El-Nasri Ahmed - Academia.edu (original) (raw)

Papers by El-Nasri Ahmed

Journal of the Neurological Sciences, 2009

Background: MEP is the most appropriate technique to assess the functional integrity of the whole... more Background: MEP is the most appropriate technique to assess the functional integrity of the whole motor pathway, particularly during scoliosis surgery. Objectives: The object of this prospective study is to assess the impact of preoperative clinical, electrophysiological (EMG, NCV, SSEPs) studies and intra-operative recording of MEPs using multi-pulse transcranial electrical stimulation on the outcome of 15 operations adolescent idiopathic scoliosis. Methods: The selected 15 cases had diverse grades of scoliosis severity according to Lenke classification of adolescent idiopathic scoliosis (AIS). All patients were under the age of 18 years old (14.3±2.46), 10 females and 5 males. Preoperative clinical, routine laboratory, electrophysiological studies and intra-operative recording were done for all patients who met all study criteria. Post-operative and electrophysiological assessments were carried out for all cases. Patients with a history of epilepsy or skull fracture were excluded. Results: Post-operative follow up for all cases was continued for 6-month and revealed nonexistence of new motor deficits either clinically or electro-physiologically. This is owing to that the cases had normal preoperative studies (n=15) as well as intraopaerative MEPs. Apart from considerable intra-operative transient MEP changes in two patients, no new EPs or clinical deficits were documented. Regarding post-operative SSEP, it remained unaltered and even it demonstrated better recovery in 7 patients, on top no complications were raised. Conclusion: All patients who had reproducible MEPs (100%) during the whole surgery procedures via APB, ADM, AH and TA recordings had had excellent clinical and electrophysiological outcomes.

Orthopaedics and Trauma, Oct 1, 2016

Thoracic and thoracolumbar fractures range from low impact osteoporotic compression injuries to h... more Thoracic and thoracolumbar fractures range from low impact osteoporotic compression injuries to high-energy fracture/dislocations with spinal cord injury. Assessment can be broadly divided into two sections. Primary assessment should follow the principles of Advanced Trauma Life Support. The secondary assessment should relate to the spinal fracture itself. In determining the optimal treatment, the stability of the injury must be assessed by following a complete clinical and radiographic evaluation. The thoracolumbar junction (T10eL2) is a transitional region between the rigid thoracic spine and the more flexible lumbar spine and hence is susceptible to injury. The thoracic spine (T1eT9) is relatively protected area, due to the rib cage; when injuries do occur they commonly involve visceral and spinal cord injury. Many classifications exist, however the AO and Thoracolumbar Injury Classification and Severity (TLICS) systems are the most clinically useful. Although they are based on thoracolumbar injuries they are commonly extended to thoracic fractures. The majority of fractures can be managed non-operatively with early mobilization and bracing. Surgical stabilization is indicated in unstable fractures. Posterior stabilization with pedicle screws is the most widely used technique; simultaneous decompression can also be achieved with this approach. Anterior surgery has biomechanical advantages and has been shown to be equally effective.

Orthopaedics and Trauma, Dec 1, 2017

Adolescent idiopathic scoliosis is the most common type of spinal deformity seen in the paediatri... more Adolescent idiopathic scoliosis is the most common type of spinal deformity seen in the paediatric population. The deformity affects otherwise normal functioning teenagers with no underlying pathological condition, no neurological abnormalities and normal imaging of the neuraxis. It produces a cosmetic deformity occasionally associated with muscular back pain and respiratory compromise in severe degrees of deformity. The aetiology is likely multifactorial and the risk of curve progression depends on the age of the patient at initial presentation, amount of remaining spinal growth and initial size of the curvature. Patients should be assessed with a thorough clinical evaluation including radiographic and often magnetic resonance imaging. Observation is recommended in growing patients with small curves up to 20e25. Bracing can stop or slow down curve progression in growing patients with curves up to 40. Surgical treatment is indicated in the presence of a severe deformity which is producing pain or pulmonary symptoms and is associated with cosmetic dissatisfaction. Most commonly this is performed through a posterior spinal fusion with the use of instrumentation and bone graft. The aim of the surgery is to stabilize the spine, correct the deformity and prevent deterioration. This has to be performed safely minimizing the risks of neurological/vascular/visceral injury, infection or non-union with instrumentation failure.

International Sportmed Journal, 2007

Spinning exercise cycle machines are becoming increasingly popular. They provide the health benef... more Spinning exercise cycle machines are becoming increasingly popular. They provide the health benefits of cycling without the injury risks of road usage. This is the report of a unique case of cervical spine fracture sustained whilst exercising in a gym on a stationary Spinning® bike.

