Does the external remote controller's reading correspond to the actual lengthening in magnetic-controlled growing rods?

PURPOSE: Magnetic-controlled growing rods (MCGRs) are now routinely used in many centres to treat early-onset scoliosis (EOS). MCGR lengthening is done non-invasively by the external remote controller (ERC). Our experience suggests that there may be a discrepancy between the reported rod lengthening on the ERC and the actual rod lengthening. The aim of this study was to investigate this discrepancy. METHODS: This was a prospective series. Eleven patients who were already undergoing treatment for EOS using MCGRs were included in this study. RESULTS: One hundred and ninety-two sets of ultrasound readings were obtained (96 episodes of rod lengthening on dual-rod constructs) and compared to their ERC readings. Only 15/192 (7.8%) readings were accurate; 27 readings (14.9%) were false positive; and 8 readings (4.2%) were an underestimation while 142 readings (74.0%) were an overestimation by the ERC. Average over-reporting by the ERC was 5.31 times of the actual/ultrasound reading. When comparing interval radiographs with lengthening obtained on ultrasound, there was a discrepancy with an average overestimation of 1.35 times with ultrasound in our series. There was a significant difference between ERC and USS (p = 0.01) and ERC and XR (p = 0.001). However, there was no significant difference between USS and XR (p > 0.99). CONCLUSION: The reading on the ERC does not equate to the actual rod lengthening. The authors would recommend that clinicians using the MCGR for the treatment of early-onset scoliosis include pre- and post-extension imaging (radiographs or ultrasound) to confirm extension lengths at each outpatient extension. In centres with ultrasound facilities, we would suggest that patients should have ultrasound to monitor each lengthening after distraction but also 6-month radiographs. These slides can be retrieved under Electronic Supplementary Material.

Do magnetic growing rods have lower complication rates compared with conventional growing rods?

BACKGROUND CONTEXT: The main advantage cited for the use of the magnetic controlled growing rod (MCGR) system over the conventional growing rod (CGR) in early-onset scoliosis is avoiding repeated invasive surgical procedures for lengthening, thus reducing, complications. PURPOSE: The study aimed to evaluate the complications of the MCGR system against the CGR system in our center. STUDY DESIGN/SETTING: This is a retrospective case control series. PATIENT SAMPLE: The sample includes patients with early-onset scoliosis treated with MCGR or CGR. OUTCOME MEASURES: Complications and unplanned return to theater were the outcome measures. RESULTS: Of the 37 patients (MCGR, N=10; CGR, N=27) in our cohort, 28 patients (76%) had at least one complication. Taking into account the follow-up period, MCGR had a higher complication rate than CGR group (0.32 complication per patient per year vs. 0.15 complication per patient per year). The use of MCGR was associated with a lower risk of deep infection (odds ratio [OR]: 0.22; p=.22) and superficial infection (OR: 0.07, p=.017) but increased risk of metalwork problems (OR: 4.67; p=.045) and unplanned return to theater (OR: 2.92; p=.05) compared with CGR. CONCLUSIONS: Although MCGR has a lower rate of both deep and superficial infections when compared with CGR, it does not completely avoid repeated invasive surgical procedures as previously suggested. It does have a significant increased risk of metalwork problems and unplanned return to theater.

Magnetic controlled growing rods for early-onset scoliosis: a 4-year follow-up.

BACKGROUND CONTEXT: There have been no studies with medium-term follow-up of magnetic controlled growing rods (MCGRs). PURPOSE: This study aimed to report our single center experience of a magnetic growing rod system with an average of 4 years' follow-up. STUDY DESIGN/SETTING: A retrospective case series was carried out. PATIENT SAMPLE: The sample comprised patients with early-onset scoliosis treated with magnetic controlled growth rods who were operated in 2011. OUTCOME MEASURES: Cobb angle, spinal growth rate, complications, and revision were the outcome measures. METHODS: Clinical case notes and radiographs were reviewed. RESULTS: There were 8 patients (5 dual-rod construct, 3 single-rod construct) who had a minimum of 44 months' follow-up and average of 48 months (44-55 months). Mean age at surgery was 8.2 years (range 3-10). Mean preoperative Cobb angle was 60° (34-94), whereas mean postoperative Cobb angle was 42° (32-63). The average number of extensions was 13.8 (range: 12-20). There were 6 patients (75%) who required 8 revision surgeries: rod problems (N=4), proximal screw pull-out (N=3), and development of proximal junction kyphosis (N=1). All three patients who had single-rod construct underwent revision procedure. Currently, four patients (50%) still have the magnetic rods in situ. The mean duration of MCGR in the patient in the removed group was 39 months (range: 34-46). CONCLUSIONS: Medium-term results of MCGR are not as promising as previously reported early results. Hence, MCGRs should be used with caution. Single-rod constructs should definitely be avoided. The role of MCGRs in revision cases still remains unknown.

