Carbon fibre instrumentation for scoliosis surgery in children with spinal cord intramedullary tumours: a novel technical note.

INTRODUCTION: Scoliosis in children is the most common spinal deformity seen by general practitioners, paediatricians and spinal surgeons. Progressive scoliosis can result in the development of a worsening deformity and cosmesis. Patients usually present with aesthetic concerns. Progressive scoliosis that fails conservative management may require or be offered surgical intervention. Intramedullary tumours may be associated with scoliosis. Management of patients with these dual pathologies can be challenging. Classical scoliosis instrumentation utilising titanium implants impairs post-operative MRI evaluation with metal artefacts. Carbon fibre instrumentations has the potential to reduce the imaging metal artefacts but has not been described in scoliosis correction. METHODS: Surgical technical note describing correction of scoliosis in two adolescents' with intradural tumours utilising carbon fibre implants. RESULTS: We developed a hybrid approach where we initially used titanium implants to manipulate the deformity then replaced the construct with carbon fibre implants in the same setting to maintain the deformity correction with good follow up outlook. CONCLUSION: Our technique is robust, safe and replicable. It enabled appropriate post-operative MRI evaluation of the neural structures with a reduced risk of metal artefacts.

Unilateral microscopic approach for lumbar spinal stenosis decompression: a scoping review.

BACKGROUND: Microscopic unilateral laminotomy for bilateral decompression (ULBD) is a minimally invasive technique used in the treatment of lumbar spinal stenosis and could limit spinal instability and be associated with better clinical outcomes. However, there is ongoing debate regarding its utility compared to conventional laminectomy (CL). The primary objective was to collate and describe the current evidence base for ULBD, including perioperative parameters, functional outcomes, and complications. The secondary objective was to identify operative techniques. METHODS: A scoping review was conducted between January 1990 and August 2022 according to the PRISMA extension for scoping reviews (PRISMA-ScR) guidelines. Major databases were searched for full text English articles reporting on outcomes following microscopic unilateral laminotomy in patients with lumbar spinal stenosis. RESULTS: Seventeen articles met the inclusion criteria. Two studies were randomised controlled trials. Two studies were prospective data collection and the rest were retrospective analysis. Three studies compared ULBD with CL. ULBD preserves the osteoligamentous complex and may be associated with shorter operative time, less blood loss, and similar clinical outcomes when compared to CL. CONCLUSION: This review highlights that ULBD aims to minimise disruption to the normal posterior spinal anatomy and may have acceptable clinical outcomes. It also highlights that it is difficult to draw valid conclusions given there are limited data available as most studies identified were retrospective or did not have a comparator group.

The Effect of COVID-19 National Lockdown on the Time from Presentation to Surgery of Patients with Suspected Cauda Equina Syndrome: Two UK Tertiary Centers' Study.

OBJECTIVE: To investigate if COVID-19 UK lockdown measures resulted in a delay in the presentation and treatment of patients with cauda equina syndrome (CES). METHODS: This is a multicenter retrospective study of patients with surgically treated CES across 3 time periods: April-May 2020 (first lockdown), August-September 2020 (no-lockdown group), and January-February 2021 (second lockdown). Data regarding duration of symptoms, time from referral to admission, time from admission to surgery, and postoperative outcomes were collected. RESULTS: A total of 56 patients (male: 26, female: 30, mean age: 44.3 years) were included in the study (n = 14, n = 18, and n = 24 in the 3 time periods, respectively). There was no significant difference in duration of symptoms across the time periods (12.6 days vs. 8.2 days vs. 3.8 days) (P = 0.16). Nearly all the patients were admitted within 48 hours of referral (n = 55, 98.2%). The majority of patients were operated on within 48 hours: first lockdown (n = 12, 85.7%), no-lockdown (n = 16, 88.9%), and second lockdown (n = 21, 87.5%). The length of hospital stay was significantly shorter in the second lockdown (3.3 days) versus the other 2 time periods (4.4 days and 6.4 days) (P = 0.02). Thirteen complications were present, with dural tear being the most common (n = 6, 10.7%). Majority reported symptom improvement (n = 53, 94.6%), with a similar number discharged home (n = 54, 96.4%). CONCLUSION: Despite the pandemic, patients with CES were promptly admitted and operated on with good outcomes. Shorter duration of hospital stay could be attributed to adaptation of spinal services.

