Role of computed tomography tractography in evaluation of back/flank stab wounds.

BACKGROUND: The clinical approach to back/flank wounds has evolved over the years. The aim of this study was to discuss the potential of computed tomography tractography in patients with a stab wound to the back or flank. METHODS: A total of 25 stable patients with stab wounds confined to the back/flank region were enrolled in this retrospective study. After initial resuscitation and physical examination, tractography was performed at the site of the stab wound. The patients subsequently underwent computed tomography with intravenous contrast. RESULTS: Computed tomography tractography helped avoid a laparotomy in 15 (60%) patients and accurately revealed a peritoneal breach in 10 (40%) patients. No missed injuries were reported in the conservatively followed patients. CONCLUSION: The addition of tractography to computed tomography is a safe, fast, and cost- and time-effective technique to evaluate back/flank stab wounds.

Hybrid Technique for Cervical Pedicle Screw Placement: Combination of Miniopen Surgery and Use of a Percutaneous Cannula System-Pilot Study.

STUDY DESIGN: Cadaver study and clinical application; a pilot study. OBJECTIVE: To minimize muscle dissection and enhance accuracy of cervical pedicle screw (CPS) placement by using a percutaneous cannula system. SUMMARY OF BACKGROUND DATA: Many studies have reported that the most frequent misplacement of CPSs is breach of the lateral wall; thus, an easy technique for securing medial convergence is required. We developed a percutaneous cannula system for this purpose and report the results of a cadaver study and its clinical application. METHODS: A cadaver study was conducted to confirm the possibility of this percutaneous technique in 5 specimens (50 CPSs, C3-C7). Then, the technique was applied in 8 patients (40 CPSs, C3-C7). The surgical technique was a hybrid of miniopen surgery and the use of percutaneous cannula system under lateral fluoroscopic guidance. Entry holes were made in the open field and a cannula was used for tapping and insertion of CPSs. A stiff pedicle probe through the cannula was used to locate the pedicle in the lateral mass. RESULTS: In the cadaver study, there were 12 (24%) misplacements among 50 CPSs used. The hybrid technique was applied clinically in 4 traumatic, 2 degenerative, and 2 failed back surgery lesions. Thirty CPSs were inserted using the percutaneous cannula system and 10 were inserted using a cannula as a retractor. Misplacement occurred in 6.7% (n = 2) and 20% (n = 2) pedicles, respectively, and there were no symptomatic complications (total incidence, 10%). An additional incision for the cannula system can be made for 2-level CPS insertions. CONCLUSION: Use of the percutaneous cannula system facilitated a secure convergence angle for CPS insertion without extending muscle dissection or shifting cervical alignment because of muscle retraction. Moreover, this system can be used for CPS insertion in bull-necked patients. LEVEL OF EVIDENCE: 3.

A novel technique of anesthesia induction in supine position with impaled knife in the back.

Current technique of airway management for impaled knife in the back includes putting the patient in lateral position and intubation. We present here a novel technique of anesthesia induction (intubation and central line insertion) in a patient with impaled knife in the back which is simple and easily reproducible. This technique can be used for single lung ventilation using double lumen tube or bronchial blocker also if desired.

[Using pedicled rectus abdominis musculocutaneous flaps in thigh and lumber defects]. / Pediküllü rektus abdominis kas deri flebinin uyluk ve sirt defektlerinde kullanimi

BACKGROUND: A series of previously described but rarely used variations of the pedicled, extended or vertical rectus abdominis musculocutaneous flap (Extended RAM, VRAM) were reviewed. METHODS: Skin paddle dimensions, ranged 8 to 28 cm in width and 10 to 35 cm in length, were used in five consecutive patients. Four flaps were placed deep to the inguinal ligament to repair the thigh as proximal to the knee region; the remaining one flap was passed transabdominally to cover the defect of the lumbar region. RESULTS: No flaps necrosis were seen and in one case wound healing problems required minimal operative intervention. Successful transfer of the VRAM and extended RAM with low rate of complication for the thigh and lumbar region defects were demonstrated to be safe and reasonable options of flap reconstruction. DISCUSSION: The flaps had the advantages of being robust and well-vascularized, easy and fast to harvest, and not requiring microsurgery experience.