Recurrence of kyphosis and its functional implications after surgical stabilization of dorsolumbar unstable burst fractures.

BACKGROUND CONTEXT: Treatment of unstable burst fractures in the dorsolumbar spine still remains controversial. Surgical stabilization has been aimed to prevent long-term back pain and progression of deformity. PURPOSE: This study was aimed to analyze the degree of loss of correction of the angle of kyphosis with pedicle screw instrumentation in place and the components responsible for the recurrence of kyphosis after surgical stabilization of dorsolumbar A3 fractures and to assess the return of functional capacity in these patients. STUDY DESIGN: Retrospective study. PATIENT SAMPLE: This study involves 26 patients who had dorsolumbar unstable burst fractures (Arbeitsgemeinschaft für Osteosynthesefragen type A3). OUTCOME MEASURES: Radiological assessment at injury, immediate postoperative period, and most recent follow-up along with functional assessment using short form 36 (SF-36) and return to work. METHODS: All the patients had posterior pedicle screw instrumentation without fusion for unstable dorsolumbar burst compression (A3) fractures. The mean follow-up period was 25.5 months. All of them had their fractures stabilized with Universal Spinal System (Synthes, Welwyn Garden City, UK) Fracture System. Serial standing lateral radiographs were taken from the immediate postoperative period to the most recent follow-up. The angle of kyphosis; the heights of the discs above and below the fractured vertebra; and the heights of the vertebral bodies above, at, and below the fractured level were measured. The height at each level was measured in three segments (anterior, middle, and posterior). The values were normalized to avoid discrepancies while comparing radiographs. The difference in the height of each segment measured between the immediate postoperative period and the most recent follow-up was computed. RESULTS: The mean angle of kyphosis was 6.3+/-8.9 in the immediate postoperative period and 15.7+/-6.7 at the most recent follow-up (p<.001). The mean patient function score from SF-36 was 52.3%, and the mean pain score was 44.9%. There was no relationship to the loss of correction angle of kyphosis to the patient function score (r=0.06, p=.76) and the pain score (r=0.11, p=.58). The correlation between the corresponding difference in the height of each segment and the degree of loss of correction of the angle of kyphosis showed positive correlation to the decrease in the anterior and middle segment heights at the fractured vertebral level. CONCLUSION: There is a progressive loss of correction of the angle of kyphosis after posterior stabilization with instrumentation even without implant removal that mainly corresponds to the decrease in the anterior segment height of the fractured vertebral body.

Data management in structural genomics: an overview.

Data management has been identified as a crucial issue in all large-scale experimental projects. In this type of project, many different persons manipulate multiple objects in different locations; thus, unless complete and accurate records are maintained, it is extremely difficult to understand exactly what has been done, when it was done, who did it, and what exact protocol was used. All of this information is essential for use in publications, reusing successful protocols, determining why a target has failed, and validating and optimizing protocols. Although data management solutions have been in place for certain focused activities (e.g., genome sequencing and microarray experiments), they are just emerging for more widespread projects, such as structural genomics, metabolomics, and systems biology as a whole. The complexity of experimental procedures, and the diversity and high rate of development of protocols used in a single center, or across various centers, have important consequences for the design of information management systems. Because procedures are carried out by both machines and hand, the system must be capable of handling data entry both from robotic systems and by means of a user-friendly interface. The information management system needs to be flexible so it can handle changes in existing protocols or newly added protocols. Because no commercial information management systems have had the needed features, most structural genomics groups have developed their own solutions. This chapter discusses the advantages of using a LIMS (laboratory information management system), for day-to-day management of structural genomics projects, and also for data mining. This chapter reviews different solutions currently in place or under development with emphasis on three systems developed by the authors: Xtrack, Sesame (developed at the Center for Eukaryotic Structural Genomics under the US Protein Structural Genomics Initiative), and HalX (developed at the Yeast Structural Genomics Laboratory, in collaboration with the European SPINE project).

Chronic recurrent multifocal osteomyelitis presenting as acute scoliosis: a case report and review of literature.