Aspergillus fumigatus causing vertebral osteomyelitis in an immunocompetent patient: a case report and literature review.

Aspergillus vertebral osteomyelitis causing deformity in immunocompetent patients is uncommon. We describe a previously healthy 68-year-old male who was referred after 2 years of lower thoracic back pain and gibbus. His inflammatory markers and HIV test were normal. Imaging demonstrated bony destruction of T12/L1 and L2 with vertebral collapse. Following inconclusive CT-guided biopsy, he underwent reconstructive spinal surgery. Histopathology showed fungi and Aspergillus fumigatus was cultured. He was treated with isavuconazole 200 mg once daily for 12 months with a satisfactory clinical outcome. We present a summary of recently published cases of atraumatic Aspergillus vertebral osteomyelitis in immunocompetent patients without risk factors. Fungal infection should be considered in culture-negative spondylodiscitis, even in the absence of risk factors.

Mean 5-Year Follow-Up Results of a Facet Replacement Device in the Treatment of Lumbar Spinal Stenosis and Degenerative Spondylolisthesis.

OBJECTIVE: Flexible stabilization has been utilized to maintain spinal mobility in patients with early-stage lumbar spinal stenosis (LSS). Previous literature has not yet established any nonfusion solution as a viable treatment option for patients with severe posterior degeneration of the lumbar spine. This feasibility study evaluates the mean 5-year outcomes of patients treated with the Total Posterior Spine System (TOPS) facet replacement system in the surgical management of lumbar spinal stenosis and degenerative spondylolisthesis. METHODS: Ten patients (2 men, 8 women, mean age: 59.6 years) were enrolled into a non-randomized prospective clinical study. Patients were evaluated with standing anteroposterior, lateral, flexion and extension radiographs and magnetic resonance imaging scans, back and leg pain visual analog scale scores, Oswestry Disability Index, Zurich Claudication Questionnaire and the SF-36 questionnaires, preoperatively, 6 months, 1 year, 2 years, and latest follow-up at a mean of 5 years postoperatively (range: 55-74 months). Flexion and extension standing lumbar spine radiographs were obtained at 2 years to assess range of motion at the stabilized segment. RESULTS: The clinical outcome scores for the cohort improved significantly across all scoring systems. Radiographs at 2 years did not reveal any loss of position or loosening of metal work. There were 2 incidental durotomies and no failures at 5 years, with no patient requiring revision surgery. CONCLUSIONS: The TOPS implant maintains clinical improvement and motion in the surgical management of LSS and spondylolisthesis, suggesting that it can be considered an option for these indications.

Paediatric spinal trauma presenting to a UK major trauma centre.

PURPOSE: Paediatric spine trauma is uncommon and is managed differently from adults due to the anatomical differences of the paediatric spine. The paediatric spine is less ossified, with lax ligaments and a higher fulcrum in the c-spine which results in a different pattern of injuries. The aim of this study is to provide a contemporary audit of paediatric spinal trauma. METHODS: A retrospective review was conducted using the Trauma and Audit Research Network database at a major trauma centre (2011-2018). All patients < 18 years old with a spine injury underwent case note and radiology review. RESULTS: A total of 72 patients (37, 51.4% male with an average age of 13.3 (± 5.9) years old) were identified. The most common mechanism of injury was road traffic collisions (n = 39, 54.2%). The most common sporting cause was motocross accidents (n = 6, 8.3%), and a further 6 (8.3%) patients had a suspected inflicted injury. Eight patients (11.1%) sustained a spinal cord injury. Twenty-seven (37.5%) patients underwent surgical intervention to treat their spinal injury. CONCLUSION: This series demonstrates the profile of injury mechanisms causing paediatric spinal injuries. Paediatric spine injuries continue to have the potential for lifelong disability and require careful, specialist management. This series also highlights certain causes such as motocross accidents and suspected inflicted injury which are more frequent than expected and raise potential public health concerns.

