Cervical transforaminal epidural steroid injections for radicular pain : a systematic review.

AIMS: Cervical radiculopathy is a significant cause of pain and morbidity. For patients with severe and poorly controlled symptoms who may not be candidates for surgical management, treatment with transforaminal epidural steroid injections (CTFESI) has gained widespread acceptance. However, a paucity of high-quality evidence supporting their use balanced against perceived high risks of the procedure potentially undermines the confidence of clinicians who use the technique. We undertook a systematic review of the available literature regarding CTFESI to assess the clinical efficacy and complication rates of the procedure. METHODS: OVID, MEDLINE, and Embase database searches were performed independently by two authors who subsequently completed title, abstract, and full-text screening for inclusion against set criteria. Clinical outcomes and complication data were extracted, and a narrative synthesis presented. RESULTS: Six studies (three randomized controlled trials and three non-randomized observational studies; 443 patients) were included in the final review. The aggregate data support the efficacy of CTFESI in excess of the likely minimal clinically important difference. No major complications were described. CONCLUSION: There is increasing evidence supporting the efficacy of CTFESI. Concerns regarding the occurrence of catastrophic complications, widely shared in the case report and anecdotal literature, were not found when reviewing the best available evidence. However, the strength of these findings remains limited by the lack of highly powered high-level studies and the heterogeneity of the studies available. Further high-quality studies are recommended to address the issues of efficacy and safety with CTFESI. Cite this article: Bone Joint J 2022;104-B(5):567-574.

Bilateral reconstructive costoplasty for razorback deformity correction in adolescent idiopathic scoliosis.

BACKGROUND: Correcting the chest wall deformity is an important goal of scoliosis surgery. A prominent rib hump deformity may not be adequately addressed by scoliosis correction alone. It has been shown that costoplasty in conjugation with scoliosis correction and instrumented spinal fusion is superior to spinal fusion alone in addressing the chest wall deformity. In cases of severe rib hump deformity unilateral convex side costoplasty alone might not adequately restore thoracic cage symmetry necessitating for additional concave side rib cage reconstruction. CASE REPORT: A 16-year-old male with adolescent idiopathic scoliosis and a sharp, cosmetically unacceptable, prominent rib hump (razorback deformity) underwent scoliosis correction with posterior spinal fusion and bilateral costoplasty. The convex-sided ribs were resected and used for concave-sided rib reconstruction. The rib hump height was reduced from 70 mm before the procedure to 10 mm after the procedure and the apical trunk rotation was reduced from 36° to 5°, respectively. Solid spinal fusion and ribs union was achieved. The patient remained very satisfied with no loss of correction at 2-year postoperative follow-up. CONCLUSION: Bilateral costoplasty in conjugation with scoliosis correction may provide a safe and effective method for the treatment of severe rib cage deformities associated with thoracic scoliosis. It should be considered in the presence of prominent rib hump deformity, where scoliosis correction alone or with unilateral costoplasty is unlikely to provide adequate correction.

Safety of fluoroscopy guided percutaneous access to the thoracic spine.

BACKGROUND: Fluoroscopy-guided percutaneous access to thoracic vertebrae is technically demanding due to the complex radiological anatomy and close proximity of the spinal cord, major vessels and pleural cavity. There is a trend towards computed tomography (CT) guidance due to a perceived reduction in the risk of spinal canal intrusion by instrumentation causing neurological injury. Due to limited access to CT guidance, there is a need for safe fluoroscopy-guided percutaneous access to the thoracic spine. PURPOSE: To evaluate the safety of a strict radio-anatomical protocol in avoiding access-related neurological complications due to tool misplacement in fluoroscopy-guided percutaneous procedures on the thoracic spine. METHOD: A combined two-surgeon prospective case series of 444 procedures (biopsy, vertebroplasty or kyphoplasty) covering all thoracic vertebral levels T1-T12. Clinical examination and routine observations were used to identify access-related complications including neurological, vascular and visceral injury using physiological parameters. RESULTS: No patient in our series was identified to have sustained a neurological deficit or deterioration of preoperative neurological status. CONCLUSION: Percutaneous access to the thoracic spine using fluoroscopic guidance is safe. The crucial step of the protocol is not to advance the tool beyond the medial pedicle wall on the anterior-posterior projection until the tip of the instrument has reached the posterior vertebral cortex on the lateral projection.

Is consent for hip fracture surgery for older people adequate? The case for pre-printed consent forms.