Cranial neuropathy due to intradural disc herniation.

BACKGROUND AND IMPORTANCE: Herniated intervertebral disc fragments rarely penetrate the thecal sac, and intracranial hypotension attributable to such penetrating fragments is even more unusual. We describe the first reported case of a cranial neuropathy due to intradural herniation of a disc fragment, in which intracranial hypotension from a resulting cerebrospinal fluid leak caused bilateral abducens palsies. CLINICAL PRESENTATION: A 45-year-old man presented with a positional headache after having experienced a "popping" sensation in his back while lifting a heavy object. He also reported blurred vision and was noted to have lateral gaze palsies bilaterally. Magnetic resonance imaging (MRI) of the brain revealed bilateral subdural collections, abnormal pachymeningeal enhancement, and cerebellar tonsillar herniation, suggesting intracranial hypotension. T2-weighted MRI of the spine revealed extrusion of the T12-L1 disc and suggested the presence of a disc fragment in the intradural space, displacing the caudal nerve roots. A myelogram demonstrated a filling defect extending into the subarachnoid space adjacent to the disc herniation, consistent with a free disc fragment in the intradural space. A diagnosis of intracranial hypotension due to a cerebrospinal fluid leak resulting from an intradural herniated disc was made. The diagnosis was confirmed intraoperatively. CONCLUSION: Surgical removal of the herniated disc fragment and repair of the dural defect resulted in complete resolution of the cranial neuropathy. This rare etiology of a cranial neuropathy, arising from pathology in the thoracolumbar spine, illustrates the clinical teaching that the sixth cranial nerve is highly sensitive to deformation induced by intracranial hypotension.

Medial scapular muscle detachment: clinical presentation and surgical treatment.

BACKGROUND: This study describes the clinical presentation and preliminary outcomes in a cohort of patients treated for detachment of the medial scapular stabilizing muscles. METHODS AND METHODS: The study included 72 patients who underwent reattachment of the lower trapezius and rhomboid muscles. Patients presented with a history of a high level of medial scapular border pain during activity and inability to perform overhead or forward flexion activities. Clinical examination demonstrated palpable tenderness along the medial scapular border, palpable defect along the medial border muscles, scapular dyskinesis, decreased scapular/rotator cuff strength, and modification of symptoms by manual scapular repositioning. Surgical exploration revealed detachment of the lower trapezius muscle or rhomboid muscles, requiring muscle reattachment to the scapula. Clinical outcomes were measured by the American Shoulder and Elbow Surgeons (ASES) self-report form, with comparisons made between the overall scores and subcomponents obtained at initial evaluation, discharge from active care, and postdischarge follow-up. RESULTS: Time from injury to treatment averaged 52 months, and time from surgery to discharge was 7.4 months. ASES scores significantly improved from initial evaluation (39 ± 16) to discharge (63 ± 21) (P < .001). At medium-term follow-up (n = 23), ASES scores significantly improved from initial evaluation (38 ± 14) to discharge (69 ± 20) (P < .001). CONCLUSIONS: Scapular muscle detachment appears to be a clinically identifiable syndrome with a homogeneous set of history and physical findings. Surgical treatment can significantly reduce pain and improve functional outcomes.

Early predictors of lumbar spine surgery after occupational back injury: results from a prospective study of workers in Washington State.

