Traumatic hyperextension-distraction injuries of the thoracolumbar spine: a technical note on surgical positioning.

PURPOSE: Hyperextension-distraction type injury of the thoracolumbar spine is an unstable fracture pattern that generally necessitates surgical stabilization by posterior instrumentation. Care must be taken when positioning these patients from supine to prone due to the unstable nature of their injury. The study objectives were (1) to describe a novel modification of the Jackson table turn technique, which may be safer and more effective than the conventional log-roll method and traditional Jackson table technique for positioning patients with hyperextension-distraction injuries of the thoracolumbar spine from supine to prone in the operating room and (2) to present two cases in which this technique was successfully performed. METHODS: Two patients were carefully positioned from supine to prone by our modification of the Jackson table turn technique, which utilizes a Wilson frame sandwiched between two flat-top Jackson frames. Case 1: a 65-year-old female presented status-post motor vehicle collision with a T9-T10 extension-distraction injury, requiring T7-T12 posterior spinal instrumented fusion (PSIF). Case 2: a 72-year-old female presented status-post motor vehicle collision with a T9-T10 extension-distraction injury and an unstable L1 burst fracture, requiring T7-L2 PSIF. RESULTS: Both patients remained hemodynamically stable and neurologically intact throughout positioning and postoperatively. CONCLUSIONS: This technique is safe and effective for positioning patients with hyperextension-distraction type injuries of the thoracolumbar spine from supine to prone in the operating room and may be superior to conventional methods. These slides can be retrieved under Electronic Supplementary Material.

Exercise During Pregnancy: Obstetricians' Beliefs and Recommendations Compared to American Congress of Obstetricians and Gynecologists' 2015 Guidelines.

Purpose Obesity and excessive weight gain during pregnancy is a growing problem, conferring severe health risks for both mother and fetus. Exercise can help combat this epidemic. However, many pregnant women are not meeting the American Congress of Obstetricians and Gynecologists' (ACOG's) 2015 guidelines for exercise during pregnancy. The objective of this study was to evaluate obstetricians' beliefs and recommendations regarding exercise during pregnancy compared to ACOG's 2015 recommendations. Method Obstetricians were recruited via three different forums to complete a twenty-question survey: at a regional conference for Alabama and Mississippi ACOG members, at the University of Alabama at Birmingham's Obstetrics and Gynecology Department's Grand Rounds, and via telephone. Univariate statistical analysis was conducted with RedCap. Results  Seventy-one surveys were completed: 33 from the ACOG conference, 27 from Grand Rounds, and 11 from those recruited by telephone. Eighty-eight percent (n=60) of respondents correctly identified ACOG's recommendation of unrestricted exercise for women with uncomplicated pregnancies. One-fourth (24%; n=16) regularly discuss exercise with most (76%-100%) pregnant patients. Most (57%; n=59) do not consistently ("never," "rarely," or "sometimes") recommend sedentary patients begin exercising during pregnancy. Nearly all (97%; n=66) advise first-trimester patients to perform aerobic exercise two to five days per week, but the recommended duration varies. One-fourth (24%; n=16) do not recommend strength-training exercise during the first trimester. Twenty-five percent (n=17) and 32% (n=22) recommend decreased aerobic or strength-training exercise, respectively, in the third trimester. More than half (54%; n=37) recommend pregnant patients limit exercise by heart rate, most commonly 121-140 bpm (25%; n=17) or 141-160 bpm (24%; n=16). Sixty-eight percent (n=46) feel "comfortable" or "very comfortable" providing advice on exercise during pregnancy. Conclusion Despite believing exercise benefits pregnant women, knowing ACOG's 2015 guidelines endorse unrestricted exercise for women with uncomplicated pregnancies, and feeling comfortable discussing this topic with patients, obstetricians are not consistently counseling their pregnant patients on exercise. Notably, physicians are not instructing their sedentary pregnant patients to exercise. While most physicians provide appropriate advice on aerobic exercise, their advice on resistance training, maximum heart rate during exercise and third-trimester exercise are often discordant with ACOG's guidelines.

A Case of a Second Intermetatarsal Space Gouty Tophus with a Presentation Similar to a Morton's Neuroma.

Non-infectious soft tissue lesions of the foot and ankle are relatively rare clinically. These include benign and malignant neoplasms, as well as non-neoplastic or pseudotumoral lesions such as ganglionic, synovial and epidermoid cysts, intermetatarsal and adventitious bursitis, inflammatory lesions like gouty tophi and rheumatoid nodules, Morton's neuroma, and granuloma annulare. A 48-year-old male with a history of medically treated tophaceous gout presented with left foot neuropathic pain and paresthesia, in the setting of a well-circumscribed soft tissue lesion of the second intermetatarsal space, suspected to be a Morton's neuroma. Magnetic resonance imaging (MRI) showed a 4.1 x 2.7 x 2.6 cm heterogeneous soft tissue mass containing multiple cystic areas. Excisional biopsy was performed and histologic examination revealed well-circumscribed nodules of amorphous material containing needle-shaped clefts, rimmed by histiocytes, and multinucleated giant cells consistent with a gouty tophus. This is the first case reported in the literature of an intermetatarsal gouty tophus causing neuropathic pain and paresthesia. While Morton's neuroma is the most common cause of this presentation, this case illustrates that other pseudotumoral lesions, such as a gouty tophus, may present similarly, and should be considered in the differential diagnosis. While most cases of tophaceous gout can be adequately treated with urate-lowering therapy, surgery may be indicated for tophi that do not resolve with medical treatment based upon symptom severity, compression of nearby structures, and functional impairment.