Chronic relapsing multifocal osteomyelitis (CRMO) is a rare condition. It commonly affects the clavicle and pelvis. Rarely it can affect the spine. Spinal deformity due to CRMO is rare. We report a case of acute scoliosis due to CRMO. A 10-year-old girl with CRMO presented with acute painful scoliosis of her spine. She was neurologically intact. Imaging suggested a neoplastic process involving T10, L2 and L3. Further imaging and subsequent biopsy was performed and a diagnosis of CRMO was established. Spinal involvement with deformity is uncommon. It is commonly misdiagnosed as infection or a neoplasm and unnecessary aggressive surgical and antibiotic therapy instituted. A high index of suspicion is needed to diagnose this disease and thus manage it appropriately. This patient with a previously normal spine had a long right sided thoracic scoliosis. We think that the particular pattern of scoliosis was a protective mechanism to offload the right sided T10 vertebral pedicle. Prognosis is generally good although the disease can relapse and remit over many years. At 9 months follow up, the lesions were resolving and the deformity had resolved. CRMO presenting as acute scoliosis is rare and to our knowledge this is the second recognised case in the reported world literature.

The Modic classification: inter- and intraobserver error in clinical practice.

STUDY DESIGN: A reliability study of the Modic classification. OBJECTIVE: To determine the reliability and reproducibility of the Modic classification for lumbar vertebral marrow changes. SUMMARY OF BACKGROUND DATA: In 1988, Modic et al described two degenerative stages of vertebral marrow and endplate morphology. These were type 1 (inflammatory phase) and type 2 (a fatty phase). Later in 1988, he added a third variety: type 3 where there was marked sclerosis adjacent to the endplates. No formal reliability or reproducibility studies had been performed on this Modic classification. METHODS: This study involved five independent observers of differing spinal experience using the Modic classification to grade 50 sagittal T1- and T2-weighted magnetic resonance imaging scans. The observers repeated the assessment at 3 weeks. Intra- and interobserver reliabilities were assessed using kappa statistics. RESULTS: There were 7 type 1, 40 type 2, 1 type 3, and 2 normal levels. The individual intraobserver agreement was substantial or excellent with kappa values ranging from 0.71 to 1. The overall interobserver agreement was excellent with a kappa value of 0.85. There was complete agreement in 78% of the levels, a difference of one type in 14% and a difference of two or more in 8% of levels. The level of experience of the observer did not correlate with a better score. CONCLUSIONS: We have shown that the classification is both reliable and reproducible. It is simple and easy to apply for observers of varying clinical experience. We therefore recommend its use in clinical research and practice.

Avulsion of the L4 spinous process: an unusual injury in a professional rugby player: case report.

STUDY DESIGN: A case of L4 spinous process avulsion following a hyperflexion injury treated with surgical excision. OBJECTIVE: To show that single photon emission computerized tomography is essential for the diagnosis and that excision can provide a successful outcome. SUMMARY OF BACKGROUND DATA: The avulsion resulted from a forced hyperflexion injury at the L4/5 area, where the interspinous ligament provides a high resistance to flexion. METHODS: A 29-year-old international rugby football player injured his low back during a match. Plain radiography and magnetic resonance imaging did not reveal the injury. Single photon emission computerized tomography and computerized tomography showed the lesion. RESULTS: Initial conservative therapy failed to control the symptoms, and, therefore, late excision was performed with pain-free return to contact sports at 3 months. CONCLUSIONS: Few cases of interspinous process avulsions have been described, and, to our knowledge, this is the first reported case of rugby football player who had a successful outcome with late surgical excision.

Surgical management of severe cervical kyphosis with myelopathy in osteogenesis imperfecta: a case report.

STUDY DESIGN: A case of a 9-year-old child with Osteogenesis Imperfecta and severe cervical kyphosis associated with wedged vertebrae and progressive neurological deterioration is presented. OBJECTIVE: To highlight the difficulties in surgical management of this condition and to discuss the appropriate surgical approach. SUMMARY OF BACKGROUND DATA: This case demonstrates an unusual case of Osteogenesis Imperfecta with associated wedged vertebrae causing a quadriparesis. Surgical decompression and stabilization can be performed with resolution of symptoms even in this age group with the appropriate approach and implants. METHODS: A 9-year-old girl presented with progressive cervical kyphosis and quadriparesis. At the age of 3 years, she underwent posterior cervical fusion (C1-C6) for instability. Radiological and laboratory investigations confirmed the diagnosis of Osteogenesis Imperfecta, and radiographs of the cervical spine revealed a kyphotic deformity of 120 degrees . Magnetic resonance imaging and computerized tomography scans showed anterior cord compression attributable to wedged vertebrae at C3 and C4. Magnetic resonance imaging-angiography was performed before surgery to identify the anatomic position of the vertebral arteries. A modified anterolateral approach to the upper cervical spine was performed, and anterior C3 and C4 corpectomies with interbody cage and plate fixation were carried out. RESULTS: After surgery the patient made a full neurological recovery, and significant correction of the deformity was achieved and maintained at follow-up. CONCLUSIONS: Cervical kyphotic deformity in Osteogenesis Imperfecta is uncommon. Association of this condition with wedged vertebrae is rare. Surgical decompression of the upper cervical spine is a challenging problem in the presence of this deformity. Which surgical approach to use is controversial. There are difficulties exposing wedged vertebrae by a standard anterior approach, and hence we have used a modified anterolateral approach to address this surgical problem, because a posterolateral approach was impossible with the intervening vertebral arteries. Spinal stabilization in children with Osteogenesis Imperfecta and poor bone stock is a challenge. We have used a small diameter MOSS cage ("Harms mesh cage") with maxillofacial plate and screws to achieve stabilization and fusion.