STUDY DESIGN: Prospective population-based cohort study. OBJECTIVE: To identify early predictors of lumbar spine surgery within 3 years after occupational back injury. SUMMARY OF BACKGROUND DATA: Back injuries are the most prevalent occupational injury in the United States. Few prospective studies have examined early predictors of spine surgery after work-related back injury. METHODS: Using Disability Risk Identification Study Cohort (D-RISC) data, we examined the early predictors of lumbar spine surgery within 3 years among Washington State workers, with new workers compensation temporary total disability claims for back injuries. Baseline measures included worker-reported measures obtained approximately 3 weeks after claim submission. We used medical bill data to determine whether participants underwent surgery, covered by the claim, within 3 years. Baseline predictors (P < 0.10) of surgery in bivariate analyses were included in a multivariate logistic regression model predicting lumbar spine surgery. The area under the receiver operating characteristic curve of the model was used to determine the model's ability to identify correctly workers who underwent surgery. RESULTS: In the D-RISC sample of 1885 workers, 174 (9.2%) had a lumbar spine surgery within 3 years. Baseline variables associated with surgery (P < 0.05) in the multivariate model included higher Roland-Morris Disability Questionnaire scores, greater injury severity, and surgeon as first provider seen for the injury. Reduced odds of surgery were observed for those younger than 35 years, females, Hispanics, and those whose first provider was a chiropractor. Approximately 42.7% of workers who first saw a surgeon had surgery, in contrast to only 1.5% of those who saw a chiropractor. The area under the receiver operating characteristic curve of the multivariate model was 0.93 (95% confidence interval, 0.92-0.95), indicating excellent ability to discriminate between workers who would versus would not have surgery. CONCLUSION: Baseline variables in multiple domains predicted lumbar spine surgery. There was a very strong association between surgery and first provider seen for the injury even after adjustment for other important variables.

The hidden devil: unexpected retained knife in the chest wall.

We report a 52-year-old woman presenting with stab wounds on her back and upper extremities. A knife retained in her chest wall was not discovered in the emergency department. This case reminds us that an obvious foreign body can be missed even after obtaining a detailed history, complete physical examination and plain film. Particularly, a retained foreign body increases the risk of infection and may cause further internal organ injury. We suggest that patients undergo computed tomography (CT) scanning whenever a penetrating wound cannot be explored adequately or the trauma surgeons are unable to perform detailed examinations on the injured patients. The CT images could delineate the course and severity of the penetrating injury, and decrease the risk of a retained foreign body.

["Happy shooting" injury of a German KFOR soldier in Kosovo]. / Verletzung eines deutschen KFOR-Soldaten durch "happy shooting" im Kosovo.

In this case report we describe a 24-year-old German KFOR soldier who was injured in the night of New Year's Eve 2009/2010 during the Kosovo Mission by a falling bullet in the right shoulder. The falling bullet was a full metal jacket probably shot during a "happy shooting" by a civilian.

Improper analysis of trials randomised using stratified blocks or minimisation.

Many clinical trials restrict randomisation using stratified blocks or minimisation to balance prognostic factors across treatment groups. It is widely acknowledged in the statistical literature that the subsequent analysis should reflect the design of the study, and any stratification or minimisation variables should be adjusted for in the analysis. However, a review of recent general medical literature showed only 14 of 41 eligible studies reported adjusting their primary analysis for stratification or minimisation variables. We show that balancing treatment groups using stratification leads to correlation between the treatment groups. If this correlation is ignored and an unadjusted analysis is performed, standard errors for the treatment effect will be biased upwards, resulting in 95% confidence intervals that are too wide, type I error rates that are too low and a reduction in power. Conversely, an adjusted analysis will give valid inference. We explore the extent of this issue using simulation for continuous, binary and time-to-event outcomes where treatment is allocated using stratified block randomisation or minimisation.

Timing of traumatic lumbar hernia repair: is delayed repair safe? Report of two cases and review of the literature.

Fewer than 100 cases of traumatic lumbar hernias are described in the English literature. The herniation has been described as a consequence of a combination of local tangential shearing forces combined with an acute increase in intra-abdominal pressure secondary to sudden deceleration sustained during blunt abdominal trauma. Delayed diagnosis is not uncommon, as nearly a quarter of these are missed at initial presentation. These hernias are best managed by operative intervention; however, there is no well-defined treatment strategy regarding either the timing or the type of repair. Several approaches, including laparoscopy, have been described to repair these defects. Various techniques, including primary repair, musculoaponeurotic reconstruction, and prosthetic mesh repair, have been described. These repairs are usually complicated because of the lack of musculoaponeurotic tissue inferiorly near the iliac crest. We describe here two cases of traumatic lumbar hernia managed by initial watchful waiting and subsequent elective repair using a combined laparoscopic and open technique and one with and one without bone anchor fixation.

