Back Pain in Adolescents and Young Adults with Idiopathic Scoliosis-Identifying Factors Associated with Significant Pain-A Multivariate Logistic Regression Analysis

(1) Background: Previous data show that patients with idiopathic scoliosis (IS) can be classified into two groups according to pain intensity. This paper aims to determine which factors can independently predict the likelihood of belonging to a high-level pain group. (2) Methods: The study used a prospective, multicenter, cross-sectional design. Two-hundred and seventy-two patients with IS (mean age 18.1 years) (females 83.5%) were included. The sample was divided into two groups. The PAIN group comprised 101 patients (37.1%) with an average NRS of 5.3. The NO-PAIN group consisted of 171 patients (62.9%) with an average NRS of 1.1. Data on various factors such as comorbidities, family history, curve magnitude, type of treatment, absenteeism, anxiety, depression, kinesiophobia, family environment, and social relationships were collected. Statistical analysis consisted of multivariate logistic regression analysis to identify independent predictors of high-level pain. (3) Results: In the final model, including modifiable and non-modifiable predictors, age (OR 1.07 (1.02-1.11)); Absenteeism (OR 3.87 (1.52-9.87)), HAD anxiety (OR 1.18 (1.09-1.29)) and an indication for surgery (OR 2.87 (1.28-6.43)) were associated with an increased risk of pain. The overall model is significant at p = 0.0001 level and correctly predicts 72.6% of the responses. (4) Conclusions: Age, an indication for surgery, anxiety, and work/school absenteeism are the variables that independently determine the risk of belonging to the high-level pain group (NRS > 3).

Shorter and sweeter: the 16-item version of the SRS questionnaire shows better structural validity than the 20-item version in young patients with spinal deformity

PURPOSE

In patients with adult spinal deformity, it was previously shown that 16 of the non-management items of the SRS-instrument showed a better fit to the theoretical four-factor model (pain, function, self-image, mental health) than did all 20 items. Whether the same phenomenon is observed in data from younger (< 20y) patients, for whom the questionnaire was originally designed, is not currently known.

METHODS

Confirmatory factor analysis was used to evaluate the factor structure of the 20 non-management items of the SRS-instrument completed by 3618 young patients with spinal deformity (75.5% female; mean age, 15.0 ± 2.0 years) and of its equivalence across language versions (2713 English-speaking, 270 Spanish, 264 German, 223 Italian, and 148 French). The root mean square error of approximation (RMSEA) and comparative fit index (CFI) indicated model fit.

RESULTS

Compared with the 20-item version, the 16-item solution significantly increased the fit (p < 0.001) across all language versions, to achieve good model fit (CFI = 0.96, RMSEA = 0.06). For both 16-item and 20-item models, equivalence across languages was not reached, with some items showing weaker item-loading for some languages, in particular German and French.

CONCLUSION

In patients with adolescent idiopathic scoliosis, the shorter 16-item version showed a better fit to the intended 4-factor structure of the SRS-instrument. The wording of some of the items, and/or their equivalence across language versions, may need to be addressed. Questionnaire completion can be a burden for patients; if a shorter, more structurally valid version is available, its use should be encouraged.

How back pain intensity relates to clinical and psychosocial factors in patients with idiopathic scoliosis

OBJECTIVE

A pain intensity of 3 can reliably distinguish idiopathic scoliosis (IS) patients with acceptable pain or not. This research aims to analyze psychosocial, family and quality of life differences in patients according to their pain status.

MATERIAL AND METHODS

Patients with IS, without previous surgery, Cobb ≥ 30° and age (12-40) were included in the study. They completed the questionnaires Numerical Rate Scale (NRS), Tampa Scale for Kinesiophobia (TSK)-11, SRS22r, Hospital Anxiety-Depression Scale (HADS), COMI item 7 (work/school absenteeism) and family APGAR. Comorbidities and family health history were collected. Analysis of covariance was performed to compare means between the PAIN (NRS > 3), (NRS <  = 3) groups controlling for the effect of age and the magnitude of the curve.

RESULTS

In total, 272 patients were included. 37.1% belonged to the PAIN group (PG). The PG showed a significantly higher Cobb grade and age than the NO-PAIN group. After controlling for these variables, the PG had worse pain, mental health and SRS22-subtotal values. However, they did not differ in function or self-image. PG showed higher levels of kinesiophobia, anxiety, depression, absenteeism from work/school and impact on social/family environment. PG patients reported a higher prevalence of comorbidities and family history of nonspecific spinal pain.

