Stephen W. Burke

Salvage and reinfusion of postoperative sanguineous wound drainage. A preliminary report.

Thirty-five patients who were to have posterior spinal arthrodesis, total hip arthroplasty, or total knee arthroplasty were entered into one of two groups: Group A, to receive unwashed, filtered sanguineous drainage from the wound, or Group B, to receive washed, filtered drainage. The purpose of this prospective study was to evaluate the safety, efficacy, and difficulty of reinfusion of washed compared with unwashed drainage that had been salvaged from the wound after an orthopaedic operation. The sixteen patients in Group A received a mean of 475 milliliters of unwashed drainage for each total knee arthroplasty, 427 milliliters for each total hip arthroplasty, and ten milliliters for the one posterior spinal arthrodesis. The complications included immediate hypotension (two patients), hyperthermia (one patient), and hypotension five hours after reinfusion (one patient). The latter patient died, four days after the operation, of a massive myocardial infarction. The nineteen patients in Group B received a mean of 193 milliliters of washed, filtered drainage for each total knee arthroplasty, 203 milliliters for each total hip arthroplasty, and 179 milliliters for each posterior spinal arthrodesis. Salvage and reinfusion of washed drainage from the wound caused no problems in these patients.

Spinal deformity, pulmonary compromise, and quality of life in osteogenesis imperfecta.

STUDY DESIGN A cross-sectional radiologic and clinical study of patients with osteogenesis imperfecta. OBJECTIVES To determine whether pulmonary compromise is more closely correlated with scoliosis, kyphosis, or chest wall deformity in the population with osteogenesis imperfecta, and to assess the impact of spinal deformity, chest wall deformity, and pulmonary function on quality of life. SUMMARY OF BACKGROUND DATA The incidence of scoliosis in osteogenesis imperfecta is between 39% and 80%. Up to 60% of patients with osteogenesis imperfecta have significant chest wall deformities. Pulmonary compromise is the leading cause of death in adults with osteogenesis imperfecta. METHODS Fifteen patients with osteogenesis imperfecta between the ages of 20 and 45 were evaluated with sitting or standing anteroposterior and lateral radiographs of the entire spine, pulmonary function testing, and a validated health self-assessment questionnaire (Short Form-36). Radiographs were evaluated for thoracic scoliosis, thoracic kyphosis, and chest wall deformity. Correlation analysis was performed. RESULTS Thoracic scoliosis was strongly correlated with decreased predicted vital capacity (r = -0.76). Significant diminution in vital capacity below 50% occurred at a curve magnitude of 60 degrees. Kyphosis and chest wall deformity were not predictive of decreased pulmonary function. Physical health (PCS) was closely correlated with predicted vital capacity (r = 0.65; P < 0.01) and with scoliosis (r = -0.52; P < 0.05). CONCLUSIONS Thoracic scoliosis of more than 60 degrees has severe adverse effects on pulmonary function in those with osteogenesis imperfecta. This finding may partly explain the increased pulmonary morbidity noted in adult patients with osteogenesis imperfecta and scoliosis compared with that in the general population.

Percutaneous Computed-Tomography-Guided Biopsy of the Thoracic and Lumbar Spine

Axial computed tomographic scans were used to guide percutaneous needle biopsies in 76 patients with thoracic and lumbar spinal lesions. Prebiopsy evaluation included spine radiographs, radionuclide bone scans, computed tomographic scans, magnetic resonance imaging scans in some cases, and coagulation studies. Forty-five patients were diagnosed as having metastatic lesions, 11 infection, and 12 primary bone tumors. Of all patients, 34 had lytic vertebral lesions with significant collapse and questionable spinal stability. Six of those had a concomitant paravertebral mass. A clinical and pathologic correlation was completed for each of the cases studied. Histologic diagnosis confirming the clinical suspicion was obtained on the first biopsy attempt in 65 (86%) of the 76 cases.

Clinical Value of Routine Preoperative Magnetic Resonance Imaging in Adolescent Idiopathic Scoliosis: A Prospective Study of Three Hundred and Twenty-seven Patients

Background: The prevalence of intraspinal pathology associated with scoliosis has been reported to be as high as 26% in some series1, and, on the basis of this finding, preoperative magnetic resonance imaging is used in the screening of patients with adolescent idiopathic scoliosis. However, this practice continues to be highly controversial. In order to better resolve this issue, we performed what we believe to be the largest prospective study to evaluate the need for preoperative magnetic resonance imaging in patients with adolescent idiopathic scoliosis requiring arthrodesis of the spine. Methods: A total of 327 consecutive patients with adolescent idiopathic scoliosis were evaluated between December 1991 and March 1999. All patients in the study presented with an adolescent idiopathic scoliosis curve pattern and had a complete physical and neurologic examination. Magnetic resonance imaging of the brain and the spinal cord were performed as part of their preoperative work-up. Results: Seven patients had an abnormality noted on magnetic resonance imaging. These abnormalities included a spinal cord syrinx in two patients (0.6%) and an Arnold-Chiari type-I malformation in four (1.2%). One patient had an abnormal fatty infiltration of the tenth thoracic vertebral body. No patient required neurosurgical intervention or additional work-up. All patients who underwent spinal arthrodesis with segmental instrumentation tolerated the surgery without any immediate or delayed neurologic sequelae. Conclusions: The fact that magnetic resonance imaging did not detect any important pathology in the large number of patients in this study strongly suggests that magnetic resonance imaging is not indicated prior to arthrodesis of the spine in patients with an adolescent idiopathic scoliosis curve pattern and a normal physical and neurologic examination.

