The Hoffmann parallax: a prospective study to determine the benefit of Hoffmann's sign.

Background: Degenerative cervical myelopathy (DCM) is the most common cause of age-related spinal cord dysfunction worldwide. Despite the widespread use of provocative physical exam maneuvers in the workup of DCM, the clinical significance of Hoffmann's sign is controversial. Objective: The purpose of this study was to prospectively assess the diagnostic performance of Hoffmann's sign for DCM in a cohort of patients treated by a single spine surgeon. Materials & Methods: Patients were divided into two groups based on the presence of a Hoffmann sign on physical examination. Advanced imaging studies were independently reviewed by four raters for confirmation of a diagnosis of cervical cord compression. Prevalence, sensitivity, specificity, likelihood, and relative risk ratios for the Hoffmann sign were calculated, with subsequent Chi-square and receiver operator characteristic (ROC) analysis to further characterize correlative findings. Results: Fifty-two patients were included - of whom, thirty-four (58.6%) patients presented with a Hoffmann sign, and eleven (21.1%) patients demonstrated cord compression on imaging. The Hoffmann sign demonstrated a sensitivity of 20% and a specificity of 35.7% (LR = 0.32; 0.16-1.16). Chi-square analysis revealed that imaging findings positive for cord compression were proportionally greater for patients lacking a Hoffmann sign than those with a confirmed Hoffmann sign (p =0.032) ROC analysis demonstrated that a negative Hoffmann sign performed moderately well in predicting cord compression (AUC.721; p =0.031). Conclusions: The Hoffmann sign is an unreliable marker for cervical cord compression, and the lack of a Hoffmann sign may be more predictive of cervical cord compression.

Location variance of the great vessels while undergoing side-bend positioning changes during lateral interbody fusion.

Background: Minimally invasive lateral lumbar interbody fusion (LLIF) is an increasingly popular surgical technique that facilitates minimally invasive exposure, attenuated blood loss, and potentially improved arthrodesis rates. However, there is a paucity of evidence elucidating the risk of vascular injury associated with LLIF, and no previous studies have evaluated the distance from the lumbar intervertebral space (IVS) to the abdominal vascular structures in a side-bend lateral decubitus position. Therefore, the purpose of this study is to evaluate the average distance, and changes in distance, from the lumbar IVS to the major vessels from supine to side-bend right and left lateral decubitus (RLD and LLD) positions simulating operating room positioning utilizing magnetic resonance imaging (MRI). Methods: We independently evaluated lumbar MRI scans of 10 adult patients in the supine, RLD, and LLD positions, calculating the distance from each lumbar IVS to adjacent major vascular structures. Results: At the cephalad lumbar levels (L1-L3), the aorta lies in closer proximity to the IVS in the RLD position, in contrast to the inferior vena cava (IVC), which is further from the IVS in the RLD. At the L3-S1 vertebral levels, the right and left common iliac arteries (CIA) are both further from the IVS in the LLD position, with the notable exception of the right CIA, which lies further from the IVS in the RLD at the L5-S1 level. At both the L4-5 and L5-S1 levels, the right common iliac vein (CIV) is further from the IVS in the RLD. In contrast, the left CIV is further from the IVS at the L4-5 and L5-S1 levels. Conclusion: Our results suggest that RLD positioning may be safer for LLIF as it affords greater distance away from critical venous structures, however, surgical positioning should be assessed at the discretion of the spine surgeon on a patient-specific basis.

Perforated ileus after L5-S1 anterior lumbar interbody fusion: a case report presentation.

Acute colonic pseudo-obstruction (ACPO) as a result of anterior lumbar spinal surgery can result in colonic perforation. ACPO is often treated successfully with conservative measures, reserving surgical intervention for severe cases. The most severe cases can result in colonic perforation with a concomitant high mortality rate. Herein we outline a case of a 72-year-old male with multiple medical comorbidities and history of intermittent constipation who underwent anterior lumbar interbody fusion (ALIF) of L5-S1. The patient's multiple medical comorbidities placed him at risk for ACPO. His postoperative course was complicated by an ileus. The patient initially underwent conservative management that failed, resulting in colonic perforation. He underwent urgent exploratory laparotomy and repair of colonic perforation by the general surgery service. The patient had spontaneous return of bowel function on postoperative day 5, and at 6 months, he was doing well. The main purpose of this case report is to present a unique case of colonic perforation after ALIF. Understanding patient risk factors can help in early identification and treatment of potentially life-threatening complications. Surgeons should discuss the possibility of this complication with the patient during surgical counseling for anterior lumbar surgery.

