Discovery of thoracic osteoma after elective lumbar spinal surgery: a case report.

Osteoma is a benign, bone-producing tumor typically found within the skull. Rare case reports have been identified within the spine, and even fewer have been identified in the thoracolumbar region. When present, these benign tumors usually present during the second and third decade of life. A history of trauma is usually present and may trigger neurologic symptoms. The authors report a case of a thoracic osteoma discovered incidentally after lumbar spinal surgery where symptoms of the intra-canal osteoma were believed to be incited by the primary decompression. Pathology results from resection of the mass revealed it to be an osteoma, though the diagnosis was not suspected at the time of the operation. Recurrence of neurological deficit after excision of symptomatic osteoma is rare. In the follow-up period, our patient has remained asymptomatic. The pertinent literature regarding spinal osteomas is reviewed.

A qualitative exploration of the role of leadership in service transformation in child and adolescent mental health services.

BACKGROUND: Recent policy in England has called on services for children and young people's mental health and well-being to develop and deliver local transformation plans to increase the provision of evidence-based, outcomes-informed and service user-informed treatments. The role of local leadership in service transformation is poorly understood, despite evidence suggesting it is key to enacting change. PURPOSE: To understand the role of local leaders and frontline practitioners in service transformation in child and adolescent mental health services. METHODOLOGY: This study was a secondary analysis of semistructured interviews with n = 20 leaders and n = 29 frontline practitioners in child and adolescent mental health services taking part in a service transformation programme. RESULTS: Leaders' role in service transformation in child and adolescent mental health services (CAMHS) was to: (a) foster impetus for transformation by demonstrating passion and commitment for change, (b) support practitioners in developing microsystem improvements and (c) bridging the organisation's goals with available resources. CONCLUSIONS: When developing transformation plans for child and adolescent mental health services, local leaders should be transparent about reasoning and processes, enable practitioners to tailor implementation to need and provide ongoing support. Practitioner engagement needs careful planning given its crucial role in enabling collaboration that will facilitate change.

Development of Postoperative Spinal Arteriovenous Fistula After Lumbar Laminectomy, Decompression, and Posterior Spinal Fusion.

Spinal dural arteriovenous fistulas are a rare cause of low back pain, bilateral lower extremity weakness, or pain with sensory changes. They are typically found in males in the fifth and sixth decades of life, associated with a progressive decline in symptoms that make initial diagnosis challenging in some patients. We present a case report and literature review of an 80-year-old woman with a long-standing history of progressively worsening back pain and lower extremity pain that has limited her daily activities. When preoperative MRI of the lumbar spine showed high-grade stenosis and listhesis of L4-L5, the patient was taken to the operating room for an L4-L5 laminectomy, decompression, facetecomy, and instrumented fusion. Her postoperative course did not show improvement of symptoms, which in fact worsened, leading to gait imbalance and instability. Postoperative MRIs of the patient were concerning for a spinal dural arteriovenous fistula, which was confirmed and treated by spinal angiography and embolization.

Biomechanical Analysis of Pedicle Screw Fixation for Thoracolumbar Burst Fractures.

Treatment of unstable thoracolumbar burst fractures remains controversial. Long-segment pedicle screw constructs may be stiffer and impart greater forces on adjacent segments compared with short-segment constructs, which may affect clinical performance and long-term out come. The purpose of this study was to biomechanically evaluate long-segment posterior pedicle screw fixation (LSPF) vs short-segment posterior pedicle screw fixation (SSPF) for unstable burst fractures. Six unembalmed human thoracolumbar spine specimens (T10-L4) were used. Following intact testing, a simulated L1 burst fracture was created and sequentially stabilized using 5.5-mm titanium polyaxial pedicle screws and rods for 4 different constructs: SSPF (1 level above and below), SSPF+L1 (pedicle screw at fractured level), LSPF (2 levels above and below), and LSPF+L1 (pedicle screw at fractured level). Each fixation construct was tested in flexion-extension, lateral bending, and axial rotation; range of motion was also recorded. Two-way repeated-measures analysis of variance was performed to identify differences between treatment groups and functional noninstrumented spine. Short-segment posterior pedicle screw fixation did not achieve stability seen in an intact spine (P<.01), whereas LSPF constructs were significantly stiffer than SSPF constructs and demonstrated more stiffness than an intact spine (P<.01). Pedicle screws at the fracture level did not improve either SSPF or LSPF construct stability (P>.1). Long-segment posterior pedicle screw fixation constructs were not associated with increased adjacent segment motion. Al though the sample size of 6 specimens was small, this study may help guide clinical decisions regarding burst fracture stabilization. [Orthopedics. 2016; 39(3):e514-e518.].

Evaluation of osteoporosis risk and initiation of a nurse practitioner intervention program in an orthopedic practice.