CONCLUSIONS

Patients with IS and unacceptable pain constitute a group with a different incidence of psychological, social, family and comorbidities factors than those with acceptable pain. In contrast, the severity of IS was not substantially different between the groups. This profile is similar to that observed in patients with nonspecific spinal pain.

Impact of early unanticipated revision surgery on health-related quality of life after adult spinal deformity surgery

BACKGROUND CONTEXT

Revision surgery represents a major event for patients undergoing adult spinal deformity (ASD) surgery. Previous reports suggest that ASD surgery has minimal or no impact on health-related-quality of life (HRQOL) outcomes.

PURPOSE

The present study aims to investigate the impact of early reoperations within the first year on HRQOL and on the likelihood of reaching the minimally clinically important difference (MCID) after ASD surgery.

DESIGN

This is a retrospective analysis of prospectively collected data from consecutive surgically treated adult deformity surgery patients included in a multicenter, international database.

PATIENT SAMPLE

The present study included 280 patients from a multicenter international prospective database.

OUTCOME MEASURE

Oswestry Disability Index (ODI), Short Form-36 (SF-36), Scoliosis Research Society-22 (SRS-22), MCID were evaluated in this work.

METHODS

Consecutive surgical patients with ASD recruited prospectively in six different centers from four countries with a minimum 2-year follow-up were stratified into two groups: R (revision surgery within the first year) and NR (no revision). Health-related-quality of life (ODI, SF-36, SRS-22) was assessed and compared at 6-month, 1-year, and 2-year follow-up stages. Statistical analysis included chi-square tests, Student t tests, and linear mixed models.

RESULTS

Forty-three patients (R Group) received 46 revision surgeries. Nineteen patients (41.3%) had implant-related complications, 9 patients (19.6%) had deep surgical site infections, 9 patients (19.6%) had proximal junctional kyphosis, 3 patients (6.5%) had hematoma, and 6 patients (13%) had other complications. Baseline characteristics differed between groups. At 6 months, all HRQOL scores improved in both groups, except in the SF-36 Mental Component Summary and SRS-22 mental health domain in the R Group. At 1 year, ODI and SRS-22 improvement was significantly greater in the NR Group, exceeding the reported MCID. At the 2-year follow-up, ODI, SRS-22, SF-36 MCS, and SF-36 PCS improvement was similar in both groups. However, postoperative change was only above the MCID for SF-36 PCS, ODI, and SRS-22 in the NR Group.

CONCLUSIONS

Early unanticipated revision surgery has a negative impact on mental health at 6 months and reduces the chances of reaching an MCID improvement in SRS-22, SF-36 PCS, and ODI at the 2-year follow-up.

The Adult Deformity Surgery Complexity Index (ADSCI): a valid tool to quantify the complexity of posterior adult spinal deformity surgery and predict postoperative complications

BACKGROUND CONTEXT

In 2008, Mirza et al. designed and validated the first and only index capable of quantifying the complexity of spine surgery. However, this index is not fully applicable to adult spinal deformity (ASD) surgery as it does not include the surgical techniques most commonly used and most strongly associated with perioperative complications in patients with ASD.

PURPOSE

The objective of this study is to develop an "Adult Deformity Surgery Complexity Index" (ADSCI) to quantify objectively the complexity of the ASD posterior surgery.

STUDY DESIGN/SETTING

This is an expert consensus (Delphi process) and retrospective analysis of prospectively collected data using multiple regression models.

PATIENT SAMPLE

Patients were prospectively enrolled in two comparable multicenter ASD databases sharing the same inclusion criteria.

OUTCOME MEASURES

The ADSCI was internally and externally validated using R² for intraoperative bleeding and length of surgery. Receiver operating characteristics (ROC) and area under the curve (AUC) analysis was used to assess the sensitivity and specificity of ADSCI.

