The prevalence of lumbar disc degeneration in symptomatic younger patients: A study of MRI scans.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVE: Low back pain (LBP) and radiculopathy present a significant burden to patients and healthcare systems. Lumbar disc degeneration (LDD) is associated with LBP. While the prevalence of LDD in older, symptomatic, patients has been extensively documented there has been little describing the prevalence in younger patients. METHODS: 1011 patients aged 20-30 years, who had undergone Magnetic Resonance Imaging (MRI), for investigation of LBP and or radiculopathy, over a 9-year period were identified. Those who had previous surgery, congenital deformities or unavailable imaging were excluded. A single surgeon evaluated the MRI images of 730 patients and classified each lumbar disc according to the Pfirrmann classification. 105 randomly selected patient's imaging was reviewed again by the primary reviewer and by a consultant musculoskeletal radiologist with the kappa coefficients for inter-rater and intra-rater agreement calculated. RESULTS: Of the 730 patients, 428 (58.6%) had MRI evidence of LDD (Pfirrmann III, IV, V). 255 (59.6%) demonstrated single level pathology and 173 (41.4%) multilevel involvement. There was very high intra/inter observer agreement with kappa coefficients for intra-observer agreement from 0.65 to 0.98 and inter-observer agreement from 0.51 to 0.88. CONCLUSIONS: This is the largest study to document the prevalence of LDD in a symptomatic young cohort. A large prospective study including non-symptomatic patients and information on associated factors would add further information. Given the considerably higher than anticipated prevalence identified in this study and the significant burden associated with LBP this study should encourage such further research.

Secondary infection of haematoma following closed acromioclavicular joint dislocation.

An unusual case of a patient presenting with a large infected haematoma following a traumatic grade II acromioclavicular joint dislocation is reported. Diagnosis of this rare complication, of an otherwise common self-limiting injury, was delayed until 19 days postinjury despite several presentations during this time with worsening swelling and pain. The patient was found to have significant tissue destruction by the time washout was performed and required multiple procedures to treat the infection. This case highlights the need for a high index of suspicion for complications, even following common self-limiting injuries, when patients represent with symptoms that do not fit the usual natural history of the condition, particularly if they have risk factors for bleeding and infection.

Iliacus haematoma causing femoral nerve palsy: an unusual trampolining injury.

We report the case of a 15-year-old boy who presented to accident and emergency following a trampolining injury. Initially, the patient was discharged, diagnosed with a soft tissue injury, but he re-presented 48 h later with worsening low back pain and neurological symptoms in the left leg. Subsequent MRI revealed a left iliacus haematoma causing a femoral nerve palsy. The patient was managed conservatively and by 6 months post injury all symptoms had resolved. This is the first reported case of an iliacus haematoma causing a femoral nerve palsy, after a trampolining injury. We believe this case highlights to our fellow clinicians the importance of a detailed history when assessing patients with trampolining injuries to evaluate the true force of injury. It also acts as a reference for clinicians in managing similar cases in future.

Unexplained perioperative vertebrobasilar stroke in a patient undergoing anterior cervical decompression and disc arthroplasty.

BACKGROUND: Vertebrobasilar stroke associated with the anterior approach to the cervical spine is rare and has not been reported in cervical disc arthroplasty surgery. We report the case of a 60-year-old patient who underwent cervical disc arthroplasty at C4-5, C5-6 and C6-7. Postoperatively, due to symptoms and signs of a cerebellar stroke, magnetic resonance imaging of the brain was obtained confirming this diagnosis. Despite thorough investigation no specific identifiable cause for the stroke has been identified. We hypothesis an unrecognised period of intraoperative hypotension may have caused a temporary reduction in vertebrobasilar blood flow. METHODS: A retrospective review of the patient's case notes and a focused review of literature has been performed. RESULTS: Now two years postoperatively the patient has regained full power but has residual problems with balance. She has neuralgic pain down the right side of her body which following investigation is believed to result from the stroke. CONCLUSIONS / LEVEL OF EVIDENCE: Surgeons should be aware vertebrobasilar stroke is a possible rare perioperative complication associated with anterior cervical decompression and disc arthroplasty. Level V.

Osteomyelitis of the patella: ensure a high index of suspicion and beware the negative aspirate.

We report the case of a 33-year-old man who presented several times to healthcare professionals over a 6-week period with a painful swollen right knee. He had a history of chronic osteomyelitis of the left femur and had recently stopped taking suppressive antibiotics. A joint aspirate did not demonstrate any organisms. On subsequent review by the orthopaedic team MRI was performed which revealed an isolated area of osteomyelitis and an abscess in his right patella. He underwent arthrotomy, debridement and irrigation of the joint alongside antibiotic treatment. We highlight this case, as isolated osteomyelitis of the patella is a rare condition, especially in adults. In addition, the presenting features of osteomyelitis of the patella are varied and joint fluid aspirates often do not reveal an organism. This case therefore aims to raise an awareness of this condition and thereby ensure a high index of suspicion when symptoms or signs are present and inform clinicians of the investigative steps in order to avoid a delay in diagnosis as seen in this case.

Neck of femur fracture fixation in a bilateral amputee: an uncommon condition requiring an improvised fracture table positioning technique.

While neck of femur fractures are common it is rare to see this injury in a bilateral leg amputee. Special consideration needs to be given to the management of these patients. We report the case of a 58-year-old man with bilateral leg amputation who presented to the emergency department with left hip pain following a fall. A fracture of the left neck of femur with extension into the femoral shaft was diagnosed. Internal fixation was planned with a dynamic hip screw. Standard fracture table setup, which allows for traction of the fractured limb and positioning of the contralateral limb such that anteroposterior and lateral X-rays can be obtained, was not possible in this case due to the amputations. We highlight considerations that need to be made in positioning a bilateral amputee for neck of femur fracture fixation and also highlight an improvised technique that can be utilised by other surgeons.

Complete C4 vertebral body destruction: a dramatic finding in a patient with a new diagnosis of myeloma.

We report the case of a 60-year-old woman who presented to accident and emergency with left arm and neck pain. She had reported these symptoms to her general practitioner over the preceding weeks but no imaging was obtained. Radiographs revealed a pathological lesion in her left humerus. On review in the Orthopaedic Fracture Clinic radiographs of the cervical spine were obtained and showed complete destruction of the C4 vertebral body. She underwent corpectomy and stabilisation. Tissue diagnosis confirmed myeloma and she is now under the care of the haematologists receiving chemotherapy and radiotherapy. Myeloma is known to cause severe destructive lesions. Through the dramatic radiographic images this case serves as a reminder to clinicians to obtain imaging of patients with a new or existing diagnosis of malignancy, who show symptoms of skeletal pain, as lesions requiring emergency management may be present.