UNLABELLED: The purpose of this study was to assess whether education and referral by a nurse practitioner could improve treatment adherence in patients with low bone mineral density in the orthopedic office. Our customized project did show some improvement but resistance to care continues in this unique population of patients. INTRODUCTION: Osteoporosis and osteopenia are significant clinical problems. Nearly 50% of adults over the age of 50 are osteopenic (Looker et al. in Osteoporos Int 22:541-549, 2011). Many patients with osteoporosis are not taking calcium or vitamin D, or any active treatment, even after dual energy X-ray absorptiometry (DXA) and demonstration of low bone mineral density (Dell et al. in J Bone Joint Surg Am 91(Suppl 6):79-86, 2009). One hypothesis to explain low adherence with osteoporosis treatment is lack of patient education. This study was designed to compare a control group with an education-intervention group (receiving patient education from a nurse practitioner) to determine any effect of education on treatment adherence. METHODS: A total of 242 females and 105 males were studied as a control: a total of 292 females and 155 male were studied in the education group. Patients in the education group received educational materials and were counseled by a single nurse practitioner. Patients had a DXA performed and patients with osteoporosis or osteopenia were followed to assess treatment. At 12 months, patients received follow-up phone calls to determine patient use of calcium, vitamin D, and/or an active treatment. Results between the groups were compared. RESULTS: Significantly more patients began calcium and vitamin D after education (p = 0.04); significantly more patients were taking or were recommended for an active treatment after education (p = 0.03). Thirty percent of patients either did not follow up or refused active treatment for osteoporosis. Approximately 50% of patients with osteoporosis were not taking an FDA-approved pharmacologic agent for osteoporosis treatment, despite education. CONCLUSION: After patient education and referral to endocrinology, significantly more patients began calcium and vitamin D supplementation. However, up to 50% of patients with osteoporosis would not complete follow-up visits and/or did not adhere to treatment recommendations for osteoporosis.

Deltoid Compartment Syndrome After Prolonged Lateral Decubitus Positioning: A Case Report.

CASE: A thirty-six-year-old man fell off a ladder and sustained an open fracture of the distal end of the left humerus. He was taken to the operating room for irrigation, debridement, and fixation of the fracture and was placed in the right lateral decubitus position for over seven hours. He subsequently developed right deltoid compartment syndrome, necessitating emergency compartment release. One year later, he had limited function, with a Disabilities of the Arm, Shoulder and Hand score of 81.3 points. CONCLUSION: Deltoid compartment syndrome can occur from operative positioning, with poor long-term outcomes as a result. Expeditious surgery, additional padding, and repeat checks are necessary for at-risk patients.

Fungal osteomyelitis and septic arthritis.

Management of fungal osteomyelitis and fungal septic arthritis is challenging, especially in the setting of immunodeficiency and conditions that require immunosuppression. Because fungal osteomyelitis and fungal septic arthritis are rare conditions, study of their pathophysiology and treatment has been limited. In the literature, evidence-based treatment is lacking and, historically, outcomes have been poor. The most common offending organisms are Candida and Aspergillus, which are widely distributed in humans and soil. However, some fungal pathogens, such as Histoplasma, Blastomyces, Coccidioides, Cryptococcus, and Sporothrix, have more focal areas of endemicity. Fungal bone and joint infections result from direct inoculation, contiguous infection spread, or hematogenous seeding of organisms. These infections may be difficult to diagnose and eradicate, especially in the setting of total joint arthroplasty. Although there is no clear consensus on treatment, guidelines are available for management of many of these pathogens.

Critical analysis of a trauma fellowship-modeled, six-year orthopaedic surgery training program.

BACKGROUND: Work-hour restrictions and increased supervision requirements have altered the clinical experience of orthopaedic surgery residents, while the specialty's body of knowledge and requisite skill set continue to expand. This dilemma means that the duration and practice experience of the traditional orthopaedic residency may not meet the needs of today's trainees. For the past eighteen years, however, residency training in the Department of Orthopaedic Surgery at Brown University has included a mandatory postgraduate year six (PGY6) trauma fellowship-modeled year, during which trainees are conferred full staff admitting and operating privileges, with time allotted for completing research. They are supervised by senior attending staff, with increasing autonomy as the year progresses. A formal, critical analysis of this transition-to-practice training model in orthopaedics has not previously been described. METHODS: An anonymous thirty-one-item questionnaire was distributed to all practicing graduates of the six-year Brown University Orthopaedic Surgery training program (n = 69). A 5-point Likert scale was used to assess attitudinal questions. An independent-sample t test was used to compare the responses of pre-duty-hour trainees with those of post-duty-hour trainees, with a p value of <0.05 utilized for significance. RESULTS: All sixty-nine practicing graduates of the Brown University PGY6 trauma fellowship completed the survey (100% response rate). Most graduates (78.2%) would choose to complete the PGY6 year if they had to do residency again, and 72.4% would recommend trauma fellowship-modeled training to residents beginning their training. Trainees who completed residency during or after the imposed 2003 Accreditation Council for Graduate Medical Education duty-hour restrictions (79.3%) were significantly more likely (p = 0.014) to rank the PGY6 year as their most valuable training year compared with trainees who completed residency prior to duty-hour restrictions (50.0%). Nearly half of the graduates (46.4%) thought that the PGY6 fellowship year was financially burdensome. CONCLUSIONS: The unique trauma fellowship-modeled sixth year of orthopaedic surgery training at Brown University was thought to be a valuable training experience by a large majority of graduates, although nearly half thought that the year was financially burdensome. These data suggest that a trauma fellowship-based sixth year of independent yet structured training has the potential to enhance orthopaedic education and could become an alternative standard given the current requirements imposed upon surgical residency training. These results may help guide further discussion among orthopaedic training programs to determine the optimal model for orthopaedic residency education in the twenty-first century.

