A New Fixation Technique for French-Door Cervical Laminoplasty: Surgical Results With a Minimum Follow-up of 6 Years.

DESIGN: A case series of 5 patients with multilevel cervical myelopathy treated by French-door cervical laminoplasty (FDCL) and use of unicortical iliac crest graft as spacer fixed with titanium miniplates and screws is described. OBJECTIVE: To report a minimum of 6-year follow-up results of our new plate-screw fixation technique for FDCL. SUMMARY OF BACKGROUND DATA: Hardware-assisted laminoplasty has the potential advantage of preventing restenosis by holding the laminar door "open" while healing progresses and also prevents spacer dislodgement. The use of titanium miniplates as internal fixation device for FDCL by our novel technique has not been reported. METHODS: Five patients suffering from multilevel cervical myelopathy harboring constitutionally narrow cervical canal (3) and multilevel cervical spondylotic myelopathy (2) who underwent 2-3 level FDCL and followed up prospectively for 6 years is presented. Modified Kurokawa and colleague's technique of FDCL was performed and autologous iliac crest bone graft was interposed between the sagittaly split spinous processes. A 12- to 15-hole titanium miniplate was contoured into a trapezoidal shape to sit flush with the posterior elements. The plate was anchored to bone graft and posterior elements with screws and patients mobilized without any external orthosis. RESULTS: The mean follow-up was 90.5 months. The mean improvement in Neck disability index at final follow-up was 35% and mean improvement in Visual analog scale was 4 points. Japanese orthopaedic association score improved from a mean of 10 to a mean of 14.8 postoperatively. The final outcome was good (3) and excellent (2) by Odom's criteria. All patients improved to Nurick's grade 0 or I and reported significant relief from their myelopathic symptoms and axial neck pain. There were no postoperative hardware-related complications or pseudoarthrosis. CONCLUSIONS: Titanium miniplates are excellent devices for stabilizing the interspinous spacers used in FDCL. They prevent cervical canal deformation, restenosis, spacer dislodgement and are durable, cost-effective in facilitating early mobilization at intermediate-term follow-up of 6 years.

The furcal nerve revisited.

Atypical sciatica and discrepancy between clinical presentation and imaging findings is a dilemma for treating surgeon in management of lumbar disc herniation. It also constitutes ground for failed back surgery and potential litigations thereof. Furcal nerve (Furcal = forked) is an independent nerve with its own ventral and dorsal branches (rootlets) and forms a link nerve that connects lumbar and sacral plexus. Its fibers branch out to be part of femoral and obturator nerves in-addition to the lumbosacral trunk. It is most commonly found at L4 level and is the most common cause of atypical presentation of radiculopathy/sciatica. Very little is published about the furcal nerve and many are unaware of its existence. This article summarizes all the existing evidence about furcal nerve in English literature in an attempt to create awareness and offer insight about this unique entity to fellow colleagues/professionals involved in spine care.

Risk factors for vertebral artery injuries in cervical spine trauma.

Blunt cerebrovascular injuries (i.e. involvement of carotid and vertebral arteries) are increasingly being recognized in setting of cervical spine trauma/fractures and are associated with high incidence of stroke/morbidity and mortality. The incidence of vertebral artery injuries (VAI) is more common than previously thought and regular screening is seldom performed. However there exists no screening criteria and conflicting reports exists between spine and trauma literature. Many clinicians do not routinely screen/evaluate patients presenting with cervical spine trauma for potential VAI. This article provides a brief summary of existing evidence regarding the incidence of VAI in the background of cervical trauma/fractures. The type and fracture pattern that is associated with a high risk of VAI warranting mandatory screening/further work-up is discussed. A brief overview of diagnostic modalities and their respective sensitivity/specificity along with available treatment options is also summarized.

Claustrophobia: a proxy for psychological distress in patients with back pain.

