Surgical correction of scoliosis in Rett syndrome: cord monitoring and complications.

AIM: Rett syndrome is a progressive neurodevelopmental disorder that predominantly affects females and is associated with a high incidence of scoliosis and epilepsy. There is scant published work about intraoperative spinal cord monitoring in these patients and little more regarding the rate of perioperative complications. We investigated our institutions' experience with both. METHODS: We retrospectively reviewed the records of 11 patients with Rett syndrome who underwent surgical correction of scoliosis at our institution between 2004 and 2010. RESULTS: Eleven patients underwent successful correction of their scoliosis at an average age of 12. Eight of the patients suffered one or more significant complications. The average curve was corrected from 71° to 27°. Successful spinal cord monitoring was achieved in eight of the nine patients where it was attempted. No patient suffered any neurological complications. Average inpatient stay was 18.2 days. CONCLUSION: Scoliosis surgery in patients with Rett syndrome carries a very high rate of complications and an average hospital stay approaching 3 weeks. Both caregivers and surgeons should be aware of this when planning any intervention. These patients frequently have useful lower limb function and spinal cord monitoring is a valid tool to aid in its preservation. We would suggest aggressive optimisation of these patients prior to surgery, with an emphasis on nutrition.

Intraoperative spinal cord monitoring during the surgical correction of scoliosis due to cerebral palsy and other neuromuscular disorders.

PURPOSE: Patients with neuromuscular scoliosis are at increased risk of neurological deficit post-operatively, but are a difficult population on whom to perform neurophysiological monitoring. We look here at a 7-year sample of our practice in the monitoring of neuromuscular patients. METHODS: A retrospective chart review was performed for 109 patients who underwent correction of neuromuscular scoliosis within our institution between 2005 and 2011. RESULTS: Of 109 patients who were identified, intraoperative monitoring was attempted in 66 cases. In eight cases (13 %), no reliable monitoring could be achieved and was therefore abandoned. On nine occasions, there was a significant drop in at least one modality intraoperatively. None of these nine suffered any clinically observable neurological deficit post-operatively. Of the 109 patients, 2 had clinically detectable deficits post-operatively, both of whom had undergone normal intraoperative monitoring. CONCLUSIONS: The two patients with observable deficit had their instrumentation left in situ after discussion with them and/or parents. Spinal cord monitoring in this population is possible but potentially unreliable. Surgeons will need to carefully consider the use of monitoring in their management of this challenging population.

The magnification of digital radiographs in the trauma patient: implications for templating.

INTRODUCTION: Digital radiographs are increasingly used for planning orthopaedic surgical procedures, despite the fact that they are frequently not calibrated to correct for magnification. The typical magnification of digital radiographs in the trauma patient has not yet been reported. The aims of this study were to assess the magnification of such radiographs, and to discuss if and when accurate calibration is required for trauma templating. MATERIALS AND METHODS: The operative notes and postoperative radiographs of 227 trauma patients were obtained. Each patient had undergone one of the following procedures: hip hemiarthroplasty, femoral nailing, tibial nailing, ankle plating, humeral nailing, humeral plating, or forearm plating. The dimensions of the implants used were measured on the uncalibrated postoperative radiographs using the hospital's Picture Archiving and Communication System software. The actual dimensions of the orthopaedic implants were obtained from the operation notes, and these were compared with the radiographic measurements. The intraobserver and interobserver variability of the radiographic measurements was also assessed. RESULTS: The radiographic magnification was greatest for the femoral head, and most variable for the femoral shaft. The magnification was least for the forearm. In general the magnitude and variability of magnification was least at the peripheries. There was good correlation between the measured and actual dimensions of the implants. The intraobserver and interobserver variability between the radiographic measurements was extremely small. CONCLUSION: Despite the ease and convenience of performing measurements on digital radiographs, these measurements are unreliable if the radiograph has not been calibrated. We believe that careful calibration of digital radiographs is essential for accurate templating in the trauma patient, although is less critical when templating the humeral canal, the tibial canal, the ankle and the forearm.

A prospective evaluation of pancreatic exocrine function in patients with acute pancreatitis: correlation with extent of necrosis and pancreatic endocrine insufficiency.