Wound hematoma after anterior cervical spine surgery: in vitro study of the pathophysiology of airway obstruction.

Airway obstruction by wound hematoma is a serious adverse event associated with anterior cervical spine surgery. Although intrinsic airway edema is the most plausible pathophysiologic mechanism of obstruction, we hypothesized that extrinsic compression of the trachea by a hematoma can result in airway occlusion at an angle to the sagittal plane. A silicone indenter and a servohydraulic test frame were used to apply pressure to the ventral neck of 7 human cadaveric specimens. Increasing pressure was applied in the anteroposterior (AP) and oblique planes until the trachea collapsed, as visualized with fluoroscopy. A paired t test was used to determine any statistically significant differences in maximum pressure or indenter displacement at tracheal occlusion between the 2 test modes. Mean (SD) pressure required to cause complete tracheal collapse was 227.9 (54.8) mm Hg in the AP test mode and 135.6 (73.4) mm Hg in the oblique test mode. The difference was statistically significant (P = .004). Indenter displacement was significantly higher in the AP mode than in the oblique mode (P = .031). The trachea can collapse from external force within a physiologic pressure range when pressure is applied in an oblique orientation. The mass effect of a wound hematoma appears to be a viable mechanism of airway occlusion.

Complex posttraumatic stress disorder and survivors of human rights violations.

PURPOSE OF REVIEW: This article reviews recent findings on Complex Posttraumatic Stress Disorder (CPTSD) and proposes future research which would help to establish the nature of CPTSD in relation to Posttraumatic Stress Disorder (PTSD). RECENT FINDINGS: Research on survivors of torture and war has found that CPTSD can occur when there is no history of childhood abuse. fMRI studies appear to highlight differences in neural activity in individuals exhibiting primary dissociation compared with individuals exhibiting secondary dissociation. Research has begun to show that, when symptoms of secondary dissociation are appropriately managed, exposure-based therapies are an effective treatment for individuals with CPTSD. SUMMARY: Much research on CPTSD has emphasized its developmental basis and the disruptive effects of trauma in childhood and adolescence on subsequent emotional development. However, some studies on survivors of torture in adult life identify similar symptom patterns, despite there being no history of childhood trauma. It is argued that comparative research is required between victims of developmental trauma (such as childhood sexual abuse) and victims who experienced prolonged interpersonal trauma in adulthood (such as torture), as this could be useful in establishing the cause of CPTSD and in delineating clinically and therapeutically meaningful subtypes. It is also proposed that a focus on underlying neurobiological processes would help in developing and refining CPTSD as a construct and informing treatment.

Dynamic biomechanical examination of the lumbar spine with implanted total disc replacement using a pendulum testing system.

STUDY DESIGN: Biomechanical cadaver investigation. OBJECTIVE: To examine dynamic bending stiffness and energy absorption of the lumbar spine with and without implanted total disc replacement (TDR) under simulated physiological motion. SUMMARY OF BACKGROUND DATA: The pendulum testing system is capable of applying physiological compressive loads without constraining motion of functional spinal units (FSUs). The number of cycles to equilibrium observed under pendulum testing is a measure of the energy absorbed by the FSU. METHODS: Five unembalmed, frozen human lumbar FSUs were tested on the pendulum system with axial compressive loads of 181 N, 282 N, 385 N, and 488 N before and after Synthes ProDisc-L TDR implantation. Testing in flexion, extension, and lateral bending began by rotating the pendulum to 5º resulting in unconstrained oscillatory motion. The number of rotations to equilibrium was recorded and bending stiffness (N·m/º) was calculated and compared for each testing mode. RESULTS: In flexion/extension, the TDR constructs reached equilibrium with significantly (P < 0.05) fewer cycles than the intact FSU with compressive loads of 282 N, 385 N, and 488 N. Mean dynamic bending stiffness in flexion, extension, and lateral bending increased significantly with increasing load for both the intact FSU and TDR constructs (P < 0.001). In flexion, with increasing compressive loading from 181 N to 488 N, the bending stiffness of the intact FSUs increased from 4.0 N·m/º to 5.5 N·m/º, compared with 2.1 N·m/º to 3.6 N·m/º after TDR implantation. At each compressive load, the intact FSU was significantly stiffer than the TDR (P < 0.05). CONCLUSION: Lumbar FSUs with implanted TDR were found to be less stiff, but absorbed more energy during cyclic loading with an unconstrained pendulum system. Although the effects on clinical performance of motion-preserving devices are not fully known, these results provide further insight into the biomechanical behavior of these devices under approximated physiological loading conditions.