STUDY DESIGN: Case-control study. OBJECTIVE: The aim of this study was to assess the levels of psychological distress in patients with back pain who expressed claustrophobia at the time of their magnetic resonance imaging (MRI) scan, compared with sex and age-matched normal controls who did not exhibit claustrophobia. The secondary aim was to document the level of disability and intervention rates in this group. SUMMARY OF BACKGROUND DATA: Psychosocial factors influence the outcomes of low back pain treatment with psychological distress being associated with poorer surgical outcomes in patients with low back pain. Up to 14% of patients experience claustrophobia during MRI scans requiring sedation to complete the scan. The effect of claustrophobia on back pain disability and outcomes has not been previously reported. METHODS: Twenty females and 13 males all requiring MRI scan under sedation for claustrophobia (group 1) were compared with an age and sex-matched cohort that had MRI scan without sedation (group 2). Both groups were drawn from a chronic back clinic. Average age in both groups was 54 years (range, 27 to 79 y). Both groups had standard conservative therapy, together with psychometric evaluation: Zung Depression Index and Modified Somatic Perception Questionnaire. Disability was measured by Oswestry Disability Index. Primary outcome measures were intervention rates (surgery, injections, and physiotherapy sessions) and prevalence of psychological distress. RESULTS: Mean Zung Depression Index in group 1 was significantly higher than in group 2 (59.5 vs. 28.9, P<0.05) as was the mean Modified Somatic Perception Questionnaire score (13.3 vs. 9.2, P<0.05.) Prevalence of psychological distress was higher in group 1 (75.8% vs. 18.2%, P<0.05). Oswestry Disability Index was the same in both groups (50% vs. 48%). Group 1 had 13 interventions (13 patients=39.4%) compared with 26 in group 2 (26 patients=78.8%) (P< 0.05). Twenty-two patients (66.7%) in group 1 were discharged after their MRI scan with no intervention compared with 7 patients (21.2%) in group 2 (P<0.05). CONCLUSIONS: Claustrophobic patients with back pain showed higher levels of depression than nonclaustrophobic patients, with a higher rate of psychological distress. Disability, however, was not higher. The majority of claustrophobic patients did not require surgical intervention. The reasons for this are unclear and require further investigation. Claustrophobia requiring sedation for MRI scans may be a proxy for psychological distress in these patients and psychometric testing is advised during assessment to help with surgical decision making.

Efficacy of exercise therapy for the treatment of adolescent idiopathic scoliosis: a review of the literature.

PURPOSE: Current evidence regarding the use of exercise therapy in the treatment of adolescent idiopathic scoliosis (AIS) was assessed with a review of published literature. METHODS: An extensive literature search was carried out with commonly used medical databases. A total of 155 papers were identified out of which only 12 papers were deemed to be relevant. RESULTS: There were nine prospective cohort studies, two retrospective studies and one case series. All studies endorsed the role of exercise therapy in AIS but several shortcomings were identified--lack of clarity of patient recruitment and in the method of assessment of curve magnitude, poor record of compliance, and lack of outcome scores. Many studies reported "significant" changes in the Cobb angle after treatment, which were actually of small magnitude and did not take into account the reported inter or intra-observer error rate. All studies had poor statistical analysis and did not report whether the small improvements noted were maintained in the long term. CONCLUSIONS: This unbiased literature review has revealed poor quality evidence supporting the use of exercise therapy in the treatment of AIS. Well-designed randomised controlled studies are required to assess the role of exercise therapy in AIS.

The effect of IV cannula length on the rate of infusion.

According to the Hagen-Poiseuille's law, rate of laminar flow through a tubular structure varies directly with fourth power of its radius and inversely with its length. Although it is well recognised that faster infusion rates can be achieved with wider-bore IV cannulae, the effect of length on flow rates is less well known. In the current in vitro study, we assessed the effect of length of an IV cannula on the rate of flow of infusion. Mathematical calculations performed using Hagen-Poiseuille's law predicted an increase of 40% in flow rates when the IV cannulae were shortened by 13mm. However, when the flow rates of the shortened cannulae were measured in vitro an increase of only 4-18% was observed. Although the increase in flow rates was statistically significant, it may not be sufficient to be significant in clinical practice. Turbulence resulting from design characteristics of the infusion system is responsible for the measured flow rates to be lower than that predicted by mathematical calculations.