METHODS

The development and validation of ADSCI was based on the construction and comparison of three different tools: ADSCI score was constructed by three rounds of expert consensus (ADSCI-Delphi) and two multiple regression models (ADSCI-RM-Simple and ADSCI-RM-Mixed). Their predictive capability was compared by means of R² values in the same subrogated of surgical complexity as in the Mirza index validation: intraoperative bleeding and duration of surgery. Sensitivity and specificity were evaluated using ROC curves and AUC analysis. The external validity was also examined by evaluating its predictive capability in another multicenter ASD database of comparable patients in the United States.

RESULTS

At the time of the study, the database included 1,325 patients. Four hundred seventy-five patients were eligible for the study, having been treated surgically using a posterior approach only (52.2 years standard deviation 20; 77.7% women; 85.4% American Society of Anesthesiologists I/II). Fifty-one international experts participated in the Delphi consensus process. The surgical variables selected by consensus and included in the equation were divided into actions and factors. Actions selected were number of fused segments, decompressions, interbody fusions, and cemented levels; number and type of posterior osteotomies; and use of pelvic fixation. The factors included were implant density, revision surgery, and team experience. ADSCI-RM-Mixed (regression model with Delphi formula interactions) provided the best estimates and predictive value, well above Mirza's invasiveness index. The ADSCI-RM-Mixed, with greater AUCs (>0.70), was also the most sensitive and specific for both of the dependent variables studied and for complication prediction. ADSCI-RM-Mixed obtained also the highest R² value in the validation cohort in predicting blood loss (R²=0.34) and surgical time (R²=0.26) with effect sizes similar to those for the derivation cohort.

CONCLUSIONS

The ADSCI is the first tool to be specifically developed for the preoperative assessment of the complexity of ASD surgery. This study confirms its validity, specificity, and sensitivity, and shows that it has greater predictive capability than the more generic Mirza invasiveness index. The ADSCI should be useful for quantitatively estimating the increased risk associated with more invasive surgery and adjusting for surgical case-mix when making safety comparisons in ASDS.

Introversion, the prevalent trait of adolescents with idiopathic scoliosis: an observational study

Background

A large number of studies about adolescents with idiopathic scoliosis focus on health-related quality of life (HRQOL). However, only a few articles aim at evaluating the personality of these patients. Therefore, the purpose of the present research is to assess the personality traits of adolescents with idiopathic scoliosis and their relationship with HRQOL.

Our hypothesis is that adolescents with idiopathic scoliosis present the principal personality trait of introversion, defined as self-reliance and inhibition in social relationships.

Methods

This was a cross-sectional study. The examined group consisted of 43 patients (only 4 boys), mean age = 14.3 (SD = 2.23). On the day of the visit, HRQOL tools (Scoliosis Research Society-22 Questionnaire (SRS-22) and Trunk Appearance Perception Scale (TAPS)) and a personality test (16 Personality Factors-Adolescent Personality Questionnaire (16PF-APQ)) were completed; in addition, a posterior-anterior radiography was performed. Correlations among demographic and medical data and HRQOL and personality tests were assessed.

Results

Results for SRS-22 were as follows: Function 4.5 (SD = .4), Pain 4.3 (SD = .5), Self-image 3.6 (SD = .7), Mental Health 3.8. (SD = .7), and Subtotal 4.2 (SD = .7). Mean TAPS was 3.5 (SD = .6).

In personality, the lowest values were assessed for Extroversion (M = 29.4, SD = 24.7) and Self-reliance (M = 71, SD = 25.3).

Independence was negatively related to Self-image (r = −.51), Mental Health (r = −.54), and Subtotal SRS-22 (r = −.60) (p < .01).

Conclusions

Adolescents with idiopathic scoliosis presented a common style of personality, characterized by social inhibition (introversion), preference for staying alone, and being self-sufficient (self-reliance).

Specific programs in promoting social abilities may help adolescent patients with idiopathic scoliosis in finding a way to express themselves and to become more sociable. Correlational studies between personality and HRQOL need to be performed to better understand these issues.

Validity and reliability of photographic measures to evaluate waistline asymmetry in idiopathic scoliosis

OBJECTIVE

Evaluate the relationship between radiological, clinical and perceived waistline asymmetry (WLA) in a sample of idiopathic scoliosis (IS) patients.