Cervical spondylosis, stenosis, and rheumatoid arthritis.

The majority of patients with rheumatoid arthritis involving the cervical spine can be managed non-operatively. These patients should be monitored closely by the treating physician for the development of neurologic symptoms or subluxation on radiographs. Non-surgical treatment in the majority of patients has a definite role. Several studies now suggest early surgical intervention in patients with progressive instability and neurologic deficit is indicated to prevent significant morbidity and mortality in these patients.

Injury patterns causing isolated foot compartment syndrome.

BACKGROUND: The true incidence and primary predictors of foot compartment syndrome remain controversial. Our aim was to better define the overall incidence of foot compartment syndrome in relation to the frequency and location of various foot injuries. We hypothesized that (1) the incidence would increase in proportion to the number of anatomic locations of injury, (2) the incidence would be higher in association with hindfoot and crush injuries compared with any other injury categories, and (3) not only would the incidence associated with calcaneal fractures be lower than the often quoted 10% but foot compartment syndrome would also be fairly uncommon after such fractures. METHODS: The National Trauma Data Bank was used to identify patients who had undergone a fasciotomy for the treatment of isolated foot compartment syndrome. Strict inclusion and exclusion criteria were used to identify only patients with foot injuries who had undergone fasciotomy for foot compartment syndrome. RESULTS: Three hundred and sixty-four patients with an isolated foot compartment syndrome were identified. The highest incidence of foot compartment syndrome was seen in association with a crush mechanism combined with a forefoot injury (18%, nineteen of 106), followed by an isolated crush injury (14%, twenty-three of 162). Only 1% (thirty-two) of 2481 patients with an isolated calcaneal fracture underwent fasciotomy. An increase in the number of anatomic locations of injury did not appear to correspond to an increased incidence of foot compartment syndrome. CONCLUSION: Our results demonstrate that injuries involving a crush mechanism, either in isolation or in combination with a forefoot injury, should raise suspicion about the possibility that a foot compartment syndrome will develop.

Minifragment screw fixation of oblique metacarpal fractures: a biomechanical analysis of screw types and techniques.

The lag screw technique has historically been a successful and accepted way to treat oblique metacarpal fractures. However, it does take additional time and involve multiple steps that can increase the risk of fracture propagation or comminution in the small hand bones of the hand. An alternate fixation technique uses bicortical interfragmentary screws. Other studies support the clinical effectiveness and ease of this technique. The purpose of this study is to biomechanically assess the strength of the bicortical interfragmentary screw versus that of the traditional lag screw. Using 48 cadaver metacarpals, oblique osteotomies were created and stabilized using one of four methods: 1.5 mm bicortical interfragmentary (IF) screw, 1.5 mm lag technique screw, 2.0 mm bicortical IF screw, or 2.0 mm lag technique screw. Biomechanical testing was performed to measure post cyclic displacement and load to failure. Data was analyzed using one-way analysis of variance (ANOVA). There was no significant difference among the fixation techniques with regard to both displacement and ultimate failure strength. There was a slight trend for a higher load to failure with the 2.0 mm IF screw and 2.0 mm lag screw compared to the 1.5 mm IF and 1.5 mm lag screws, but this was not significant. Our results support previously established clinical data that bicortical interfragmentary screw fixation is an effective treatment option for oblique metacarpal fractures. This technique has clinical importance because it is an option to appropriately stabilize the often small and difficult to control fracture fragments encountered in metacarpal fractures.

Acetabular fracture through the triradiate cartilage after low-energy trauma.

Although rare, injury to the triradiate cartilage is both a diagnostic and therapeutic challenge. Trauma to the triradiate cartilage or its blood supply can adversely affect acetabular development due to premature physeal closure. A shallow acetabulum with a lateralized hip joint that is prone to subluxation, premature degenerative changes, chronic pain, and functional limitations can result. We present a case of an acetabular fracture with injury to the triradiate cartilage after low-energy trauma in an adolescent male treated nonoperatively and healed without complications.