Relationship of early magnetic resonance imaging for work-related acute low back pain with disability and medical utilization outcomes.

OBJECTIVE: To examine early magnetic resonance imaging (MRI) utilization for workers compensation cases with acute, disabling low back pain and further, to examine low or high propensity to undergo early MRI with disability duration, medical costs, and surgery. METHODS: Two-year follow-up of 3264 cases. Cox regression and generalized linear models were used to examine the association between both early MRI (first 30 days postonset) and propensity of belonging to the early MRI group (estimated by demographic and severity indicators) with outcomes. RESULTS: A total of 21.7% cases had early MRI. After controlling for covariates, cases that had early MRI and simultaneously had a low propensity to undergo early MRI were more likely to have worse outcomes. CONCLUSIONS: The majority of cases had no early MRI indications. Results suggest that iatrogenic effects of early MRI are worse disability and increased medical costs and surgery, unrelated to severity.

The cost-effectiveness of spinal cord stimulation in the treatment of failed back surgery syndrome.

OBJECTIVES: Healthcare policy makers and payers require cost-effectiveness evidence to inform their treatment funding decisions. Thus, in 2008, the United Kingdom's National Institute of Health and Clinical Excellence analyzed the cost effectiveness of spinal cord stimulation (SCS) compared with conventional medical management (CMM) and with reoperation and recommended approval of SCS in selected patients with failed back surgery syndrome (FBSS). We present previously unavailable details of the National Institute of Health and Clinical Excellence analysis and an analysis of the impact on SCS cost effectiveness of rechargeable implanted pulse generators (IPGs). METHODS: We used a decision analytic model to examine the cost effectiveness of SCS versus CMM and versus reoperation in patients with FBSS. We also modeled the impact of nonrechargeable versus rechargeable IPGs. RESULTS: The incremental cost-effectiveness of SCS compared with CMM was pound5624 per quality-adjusted life year, with 89% probability that SCS is cost effective at a willingness to pay threshold of pound20,000. Compared with reoperation, the incremental cost-effectiveness of SCS was pound6392 per quality-adjusted life year, with 82% probability of cost-effectiveness at the pound20,000 threshold. When the longevity of an IPG is 4 years or less, a rechargeable (and initially more expensive) IPG is more cost-effective than a nonrechargeable IPG. DISCUSSION: In selected patients with FBSS, SCS is cost effective both as an adjunct to CMM and as an alternative to reoperation. Despite their initial increased expense, rechargeable IPGs should be considered when IPG longevity is likely to be short.

[The influence of multipotent mesenchymal stromal cells of bone marrow on process of local radiation injury in rats after local beta-irradiation].

The influence of multipotent mesenchymal stromal cells (MMSC), got from allogenic bone marrow, on local radiation injury in rats after beta-irradiation by a source 90Sr/90Y in a dose 140 Gy under various conditions and ways transplantation was studied. It was established, that transplantation MMSC, allocated on biodegradative membranes, which have been carried out for 21 day after an irradiation in conditions minor surgical of ulcers, resulted in reduction of the area of local beam defeats and acceleration of healing of skin, in comparison with the control of an irradiation. The introduction of suspension MMSC subcutaneous around of the center of a defeat at 8 day after an irradiation caused earlier healing of ulcers. It was concluded, that application of MMSC is perspective for treatment of local radiation injury and necessity of development of optimum conditions of their use at cell therapy of radiation injury of skin.

Traumatic L4-L5 spondylolisthesis: case report.

We report a case of L4-L5 traumatic anterolisthesis. The patient was treated surgically 4 months after the injury. His radiological and operative findings showed L4 inferior facet tip fracture, L4-L5 anterior displacement and left L4-L5 foraminal disc protrusion. Decompression, reduction with L3, L4, L5 pedicular screw fixation, L4-L5 disc excision and interbody cage insertion with autologous bone grafts were done. Flexion type injury was thought to be the probable mechanism.