METHODS

77 patients were included (mean age 20.3 years; 85 % women). We obtained a full X-ray of the spine and back clinical photography for all patients. On photographs, waist height angle (WHA), right/left waist angles (WA) and right/left waistline distance ratio were measured. SRS22, Trunk Appearance Perception Scale (TAPS) and Spinal Appearance Questinnaire (SAQ) questionnaires were also completed. The intra and inter-observer reliability of each photographic measure was assessed. A correlation analysis between all variables was done using Pearson Correlations Coefficient.

RESULTS

All measures reported have excellent intra- and inter-observer (ICC ≥0.8) reliability. A significant correlation was found between WHA and Cobb angle, mainly with Main Thoracic (MT) (r = -0.56). Right and left waist angles, and especially the difference between them (RLWAD), is related to the thoracolumbar/lumbar (TLL) curve. We have found a significant correlation between RLWAD and TLL curve magnitude (r = -0.54) and with the inclination of the lower end vertebra (LEV) (r = 0.74). Only WHA has a significant, but poor correlation (r ≅ 0.3) with trunk perception scales (TAPS and SAQ). No other significant correlations were found between WLA measures and patient related outcome scores.

CONCLUSION

WLA measures proposed in this article are reliable tools to assess WLA. We have found a significant correlation between clinical WLA and skeletal deformity (Cobb angle). WHA is related with MT curve while the RLWAD depends on the TLL curve magnitude and its LEV. We have also found a significant relation between WHA and the patient's perception of the deformity. It seems that WLA is a cosmetic concern to take into account in clinical evaluation of IS patients.

Reliability and validity study of measurements on digital photography to evaluate shoulder balance in idiopathic scoliosis

Objective

To determine the validity of digital photography as an evaluation method for shoulder balance (ShB) in patients with idiopathic scoliosis.

Material and methods

A total of 80 patients were included (mean age 20.3 years; 85% women). We obtained a full x-ray of the vertebral column and front and back clinical photography for all patients. For antero-posterior x-rays we measured the proximal thoracic curve angles (CPT). To evaluate radiological shoulder balance we calculated the clavicle-rib intersection angle (CRIA) and T1-tilt. For clinical photography we measured shoulder height angle (SHA), axilla height angle (AHA) and the left right trapezium angle (LRTA). We analyzed the reliability of the different photographic measurements and the correlation between these and the radiological parameters.

Results

The mean magnitude of PTC, CRIA and T1-tilt were 19°, −0.6° and 1.4° respectively. Mean SHA from the front was −1.7°. All photographic measurements revealed an excellent-near perfect intra and inter-observer reliability in both photographic projections. No correlation was found between the ShB and the magnitude of the PTC. A statistically significant correlation was found between clinical balance of the shoulders and radiological balance (r between 0.37 and 0.51).

Conclusions

Digital clinical photography appears to be a reliable method for objective clinical measurement of ShB. The correlation between clinical and radiological balance is statistically significant although moderate/weak.

Electronic supplementary material

The online version of this article (doi:10.1186/s13013-014-0023-6) contains supplementary material, which is available to authorized users.

Implant survival after deep infection of an instrumented spinal fusion

This study evaluates the long-term survival of spinal implants after surgical site infection (SSI) and the risk factors associated with treatment failure. A Kaplan-Meier survival analysis was carried out on 43 patients who had undergone a posterior spinal fusion with instrumentation between January 2006 and December 2008, and who consecutively developed an acute deep surgical site infection. All were appropriately treated by surgical debridement with a tailored antibiotic program based on culture results for a minimum of eight weeks. A 'terminal event' or failure of treatment was defined as implant removal or death related to the SSI. The mean follow-up was 26 months (1.03 to 50.9). A total of ten patients (23.3%) had a terminal event. The rate of survival after the first debridement was 90.7% (95% confidence interval (CI) 82.95 to 98.24) at six months, 85.4% (95% CI 74.64 to 96.18) at one year, and 73.2% (95% CI 58.70 to 87.78) at two, three and four years. Four of nine patients required re-instrumentation after implant removal, and two of the four had a recurrent infection at the surgical site. There was one recurrence after implant removal without re-instrumentation. Multivariate analysis revealed a significant risk of treatment failure in patients who developed sepsis (hazard ratio (HR) 12.5 (95% confidence interval (CI) 2.6 to 59.9); p < 0.001) or who had > three fused segments (HR 4.5 (95% CI 1.25 to 24.05); p = 0.03). Implant survival is seriously compromised even after properly treated surgical site infection, but progressively decreases over the first 24 months.