AIMS: The aim of this prospective study was to assess pancreatic exocrine function in patients recovering from a first attack of acute pancreatitis, and to evaluate its relationship to severity of attack, extent of pancreatic necrosis and severity of pancreatic endocrine insufficiency. METHODS: Between December 2000 and November 2001, 23 patients were prospectively evaluated. Pancreatic exocrine function was measured by the faecal elastase-1 test and insufficiency was classified as moderately impaired or severely impaired. Pancreatic necrosis was determined by contrast-enhanced CT scan, and its extent was categorised according to Balthazar's classification. The severity of pancreatic endocrine insufficiency was categorised according to insulin dependence. Attacks were classified as mild (n = 16) or severe (n = 7) according to the Atlanta criteria. RESULTS: Pancreatic exocrine insufficiency was significantly more frequent in patients recovering from severe attacks than mild (n = 6, 86% vs. n = 2, 13%; p = 0.002), and in those who developed pancreatic necrosis or pseudocyst than those who did not (6 of 7 patients vs. 2 of 16 patients, and 5 of 5 patients vs. 3 of 18 patients respectively; p = 0.002). The development of exocrine insufficiency correlated strongly with the extent of pancreatic necrosis (r = -0.754, p < 0.001), and the severity of pancreatic endocrine insufficiency (n = 4, r = -0.453, p = 0.03). CONCLUSION: Pancreatic exocrine insufficiency is a common occurrence in patients recovering from severe acute pancreatitis, and its severity correlates with the extent of pancreatic necrosis and the severity of concomitant pancreatic endocrine insufficiency.

The biochemical detection of biliary etiology of acute pancreatitis on admission: a revisit in the modern era of biliary imaging.

INTRODUCTION: Compared with traditional radiologic methods for the detection of cholelithiasis, early transient hypertransaminasemia had provided a useful prediction of biliary etiology in patients with acute pancreatitis. AIM: To investigate whether this application remains valid in the modern era of imaging for microlithiasis. METHODOLOGY: The biochemical detection (LFT) of cholelithiasis was based on an increase in serum alanine transaminase of >or=80 IU/L (normal range, 0-45 IU/L) within 24 hours of admission. We have taken the collective findings of abdominal ultrasound (USS), endoscopic ultrasound (EUS), and postmortem examination to represent the denominator for the diagnosis of cholelithiasis against which comparison with LFT was made. RESULTS: Of 68 patients with acute pancreatitis who were treated between October 2000 and December 2001, cholelithiasis was the etiological factor in 44 patients (65%). EUS detected microlithiasis in 5 of 10 patients examined. The etiology remained idiopathic in 3 patients (4.4%). The sensitivity, specificity, and positive and negative predictive values for USS were 86%, 100%, 100%, and 80% respectively; for LFT, they were 91%, 100%, 100%, and 86%; and for USS and LFT combined, they were 98%, 100%, 100%, and 96%, respectively. CONCLUSIONS: In patients with acute pancreatitis, the biochemical analysis within 24 hours of admission provided a simple, rapid, and more accurate prediction of cholelithiasis than USS. The combination of LFT and USS detected or excluded a biliary etiology in almost all patients.

Annual occupational exposure to ultraviolet radiation in central Queensland.

The purpose of this study was to determine annual occupational exposure to UV radiation by measurement and derive ambient exposure fractions for an entire year that could be applied in the human exposure model. Using polysulphone the daily occupational erythema effective solar ultraviolet radiation exposure at selected body sites of Australia Post mail delivery personnel and physical education teachers were measured over an 18-mo period on a daily basis in the Rockhampton (lat. 23.5 degrees S) region. The daily exposures were summed to estimate an annual exposure for these occupations in this region. For the Australia Post mail delivery personnel, who had very little change to the posture or route during delivery, the annual mean estimates of exposure to erythema effective solar irradiance for the chest, hands, and back were in the range of 192+/-27 kJ m(-2), 388+/-45 kJ m(-2), and 283+/-32 kJ m(-2), respectively. Physical education teachers had varied duties on a day-to-day basis and many changes in their posture and outdoor locations where the exposure occurred. Their annual mean exposure on the vertex (hat), chest, shoulder, thigh, and back were in the range 340+/-71 kJ m(-2), 140+/-28 kJ m(-2), 180+/-40 kJ m(-2), 129+/-24 kJ m(-2), and 212+/-42 kJ m(-2), respectively. The annual exposure range for erythema effective solar irradiance at different body sites during the experimental period was between 120 and 440 kJ m(-2) for the two occupational groups. These exposures greatly exceed the National Health and Medical Research Council occupational standard limit of 30 J m(-2) for daily exposure, which indicates the need for additional protective measures. The ambient exposure was also measured and used to compute ambient exposure fractions for the different body sites over an entire year, which are useful for model calculations on human exposure and assess increase in risk of n on melanoma skin cancer.