Delayed paraplegia complicating sublaminar segmental spinal instrumentation.

The cases of two patients with delayed paraplegia after segmental spinal instrumentation with sublaminar wiring are reported. Both patients had complex spinal deformities and had transient neural deficits after the first-stage procedure of anterior release and spine fusion. They had uneventful spinal-cord monitoring during the second-stage procedure of posterior instrumentation and fusion, and function of the lower extremities was present immediately after that operation. Paraplegia then ensued, and was recognized thirty hours later in one patient and six days later in the other. Considering our reproducible and reliable experience (no false-negative results) with spinal cord monitoring in 307 operations, we propose that the delayed onset of paraplegia resulted from a progression of ischemic and edema-producing events that had not developed sufficiently intraoperatively to be reflected by the monitoring. The paraplegia became evident only when the subarachnoid space was obstructed because of progressive postoperative neural edema. The presence of sublaminar implants in narrow, kyphotic segments of the spinal canal probably exacerbated the neural irritation by dural impingement, which was seen myelographically.

Resection arthroplasty of the hip for patients with cerebral palsy: an outcome study.

Thirteen patients (18 hips) with cerebral palsy and painful hip subluxation or dislocation underwent proximal femoral resection-interposition arthroplasty (PFRIA) as a salvage procedure for intractable pain or seating difficulty. Eleven patients (14 hips) had a prior failed soft-tissue or bony reconstruction. The average age at surgery was 26.6 years (range, 10.7-45.5 years), and average follow-up was 7.4 years (range, 2.2-20.8 years). All patients/caregivers noted significant improvement in subjective assessment of pain after the surgery. Upright sitting tolerance improved from an average preoperative value of 3.2-8.9 h postoperatively (p < 0.01). Four patients who were unable even to sit in a customized wheelchair before the operation could be easily seated in a custom chair after surgery. Hip range of motion including flexion, extension, and abduction was significantly improved postoperatively (p < 0.05). Single-dose radiation therapy was used postoperatively for five hips and resulted in a significantly lower grade of heterotopic ossification at final follow-up (p < 0.005). Skeletal traction in the postoperative period did not prevent proximal migration of the femur compared with skin traction. Maximal pain relief was achieved at an average of 5.6 months postoperatively (range, 0.03-14 months). Complications included transient postoperative decubitus ulceration (four patients), pneumonia (two patients), and symptomatic heterotopic bone (two patients). The significant improvements in pain management, sitting tolerance, and range of motion suggest that PFRIA is a reasonable salvage procedure for the painful, dislocated hip in cerebral palsy. Resolution of pain may not be immediate, as was noted in this series.

Unilateral blindness as a complication of patient positioning for spinal surgery. A case report

Percise patient positioning is crucial to the success of a surgical procedure in terms of both gaining adequate operative exposure and preventing the potential sequelae of excessive pressure on neural or vascular structures.

Assessment of bone mineral density in adults and children with Marfan syndrome

Recent studies indicate that decreased bone mineral density (BMD) occurs in the spine, femoral necks and greater trochanters of some adults and children with Marfan syndrome. Because there is uncertainty regarding the BMD status of patients with Marfan syndrome, we undertook an analysis of BMD in both adults and children with Marfan syndrome. Dual energy X-ray absorptiometry analysis was performed on a convenience sample of 51 patients (30 adults and 21 children) with diagnosed Marfan syndrome from 1993 to 2000. T-Scores (i.e. the number of standard deviations above or below the average normal peak bone density) were determined for comparison of adults. Mean±SD of individual BMD values were used for comparison of the data of children. Compared to standard values obtained from normal adult patients, adult males with Marfan syndrome demonstrated significantly reduced femoral neck BMD with an average T-score of -1.54 (P<0.001), diagnostic of osteopenia. Although osteopenia and osteoporosis were observed in several middle aged and pre- and postmenopausal women, the average T-score value for adult females and children were within normal limits. The etiology and full significance of decreased BMD in adult male patients with Marfan syndrome remain uncertain at the present time. Our results lead us to question the value of aggressive BMD evaluations by DXA in these patients, particularly prior to reaching mid-age. Further investigations will be required to shed insights into the natural history of BMD in adults and children with Marfan syndrome. Any application of bone mineral replacement therapy such as bisphosphonate, selective estrogen receptor modulators, hormone replacement therapy and vitamin D in these patients may be premature based on the existing evidence.

Routine preoperative MRI and SEP studies in adolescent idiopathic scoliosis.

In this prospective study, 72 patients with the clinical diagnosis of adolescent idiopathic scoliosis underwent routine preoperative magnetic resonance imaging (MRI) scans and neurologic consultations. Forty-eight patients also had preoperative somatosensory evoked potentials (SEPs). All patients had normal neurologic examinations. Abnormal findings included two patients with Chiari type I malformation and one with a finding of a fatty collection in a vertebral body. In four cases, interpretation of the MRI was suspicious or equivocal, necessitating a computed tomography myelogram or other additional studies for clarification. Abnormal preoperative SEP results were obtained in three patients, none of which proved significant. All surgical patients underwent instrumentation and fusion without incident. The results indicate that routine preoperative SEP is not necessary. Routine preoperative MRI is probably not indicated in adolescent idiopathic scoliosis if the patient has a normal neurologic examination.

Sports participation of children with down syndrome

Patients with Down syndrome, by virtue of ligamentous laxity, are prone to a number of orthopedic problems with potentially serious sequelae. These disorders need to be evaluated throughout childhood and, when detected, appropriately managed. Given such management, the child with Down syndrome should be able to participate actively in and derive benefits from sports activities.