Is Routine Postoperative Radiologic Follow-up Justified in Adolescent Idiopathic Scoliosis?

STUDY DESIGN

Retrospective review.

OBJECTIVES

To determine whether routine periodic radiographic examination is worthwhile in adolescent idiopathic scoliosis (AIS) patients undergoing instrumented fusion with third-generation implants.

SUMMARY OF BACKGROUND DATA

In common practice, patients who have undergone surgery for idiopathic scoliosis are followed up for a minimum of 2 years by clinical assessment and routine radiographic study at 3, 6, 12, and 24 months. The radiation related to these examinations is not negligible. To our knowledge, the use of routine radiographic follow-up after posterior spinal fusion for adolescent idiopathic scoliosis has not been evaluated.

METHODS

We retrospectively analyzed full-spine X-rays and clinical records from the first 2 postoperative years of 43 patients. We sought any clinical feature (eg, pain, deformity progression, material protrusion) justifying X-ray, and any relevant radiologic finding (eg, loss of correction, instrumentation loosening, junctional kyphosis).

RESULTS

Excluding the immediate postoperative films, 14.8% of X-rays were clinically justified, 8.3% were associated with a relevant finding, and 4.3% led to a therapy change. All patients with clinical deformity progression had a relevant X-ray finding. Pain was associated with a relevant finding in 23.5% of cases (positive predictive value, 0.1); 7.4% of films with no clinical justification showed a relevant finding (negative predictive value, 0.86). Lower Risser sign increased the risk of having a relevant radiographic finding (p < .05).

CONCLUSIONS

With the current use of third-generation implants, routine biplanar postoperative X-rays at 3, 6, 12, and 24 months do not seem to be justified in AIS and should be avoided in mature, asymptomatic patients.

Outcome instruments to assess scoliosis surgery

PURPOSE

To review and summarize the current knowledge regarding the outcome measures used to evaluate scoliosis surgery.

METHODS

Literature review.

RESULTS

Outcome instruments should be tested to ensure that they have adequate metric characteristics: content and construct validity, reliability, and responsiveness. In the evaluation of scoliosis, generic instruments to assess health-related quality of life (HRQL) have been used, such as the SF-36 questionnaire and the EuroQol5D instrument. Nonetheless, it is preferable to use disease-specific instruments for this purpose, such as the SRS-22 Patient Questionnaire and the quality of life profile for spinal deformities (QLPSD). More recently, these generic and disease-specific instruments have been complemented with the use of super-specific instruments; i.e., those assessing a single aspect of the condition or specific populations with the condition. The patients' perception of their trunk deformity and body image has received particular attention, and several instruments are available to evaluate these aspects, such as the Walter-Reed Visual Assessment Scale (WRVAS), the Spinal Appearance Questionnaire (SAQ), and the Trunk Appearance Perception Scale (TAPS). The impacts of brace use can also be measured with specific scales, including the Bad Sobernheim Stress Questionnaire (BSSQ) and the Brace Questionnaire (BrQ). The available instruments to evaluate the treatment for non-idiopathic scoliosis have not been sufficiently validated and analyzed.

CONCLUSIONS

Evaluation of scoliosis treatment should include the patient's perspective, which can be obtained with the use of patient-reported outcome measures.

Minimal important differences of the SRS-22 Patient Questionnaire following surgical treatment of idiopathic scoliosis

