Minimizing the need for high dependency unit support in adolescent idiopathic scoliosis surgery. Is enhanced recovery and the multidisciplinary team key?

Current trends in the surgical treatment of patients with adolescent idiopathic scoliosis (AIS) involve the use of high dependency unit (HDU) in the postoperative period. The British Scoliosis Society also recommends the availability of HDU support in the postoperative period for these patients. However, this practice may lead to unexpected theatre cancellations due to lack of availability of HDU bed on the day of surgery. We also hypothesize that this practice may eventually lead to longer inpatient stay for the patients. All AIS patients at our unit are managed on a paediatric ward postoperatively, without HDU support. The primary aim of the study therefore is to evaluate whether operating on AIS patients without HDU support is well tolerated practice. Secondary aims were to evaluate patient related outcomes, including length of stay (LOS), and postoperative analgesia requirements. Adolescents aged 12-17 years with idiopathic scoliosis deformity who were treated with posterior instrumented scoliosis (PIS) correction were included in this prospective cohort study. The study period was between 12 November 2012 and 6 August 2018. Twenty-two patients were included in the HDU group and 33 patients in the non-HDU group. These were two matched cohort groups. Data were collected on complication rates, LOS, analgesic requirements, time to bowel opening, and attainment of physiotherapy goals in the immediate postoperative period. Statistical analysis was performed using statistical software R (3.4.3). There were no complications in the non-HDU group and one pneumothorax in the HDU group. There was a significant reduction in the LOS from 7.4 days (SD ±2.3, CI 0.012) days, to 5.8 (SD ±1.4, CI 0.01) days in the non-HDU group (P = 0.0001). There was no significant difference statistically or clinically in opiate usage between the HDU group, 115 mg (SD ±60.7, CI 0.8) and the non-HDU group 116 mg (SD ±55.8, CI 0.6) (P = 0.609). However, there was an improvement in pain scores in the non-HDU group where oral analgesics only were used (P = 0.002). A cost saving of £2038.80 per AIS case was made in the non-HDU group. AIS surgery can be performed safely without the need for HDU support in healthy adolescents. An oral analgesia-based enhanced recovery regime compares favourably to patient-controlled analgesia (PCA) and indicates these patients can be managed safely with strong multidisciplinary support on a paediatric ward.

A novel technique for the subfascial insertion of magnetically controlled growing rods - The Alder Hey technique.

PURPOSE: In this study, we would like to describe a novel technique for subfascial insertion of magnetically controlled growing rods using chest drain during surgery for early-onset scoliosis. MATERIALS AND METHODS: Posterior approach, surgical dissection to the spine is performed exposing the relevant anatomy to allow placement of pedicle screws always in the distal construct and pedicle screws or hooks in the proximal construct. To allow easy passage of the Magnetic Expansion Control (MAGEC) rod, as well as easy maneuvering of the rod in either the cranial to caudal direction, we use a chest drain of size 24 French diameter as a tunnel. This allows surgeons to fit the nonflexible part of MAGEC rod in the middle of the deformity and cut to length passed through the chest drain from a cranial to caudal position and then chest drain is removed. RESULTS: A total of 40 children with early-onset scoliosis had insertion of MAGEC rods using this technique. There were 21 female and 19 male patients. Early-onset scoliosis etiology is idiopathic in 20 patients, neuromuscular in 16 patients, and others in 4 patients. Median age across all groups was 7 years (range 4-13) at the time of surgery. Follow-up ranged from 11 to 56 months with a median of 24 months. CONCLUSION: The use of a chest drain during subfascial passage of magnetically controlled growing rod is a safe, reliable, reproducible novel technique. This shortens overall time of surgery in our experience.

High content and high throughput screening to assess the angiogenic and neurogenic actions of mesenchymal stem cells in vitro.

Mesenchymal stem cells are universally regarded across many fields of medicine, as one of the most promising cell types for use in cell-based therapies. Although not yet fully understood, the therapeutic effects of these cells are largely attributed to the trophic actions of growth factors and cytokines present in the cell secretome. Specifically, the angiogenic and neurogenic properties of these cells make them attractive for the repair of vascularised and innervated tissues. In this study, we investigate the effect of mesenchymal stem cell conditioned media on in vitro assays of angiogenesis and nerve growth. We describe the use of two state of the art high content and high throughput cell analysis systems and compare them against manual analysis techniques. Mesenchymal stem cell secretomes stimulated angiogenesis and nerve growth in vitro in a donor dependant manner. Levels of neuroregulin, platelet-derived growth factor-AA and glial-derived neurotrophic factor, positively correlated with the observed angiogenic effects of these cells. High content and high throughput cell analysis systems such as the ones used in this study, may provide rapid screening tools to assist not only with patient selection but the identification of predictive therapeutic markers to support clinical outcome monitoring for patients treated with stem cell therapies.

Does walking change the Romberg sign?

The Romberg sign helps demonstrate loss of postural control as a result of severely compromised proprioception. There is still no standard approach to applying the Romberg test in clinical neurology and the criteria for and interpretation of an abnormal result continue to be debated. The value of this sign and its adaptation when walking was evaluated. Detailed clinical examination of 50 consecutive patients of cervical myelopathy was performed prospectively. For the walking Romberg sign, patients were asked to walk 5 m with their eyes open. This was repeated with their eyes closed. Swaying, feeling of instability or inability to complete the walk with eyes closed was interpreted as a positive walking Romberg sign. This test was compared to common clinical signs to evaluate its relevance. Whilst the Hoffman's reflex (79%) was the most prevalent sign seen, the walking Romberg sign was actually present in 74.5% of the cases. The traditional Romberg test was positive in 17 cases and 16 of these had the walking Romberg positive as well. Another 21 patients had a positive walking Romberg test. Though not statistically significant, the mean 30 m walking times were slower in patients with traditional Romberg test than in those with positive walking Romberg test and fastest in those with neither of these tests positive. The combination of either Hoffman's reflex and/or walking Romberg was positive in 96% of patients. The walking Romberg sign is more useful than the traditional Romberg test as it shows evidence of a proprioceptive gait deficit in significantly more patients with cervical myelopathy than is found on conventional neurological examination. The combination of Hoffman's reflex and walking Romberg sign has a potential as useful screening tests to detect clinically significant cervical myelopathy.

Spinal trauma: therapy--options and outcomes.

The management of patients with spinal trauma is based on the following goals: (1) the preservation of life; (2) preserving and maximising the neurological function; and (3) providing a stable, painless vertebral column. There have been advances in both non operative as well operative modalities of treatment of patients with spinal injuries. These advances have led to renewed interest in the management of a spinally injured patient. However, despite these advances controversies exist regarding the classification of these fractures, the use of pharmacological intervention, the timing of surgical intervention and indeed the use of surgical intervention itself in the management of these fractures. Most of these controversies surround the treatment of thoracic and lumbar fractures. The purpose of this article is to provide an over view of the therapy options available in the treatment of these fractures. The article shall also look at some of the controversies surrounding the management of these fractures.