UNLABELLED: OJECTIVES: Low energy hip fractures are one of the greatest causes of morbidity and mortality in orthopaedics. This study aims to evaluate written consent forms with respect to basic standards as set out in the Good Practice in Consent Initiative. In particular the stated risks and benefits of each procedure were assessed. METHODS: 100 consecutive consent forms were reviewed prospectively. The stated procedure, side and complications were recorded. Appropriate signature and legibility was assessed. 13 consultant orthopaedic surgeons were surveyed to identify what risks and benefits they thought should be stated. RESULTS: Of 100 consent forms, 31 were for patients who are unable to consent. All 100 consent forms were correctly filled in with patient details and signed. 98% were legible. All stated the side of the operation. The number of complications listed per form ranged from 4 to 11. Infection, bleeding and thromboembolic complications were stated in the majority of consent forms. In total, 30 different complications were recorded; some were only stated once. DISCUSSION AND CONCLUSIONS: This work suggests consent forms are completed well with respect to patient identifiers, legibility and procedure. The variability of complications stated is vast. We suggest standard pre-printed consent forms containing risks and benefits should be used as this may improve standards of informed consent. This has also been recently supported by the British Orthopaedic Association.

Percutaneous approach to the upper thoracic spine: optimal patient positioning.

Percutaneous access to the upper thoracic vertebrae under fluoroscopic guidance is challenging. We describe our positioning technique facilitating optimal visualisation of the high thoracic vertebrae in the prone position. This allows safe practice of kyphoplasty, vertebroplasty and biopsy throughout the upper thoracic spine.

Do Independent Sector Treatment Centres (ISTC) impact on specialist registrar training in primary hip and knee arthroplasty?

INTRODUCTION: The introduction of Modernising Medical Careers (MMC) is likely to reduce specialist registrar (SpR) operative experience during higher surgical training (HST). A further negative impact on training by local Independent Sector Treatment Centres (ISTCs) could reduce experience, and thus competence, in primary joint arthroplasty at completion of higher surgical training. PATIENTS AND METHODS: Retrospective case note and radiograph analysis of patients receiving primary hip and knee arthroplasty in a teaching hospital, before and after the establishment of a local ISTC. Patients and operative details were recorded from the selected case notes. Corresponding radiographs were assessed and the severity of the disease process assessed. RESULTS: Fewer primary hip and knee replacements were performed by SpRs in the time period after the establishment of an ISTC. CONCLUSIONS: ISTCs may adversely affect SpR training in primary joint arthroplasty.

A study of the radiologic predictors of curve flexibility in adolescent idiopathic scoliosis.

STUDY DESIGN: A study of flexibility of 101 idiopathic scoliosis antero-posterior radiographs. OBJECTIVE: To discover if there are any parameters on plain antero-posterior radiographs that can predict the flexibility of scoliosis curves. SUMMARY OF BACKGROUND DATA: Previously the flexibility index, generated from fulcrum bending x-rays, has been shown to be an accurate measure of curve stiffness. METHODS: Five postulated predictors of flexibility, measured on 101 immediate preoperative scoliosis radiographs, were compared with the flexibility index generated from fulcrum bending radiographs. Correlation between the 5 parameters and flexibility index was studied. Further analysis was performed to assess the significance of curve location in prediction of flexibility. Linear regression analysis was used. RESULTS: Linear regression including all 5 predictors showed Cobb angle and age to be the only significant predictors of flexibility. When Cobb angle and age were analyzed with location (thoracic, thoracolumbar) this was also found to be a significant factor. CONCLUSIONS: Cobb angle, age, and curve location are useful predictors of flexibility on antero-posterior radiographs. This may aid preoperative planning in the out-patients department.

Bioelectrical impedance: a new method for measuring post-traumatic swelling.

OBJECTIVES: The aim of this pilot study was to investigate whether measurement of the bioelectrical impedance of the lower limb could be used to measure the swelling resulting from acute ankle fracture. METHODS: The impedance of each ankle was measured in 14 patients with isolated acute ankle fracture. The degree of ankle swelling was also directly assessed by measurement of the ankle circumference and diameter and by the water displacement method. A control group of 17 healthy subjects with uninjured ankles was similarly assessed. RESULTS: The impedance of the ankle was significantly reduced in patients with ankle fracture, and there was a strong inverse relationship between the degree of this reduction and the amount of swelling as directly measured. The relationship was stronger using the impedance method than the circumference and diameter methods. CONCLUSIONS: We conclude that bioelectrical impedance can be used to measure ankle swelling in the presence of injury and could potentially be used both to monitor swelling clinically and as a research tool in studies of swelling management. More research is required to further define the potential role for this technique.