The responsiveness of an instrument measuring health-related quality of life is an important indication of its construct validity. The SRS-22 Patient Questionnaire has become the most widely used patient-reported outcome instrument in the clinical evaluation of patients with idiopathic scoliosis. The responsiveness of the SRS-22 following surgical treatment in patients with idiopathic scoliosis has not been fully assessed. The aim of this study is to evaluate this factor by calculating the minimal important differences (MIDs) of the SRS-22 Questionnaire. The study included 91 patients with idiopathic scoliosis (77 females and 14 males), who underwent surgical treatment; mean age at the time of surgery was 18.1 years. Patients completed the SRS-22 questionnaire before surgery and at a follow-up visit (mean follow-up, 45.6 months). At follow-up, patients rated their overall situation as related to before surgery with a four-point Likert scale: 1-Worse, 2-Same, 3-Better, 4-Much Better. This evaluation represented the global perceived effect (GPE) and served as the anchor criterion for calculating the MID. MIDs were calculated using two approaches. The anchor-based MID (MID-A) was defined as the mean preoperative/follow-up difference in SRS-22 scores in the group of patients who stated they were much better than before surgery (GPE = 4). Using the same anchor criterion, the optimal cut-off value able to identify patients that had clearly improved was determined on a receiver operating characteristic (ROC) curve. In addition, the distribution-based MID (MID-D) was calculated by the standard error of measurement method. The MID-As found for the different subscales and the sum score were: pain 0.6, function 0.3, image 1.3, mental health 0.3, average sum score 0.6, and raw sum score 13.1. The cut-off values on the ROC curve were: pain 0.2, function 0.0, image 1.6, mental health 0.4, average sum score 0.4, and raw sum score 10. The MID-Ds were: pain 0.6, function 0.8, image 0.5, mental health 0.4, average sum score 0.5, and raw sum score 6.8. As was expected, the MID values differed according to the calculation method used. In light of the fact that the MID-As for the function and mental health subscales are below the measurement error of the instrument, it seems preferable to use the MID-D values for determining subscale changes. If the purpose is to analyze sum score changes (either the raw or average values), the MID-A is preferable because it includes the patient's evaluation of the results of surgery.

Human adipose tissue-derived mesenchymal stromal cells as vehicles for tumor bystander effect: a model based on bioluminescence imaging

Human adipose tissue mesenchymal stromal cells (AMSCs) share common traits, including similar differentiation potential and cell surface markers, with their bone marrow counterparts. Owing to their general availability, higher abundance and ease of isolation AMSCs may be convenient autologous delivery vehicles for localized tumor therapy. We demonstrate a model for tumor therapy development based on the use of AMSCs expressing renilla luciferase and thymidine kinase, as cellular vehicles for ganciclovir-mediated bystander killing of firefly luciferase expressing tumors, and noninvasive bioluminescence imaging to continuously monitor both, tumor cells and AMSCs. We show that the therapy delivering AMSCs survive long time within tumors, optimize the ratio of AMSCs to tumor cells for therapy, and asses the therapeutic effect in real time. Treatment of mice bearing prostate tumors plus therapeutic AMSCs with the prodrug ganciclovir induced bystander killing effect, reducing the number of tumor cells to 1.5 % that of control tumors. Thus, AMSCs could be useful vehicles to deliver localized therapy, with potential for clinical application in inoperable tumors and surgical borders after tumor resection. This approach, useful to evaluate efficiency of therapeutic models, should facilitate the selection of cell types, dosages, therapeutic agents and treatment protocols for cell-based therapies of specific tumors.

Analysis of nutritional parameters in idiopathic scoliosis patients after major spinal surgery

OBJECTIVE

The aim of the study is to investigate the evolution of nutritional parameters after major spinal surgery in patients with idiopathic scoliosis.

METHODS

This retrospective study included 31 patients with a mean age of 18 y, diagnosed with idiopathic scoliosis. The following variables were analyzed: demographic, surgical (type, number of fused segments, duration, and blood loss), nutritional assessment (proteins, albumin, prealbumin, transferrin, lymphocytes, and body mass index), and duration of hospitalization at different time points. Statistical analyses were performed with the SPSS 6.1 software.

RESULTS

Before surgery, nutritional status was normal in all patients. At 24-48 h after surgery, statistically significant decrease with respect to preoperative values was recorded for all the parameters studied: proteins (P < 0.001), albumin (P < 0.001), prealbumin (P < 0.01), transferrin (P < 0.001), and lymphocytes (P < 0.001).

CONCLUSION

Our results showed a significant postoperative decrease in the nutritional parameters analyzed in a previously well-nourished population considered to be at low risk for nutritional depletion.