Lumbar intravertebral disc herniation secondary to idiopathic calcific discitis.

Calcific discitis is a well recognized entity in the paediatric population but more recently has been increasingly reported in adults. It typically involves the lower thoracic vertebrae and is of unknown aetiology. Herniation of the calcified fragment is rare but typically occurs out through the annulus fibrosus into the canal space. Herein we describe the first reported case of calcific discitis involving the lumbar vertebrae with subsequent herniation of the calcified disc into and through the anterior aspect of the L5 vertebra. The patient first presented with a history of right back pain and leg sciatica. Radiographic imaging demonstrated calcification within the L4/5 interspace, which was managed with simple analgesia. She subsequently re-presented 24-months later with worsening sciatica, right leg weakness and faecal incontinence. No evidence of cord or root compression was noted on MRI. However, an abnormality was noted at the anterior body of L5 with evidence of superior endplate depression and marrow signal change. Subsequent radionucleide bone studies confirmed a solitary focus of increased linear activity extending across the width of the L4-L5 interspace. Her symptoms were managed medically. Serial radiographic imaging demonstrated regression of the disc space calcification and healing of the L5 fracture. Despite its sinister presentation this condition was self-limiting. We describe the radiographic evolution of this pathology and postulate a putative hypothesis through which it may have arisen.

The acacia thorn--An unusual cause of Achilles tenosynovitis.

We describe an unusual case of Achilles tenosynovitis caused by a prick from an acacia thorn. The clinical sequelae are presented as well as a review of the literature.

Vertebral artery dissection presenting with multilevel combined sensorimotor radiculopathy: a case report and literature review.

STUDY DESIGN: This study is a case report demonstrating a rare clinical presentation of vertebral artery dissection. We believe that this is the first reported case with multilevel combined sensorimotor radiculopathy. We have also included a literature review. OBJECTIVE: The purpose of this report is to inform the reader of a unique clinical presentation and to draw attention to some of the rare features of extracranial vertebral artery dissection. We believe that this condition is perhaps underrecognized and this paper may help to increase awareness, thereby encouraging prompt investigation, diagnosis, and implementing early treatment. The literature review also includes a brief anatomic and physiologic description of the underlying pathologic process. SUMMARY OF BACKGROUND DATA: Only a small number of similar cases are described in the literature, though most describe a motor deficit at a single root level. Our case included both motor and sensory deficits at more than 1 level and we describe the possible physiologic and anatomic reasons for this. METHODS: The case described is one that presented to our institution and was initially assessed by the first (corresponding) author. The literature review is based on articles identified from a PubMed search on vertebral artery dissection. RESULTS: The clinical and radiologic findings are discussed in the case report. CONCLUSIONS: Peripheral motor deficits are a rare clinical presentation of spontaneous vertebral artery dissection and tend to affect a solitary root level, typically C5. Sensation is usually preserved. We describe a case presenting with multilevel combined sensorimotor radiculopathy, which we believe has not previously been reported.

Arthroscopically assisted percutaneous fixation of triplane fracture of the distal tibia.

Triplane ankle fractures typically occur in the adolescent age group. Although many are minimally displaced and can be managed nonoperatively, some are displaced and difficult to reduce by closed methods and need open reduction and internal fixation. Traditionally satisfactory articular reduction is achieved through an open approach, which can be extensive. We describe our experience of treating displaced triplane fractures in four patients, assisted by ankle arthroscopy to ensure anatomical reduction and minimal soft tissue disruption. We achieved excellent reduction and stable fixation in all four cases. All patients regained full range of movement within 6 weeks.