CT evaluation of the pattern of odontoid fractures in the elderly--relationship to upper cervical spine osteoarthritis.

Odontoid fractures are common in the elderly following minor falls. Almost all of them have osteoarthritis of the cervical spine below the axis vertebra. As a result, there is increased stress on the spared upper cervical spine, resulting in a higher incidence of injuries. As movement in the upper cervical spine involves participation of five joints, degeneration in any one particular joint may affect the biomechanics of loading of the upper cervical spine. We aimed to analyse the relationship of odontoid fractures to the pattern of upper cervical spine osteoarthritis in the elderly. We studied the CT-scan images of the cervical spine in 23 patients who were over the age of 70 years and had odontoid fractures. In each patient, the type of odontoid fracture and the characteristics of the degenerative changes in each joint were analysed. Twenty-one of 23 patients had Type-II odontoid fractures. The incidence of significant atlanto-odontoid degeneration in these individuals was very high (90.48%), with relative sparing of the lateral atlantoaxial joints. Osteoporosis was found in 13 of 23 patients at the dens-body junction and in seven of 23 patients at the odontoid process and body of the axis. With ageing, progressively more severe degenerative changes develop in the atlanto-odontoid joint. These eventually obliterate the joint space and fix the odontoid to the anterior arch of the atlas. In contrast, the lateral atlantoaxial joints are hardly affected by osteoarthritis. Thus, ultimately, atlantoaxial movements including atlantoaxial rotation are markedly limited by osteoarthritis of the atlanto-odontoid joint. However, there is still potential for movement in the lateral atlantoaxial joints, as they remain relatively free of degenerative change. The vulnerability of the atlantoaxial segment is further increased by markedly limited rotation below the axis vertebra due to severe facet-joint degeneration. As a consequence, a relatively low-energy trauma to the lateral part of the face, for instance by a fall, will induce forced atlantoaxial rotation. This, with the marked limitation of movement at the atlanto-odontoid joint, will produce a torque force at the base of the odontoid process leading to a Type II fracture.

Anterior screw fixation for a pediatric odontoid nonunion: a case report.

STUDY DESIGN: A case of an odontoid nonunion in a child treated with anterior screw fixation. OBJECTIVES: To demonstrate that an anterior screw procedure can be performed with an odontoid nonunion with resultant fusion to maintain range of motion. METHODS: A 15-year-old boy presented with pain in his neck following a rugby football injury. Admission plain radiographs and computed tomography scan demonstrated an odontoid nonunion. Radiographs of a previous cervical spine injury 2 years before demonstrated a missed odontoid fracture. RESULTS: The child was initially treated conservatively with halo vest immobilization, which did not result in healing. Direct anterior screw fixation was performed and the fracture united 5 months following surgery. DISCUSSION: The nonunion was asymptomatic for 2 years until the second injury when it became clinically symptomatic. It did not respond to conservative treatment and was unstable on screening requiring operative intervention. CONCLUSIONS: Very few cases have been reported of pediatric odontoid nonunions. If the fracture pattern allows, then direct anterior screw fixation should be considered in order to maintain range of motion at the atlantoaxial articulation.

Unilateral septic arthritis of a lumbar facet joint secondary to acupuncture treatment--a case report.

This report describes a case of septic arthritis of the lumbar facet joint probably as a result of acupuncture treatment. A 48 year old man with a long history of back pain presented with a two week history of increasing pain following a third session of acupuncture. Examination revealed tenderness in the right lumbosacral area and laboratory investigations revealed raised inflammatory markers with negative blood cultures. A bone scan and MRI scan showed evidence of septic arthritis of the right L5/S1 facet joint. An x ray computed tomography guided biopsy was carried out which isolated staphylococcus aureus. The patient was initially treated with intravenous antibiotics. A repeat MRI scan demonstrated persistent septic arthritis with adjacent early abscess formation. Surgical debridement of the facet joint was therefore performed. The patient had resolution of his symptoms and the inflammatory markers returned to normal. He regained a full range of movement of the lumbar spine. Very few cases have been reported of lumbar facet joint septic arthritis and this condition is rare in association with acupuncture treatment. A high index of suspicion needs to be maintained and if conservative management fails then debridement can result in an acceptable outcome.