Preoperative erythropoietin in spine surgery

Spine surgery may be associated with profuse intraoperative bleeding that often requires blood transfusions. In recent years several techniques have been developed to avoid allogenic transfusions and their potential complications to surgical patients. In this study we review and analyse the role of preoperative recombinant human erythropoietin (rHuEPO) administration in spine surgery as a blood conservation strategy. Between 1998 and 2002, a total of 250 patients scheduled for spine surgery were included in our blood-sparing program: 114 patients (group 1), operated on before rHuEPO approval (2000), underwent preoperative autologous blood donation (ABD) alone, and 136 patients operated on after rHuEPO approval (groups 2 and 3) received rHuEPO while undergoing ABD. Adding rHuEPO to ABD resulted in higher haemoglobin and haematocrit values the day of surgery, more ABD units retrieved per patient and, consequently, reduced allogenic transfusion requirements. The effectiveness of rHuEPO as the only preoperative blood conservation technique was evaluated in ten patients with a predicted blood loss of less than 30% of their total volume, scheduled for lumbar surgery. Data from these patients were matched with those from a similar group of patients who had undergone ABD. Patients receiving rHuEPO alone had higher haemoglobin levels the day of surgery than did patients in the ABD program. Neither group required allogenic transfusions.

CONCLUSIONS

preoperative rHuEPO is useful for reducing allogenic blood requirements in elective spine surgery. In patients with an expected blood loss of around 50% of blood volume, rHuEPO improves ABD, minimising preoperative anaemia and increasing the number of ABD units collected. In patients with expected blood loss below 30% of total volume, rHuEPO administration may replace ABD.

[Total parenteral nutrition in major surgery of the spine]

This paper presents clinical experience with the use of total parenteral nutrition (TPN) in patients undergoing major spinal surgery, as well as the identification of possible risk factors involved in the extended duration of TPN. Although TPN is an expensive therapy, it may even represent a cost saving in patients with a high risk of developing malnutrition. Therefore, it is necessary to identify those patients with the greatest likelihood of presenting nutritional deterioration in order to select those who would benefit from post-operative TPN. During the period under analysis (1995-1998), 137 patients were operated on and could be analyzed retrospectively. The variable considered were: age, sex, weight, body mass index, height, diagnosis, type and time of surgery involved, bleeding, duration of TPN and number of days admitted. The statistical analysis was carried out using the SPSS 6.1 for Windows software package. It comprised a descriptive univariate study, a bivariate comparative means analysis using Student's t test and multi-variant analysis using multiple regression. In the bivariate analysis, a greater duration of TPN was found in those patients subjected to circumferential arthrodesis (p = 0.0001), as well as in patients diagnosed as having kyphoscoliosis following neuromuscular disease (p = 0.0041). The multi-variant analysis gave a correlation statistically significant duration of TPN and surgery time (p = 0.00001), intra-operative bleeding (p = 0.01) and weight (p = 0.0002). No link was found between the duration of TPN and age, nor with the number of days spent in hospital.

Isolated thrombosis of the external jugular vein

Thrombosis of the external jugular vein (EJV) is an infrequent clinical condition that has been associated with central venous catheterization, head and neck infections, intravenous drug abuse, and compression at the affected site. The authors report a case of thrombotic obstruction of the EJV in the late postoperative period after laparoscopic anterior lumbar interbody fusion. A 40-year-old morbidly obese woman with a depressive syndrome was diagnosed with L5-S1 discopathy and was submitted to laparoscopic anterior isthmic fusion. The operation lasted approximately 6 hours, during which the patient remained in a supine decubitus and Trendelenburg position. The left radial artery, peripheral veins, and right internal jugular vein were canalized. The internal jugular vein catheter was electively withdrawn 24 hours after the intervention. The postoperative period was satisfactory, and the patient was started on prophylaxis with low-molecular-weight heparin. She sat up and began walking at 24 hours and was discharged to her home 4 days after the procedure. Eight days after discharge she returned, experiencing right cervical pain. Palpation revealed a painful induration and erythematous area under the anterior edge of the sternocleidomastoid muscle. Results of otoscopy and laryngoscopy were normal. Cervical echo-Doppler disclosed an image consistent with EJV thrombosis. The most frequent causes of jugular vein thrombosis are mentioned above. A higher incidence has been described after upper abdomen and pelvic surgery; other contributing factors are age, obesity, and associated illness. There are few references in the literature to position-induced EJV thrombosis in the late postoperative period. The authors' patient presented signs and symptoms of EJV thrombosis (probably because of various factors), which was confirmed by echo-Doppler study and treated with 10 days of calcic heparin.

Traumatic lumbosacral dislocation

STUDY DESIGN

Case report of a patient with lumbosacral dislocation.

OBJECTIVES

To report a case of traumatic lumbosacral dislocation treated nonoperatively, with 10 years of follow-up.