Use of CT-arthrography and ultrasound in ACL surgery during Operation Enduring Freedom in Afghanistan: a case report and practice recommendations.

The availability of magnetic resonance imaging is severely limited in a deployed environment. However, advanced imaging for diagnosis and treatment of musculoskeletal soft-tissue injuries in theater does exist. Computed tomography (CT), arthrography, and ultrasound are readily available at Role 2 and 3 Medical Treatment Facilities in Afghanistan in support of Operation Enduring Freedom. In this report, we describe a case using CT arthrogram and ultrasound to assist with the diagnosis, treatment, and follow-up of an anterior cruciate ligament reconstruction surgery performed at a Role 2E hospital at Camp Arena, Herat, Afghanistan on a coalition soldier. All physicians who treat musculoskeletal injuries in theater should be familiar with the musculoskeletal applications of ultrasound and CT arthrography. Finally, treatment of the local population and coalition soldiers who do not have access to magnetic resonance imaging will be improved with the knowledge and use of existing advanced imaging in a deployed and austere setting.

ACL reconstruction in a deployed environment in support of operation enduring freedom: a surgical technique.

Military orthopaedic surgeons in deployed environments along with orthopaedic surgeons working in more austere environments often find themselves without surgical equipment that they are normally accustomed to having in the operative suite. Today's U.S. Army Combat Support Hospital is appropriately focused on being prepared for modern battlefield trauma but lacks the resources for advanced sports medicine surgery to include arthroscopic equipment and implants. In this report, we describe an autograft anterior cruciate ligament reconstruction procedure using a combined mini-open extra-articular/intra-articular technique. This method could serve as a model for orthopaedic surgeons operating in more austere environments without modern sports medicine equipment and when working with the local national population who do not have access to modern health care facilities.

Biomechanical evaluation of a new AxiaLIF technique for two-level lumbar fusion.

Single level axial lumbar interbody fusion (AxiaLIF) using a transsacral rod through a paracoccygeal approach has been developed with promising early clinical results and biomechanical stability. Recently, the transsacral rod has been extended to perform a two-level fusion at both L4-L5 and L5-S1 levels (AxiaLIF II). No biomechanical studies have been conducted on multilevel fusion using the AxiaLIF technique. In this study, the biomechanics of L4-S1 motion segments instrumented with the AxiaLIF II transsacral rod was evaluated. Six human cadaveric lumbosacral spine segments from L4 to S1 were used (age ranges 46-74 years). Unconstrained and non-destructive pure moments in axial torsion, lateral bending, and flexion extension were applied to each specimen following intact, standalone AxiaLIF II, and AxiaLIF II with two posterior fixation options: facet screws and pedicle screws with rods. Range of motion was calculated from the raw data collected with an optical motion tracking system. The two-level transsacral rod was successfully inserted in all the specimens. At L4-L5 level in axial torsion (AT) and flexion extension (FE), none of the surgical treatments showed statistically significant difference between the procedures (all P > 0.05) although facet screws and pedicle screws had higher stability on average. In lateral bending (LB), the two posterior fixation techniques had significantly higher construct stability (P < 0.05) than the standalone rod. No significant difference was found between facet screws and pedicle screws (P = 0.821). At L5-S1 level in AT and LB, none of the surgical treatments were found to be statistically significant (all P > 0.05). In FE, standalone two-level transsacral rod had significantly higher range of motion (ROM) compared with the posterior fixation techniques (P < 0.05). In conclusion, the standalone rod reduced intact ROM significantly. Supplementary fixations including facet screws and pedicle screws are required to achieve higher construct stability for successful fusion. Further clinical studies are essential to evaluate the practical success of this technique.

Vacuum-assisted closure therapy: wound care and nursing implications.

The management of chronic, nonhealing, draining wounds is challenging for the wound, ostomy, and continence nurse and other health care providers involved in skin integrity care. Vacuum-assisted closure (VAC) therapy has proven cost efficient, safe, and effective as a treatment modality in wound care. The background, description, mechanisms of action, indications for use, and nursing implications of VAC therapy are presented.