater relative expression in comparison to unsorted digests. 5 of 6 sorted samples contained ILC2s, median proportion 0.20% (range 0–0.49). RORγt expression was detected in knee OA and there was widespread expression of RORγt in inflammatory infiltrates in injured enthesis as shown by IHC. Conclusions Our findings show that ILCs are present in the normal human spinal enthesis and may be greatly increased in frequency following injury. These findings provide strong evidence of ILC presence in normal human enthesis and suggest a potential link between cellular dysregulation of the IL-23/17 axis and SpA pathology at sites of micro damage.

An unusual sensory supply to the palmar aspect of the little finger

Dear Sir, An unusual branching pattern and distribution of the ulnar nerve was found during the dissection of a left hand from a 76 year-old female cadaver. The hand was fixed in Cambridge Cantabrian Formulation 3713 (Vickers Laboratories Ltd., Pudsey) and the vascular system injected with latex liquid rubber (Trylon Ltd., Wollaston). The divisions of the ulnar nerve (UN) in this specimen are shown in Fig 1. The UN was identified in the forearm and gave off its dorsal branch just proximal to the pisiform bone. This dorsal branch passed deep to the flexor carpi ulnaris where it divided into two branches. The medial of the two branches passed distally and posteriorly over the wrist on the ulnar side. As it reached the origin of the hypothenar muscles it divided into two branches; the lateral division continued distally on the posterior aspect of the hand to become the dorsal proper digital nerve of the little finger on the ulnar side and the

An Accurate Method Of Bone Graft Application In Spinal Surgery

B one grafting is a commonly used technique in orthopaedic surgery. In posterior spinal surgery, accurate placement of postero-lateral bone graft is important in achieving solid bony fusion. This can be difficult and messy due to the overlying muscles and bulky implants when applied manually. We have devised a simple and effective method of bone graft application for posterior spinal surgery. The nozzle end of a standard 10ml syringe is removed (Figure 1). The syringe is then packed full of bone graft and compacted (Figure 2 & 3). We routinely use an autograft and synthetic bone substitute mixture. The compacted graft can be accurately applied by placing the cut syringe end at the desired site and depressing the syringe plunger. This method is more accurate than manual application of bone graft by hand. This method is used routinely at our institution for spinal fusion and is being applied to other orthopaedic procedures requiring bone grafting.