SUMMARY OF BACKGROUND DATA

Lumbosacral dislocation is rare, with only 48 cases reported in the literature. Surgical treatment by means of open reduction and fusion is advisable. However, the literature shows six cases of patients with complete lumbosacral dislocation treated nonoperatively with good results.

METHODS

A 38-year-old man was involved in a highspeed vehicle accident. The lumbosacral dislocation (anterior displacement of L5 on S1, 44% slippage) was initially missed, and the patient was treated conservatively.

RESULTS

Slippage did not progress, and the patient returned to full, normal activity. Ten years later he is asymptomatic and is able to work and play sports.

CONCLUSIONS

This study reports a rare injury of the lumbosacral junction that was detected 3 months after injury. Satisfactory results were obtained with nonoperative treatment in this case. Although a surgical approach is advisable in acute cases to decompress the neurologic structures and to stabilize the lumbosacral junction, conservative management may be the treatment of choice in inveterate lesions.

Clinical and CT scan evaluation after direct defect repair in spondylolysis using segmental pedicular screw hook fixation

Direct defect repair using segmental pedicular screw hook fixation was carried out in nine patients with spondylolysis and a mean age of 24.2 years. One patient was fused 3 years after isthmic reconstruction. In the remaining eight patients, after a mean follow-up of 41 months (range, 12-78), three self-evaluation scales revealed a significant (p < 0.05) improvement in clinical status. Computed tomography scans were carried out in seven patients. There was bilateral bony union in two cases, in three pars healing was unilateral, and in two the isthmic defect persisted bilaterally. No correlation was observed between the status of the pars and follow-up. We conclude that repair of defects in spondylolysis may result in a favorable clinical outcome even when anatomic reconstruction of pars interarticularis is not successful.

Vertebral fracture in a fused spine for scoliosis. A case report

STUDY DESIGN

A case report.

OBJECTIVES

To document a fracture of the 11th thoracic vertebra after spine fusion for adult idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA

Three cases of vertebral fractures associated with spine fusion for scoliosis were found in the literature.

METHODS

Medical and radiologic records and related literature were reviewed.

RESULTS

A 30-year-old woman had undergone anterior and posterior fusion with Cotrel-Dubousset instrumentation for progressive idiopathic scoliosis. Two years after surgery, she was in a car accident. A radiographic study and computer tomographic scanning depicted a fracture of T11 and bending of the rods. Observation was instituted and symptoms resolved.

CONCLUSIONS

Fracture of a vertebra within an extensive spine fusion for scoliosis is rare. The 360 degrees solid fusion together with strong posterior instrumentation may have had some protective effect in this patient.

Four radiological measures to estimate shoulder balance in scoliosis

We studied four indirect radiological measures of shoulder balance, their correlation with true shoulder balance, and measurement error of each method. Thirty-three consecutive patients with idiopathic scoliosis requiring surgical treatment were selected. Actual shoulder level was determined from a line in the top margin of the acromion clearly visualized in the wide chart. Indirect references used to assess shoulder balance were tilting of cephalic end-plate of T1, inclination of a line through superior border of both first ribs, the level of top margin of coracoid processes, and the level of two specific points where the clavicle intersects the rib cage. All radiographs were assessed by three independent observers. Correlation coefficients between each measurement and true shoulder level were 0.54 for T1 tilting (p = 0.001), 0.63 for first rib inclination (p < 0.001), 0.96 for coracoid process (p = 0.0001), and 0.93 for clavicle-rib cage intersection (p = 0.0001).

Lateral distraction injury to the lumbar spine. Report of spontaneous reduction

STUDY DESIGN

A patient with a lateral distraction injury of the lumbar spine that reduced spontaneously and not associated with any thoracic or abdominal injury is reported.

SUMMARY OF BACKGROUND DATA

A brief summary of the clinical presentation is given as is the surgical technique employed. Lateral distraction injuries of the thoracolumbar spine associate a distraction injury with lateral bending in the frontal plane, causing unilateral disruption of the ligamentous and osseous restraints. The have been associated with life-threatening thoracic and abdominal injuries. Closed reduction of this spine injury is not believed to be feasible.

CONCLUSIONS

This case introduces interesting new features to this spine lesion. It is the first reported case with documented spontaneous reduction.