Orthopaedic Proceedings, Feb 21, 2018

The current trend in kyphosis correction is for “every level” instrumentation to achieve intraope... more The current trend in kyphosis correction is for “every level” instrumentation to achieve intraoperative stability, correction, fusion and implant longevity. We evaluate the medium term follow up of a low implant density (LID) construct. All patients with adolescent kyphosis (idiopathic or Scheurmann9s) on our deformity database were identified. Radiographs and records were analysed for neurological complications, correction and revision. The constructs included were all pedicle screw anchors with multiple apical chevron osteotomies and a proximal and distal “box” of 6 to 8 screws. A four rod cantilever reduction manoeuvre with side to side connectors completed the construct. Kyphosis for any other cause was excluded. Follow up less than 12 months was excluded. 23 patients were identified with an average follow up 27 months (72 to 12 months) and a mean implant density of 1.1 (53.5% of “available” pedicles instrumented). There was 1 false positive neurophysiological event without sequelae (4%). There were no proximal junctional failures (0%). There were no pseudarthroses or rod breakages (0%). There was 1 loss of distal rod capture (early set screw failure) (4%). This was revised uneventfully. There were 4 infections requiring debridement (early series). Average initial correction was 44% (77.7 degrees to 43.5 degrees) with a 1% loss of correction at final follow up (43.5 to 44.0 degrees). The fulcrum bending correction index was 107% (based on fulcrum extension radiographs). 85% of curves had a fulcrum flexibility of less than 50%. The average cost saving compared to “every level “instrumentation was £5700 per case. This paper shows that a LID construct for kyphosis has technical outcomes as good as high density constructs. The obvious limitation of the study is the small number of patients in the cohort. The infection rates have improved with changes to perioperative process in the later series of patients. We do not believe these are a consequence of the construct itself.

Orthopaedic Proceedings, Aug 1, 2008

The use of blood transfusion in elective spinal surgery still remains a topic of debate in spite ... more The use of blood transfusion in elective spinal surgery still remains a topic of debate in spite of several guidelines on transfusion in orthopaedic surgery. We report on a study done to look at the transfusion practice in 64 patients who underwent scoliosis correction surgery in our institution. There were 16 males and 48 females, with an average age of 19.8 years (range 3–70 years). There were 50 patients with idiopathic scoliosis, seven with degenerative scoliosis, five with neuromuscular scoliosis, and one each of congenital and neurologic scolioses. 31 of the patients underwent posterior correction and 13 patients underwent anterior surgery and 11 patients underwent posterior surgery with costoplasty and 5 patients underwent front and back surgery while 4 patients had front and back surgery with costoplasty. 10 patients underwent iliac crest bone grafting. The mean preop haemoglobin was 13.1 g % (range11.3–16.2 g %) and the mean postop haemoglobin was 8.9 g % (5–14.9 g %). The average amount of intraoperative fluids infused was 4100 ml (range: 300–11000 ml). The mean blood loss was 803.3 ml (range: 300–1800 ml). Sixteen patients were transfused in all requiring 32 units of blood, with an average of 2 units per patient. The average duration of hospital stay was 10.1 days (5–45 days). The mean blood loss through drains was 396 ml (10–2000 ml).

Introduction: Scheuermann9s kyphosis is a fixed round back deformity characterised by wedged vert... more Introduction: Scheuermann9s kyphosis is a fixed round back deformity characterised by wedged vertebrae seen on radiograph. It is known patients presented with a negative sagittal balance before operation. Few studies investigated the outcome after operation, especially the change in the lumbar hyperlordosis. Aim: To investigate the change in sagittal profile after correction surgery. Method: This is a retrospective review of cases from 2001 to 2012. Our centre uses a posterior, four rod cantilever reduction technique for all Scheuermann9s Kyphosis correction. 36 cases are identified. They include 24 males and 12 females with an average age of 20 and follow up of 27 months. First 8 cases used the stainless steel hybrid implants. The remaining 28 had titanium all pedicle screw system. All had intra-operative spinal cord monitoring. Results: The target of thoracic kyphosis correction is around the accepted upper end of normal limit (40°). The average thoracic kyphosis Cobb angle was 78.5°. The immediate post-op angle was 43.2° and at final follow up, 43.6°. The average lumbar lordosis changed from 65.7° pre-op to 48.8° post-op, which is now bigger than the thoracic kyphosis. The result is the transfer of average sagittal balance (C7 plumb line) from −2.2 cm to −3.5 cm, which remains posterior to the posterior corner of S1 after the surgery. Discussion: Surgery can improve the roundback deformity but not the overall sagittal profile. We have no explanation to this phenomenon. This could imply the pathology of Scheuermann9s Kyphosis involves the whole spine, not just the wedging thoracic segment. Conflict Of Interest Statement: No conflict of interest.

Orthopaedic Proceedings, Mar 1, 2006

Objective: To describe the prevalence and incidence of methicillin resistant Staphylococcus aureu... more Objective: To describe the prevalence and incidence of methicillin resistant Staphylococcus aureus (MRSA) colonisation in patients in the Trauma and Orthopaedic wards of the University Hospital of North Staffordshire. Design Prospective audit. Patients and methods: Over a three month period from 1st March to 31st May 2003 359 patients attending the elective orthopaedic outpatient department for major joint surgery were screened at the pre-operative assessment clinic; 105 of these patients were screened again on the elective orthopaedic wards. 197 patients were screened on the trauma wards. 31 patients of other/outlying specialities were screened. Patients whose stay was expected to be for 48 hours or more were included in the audit. Patients were screened for MRSA colonization on admission, transfer and discharge. Colonised patients were treated according to the local infection control policy. Results: 31 elective orthopaedic patients (29%); 46 trauma patients (23%) and 8 other/outlying patients (26%) were colonized with MRSA. On admission, 23 elective orthopaedic patients (22%), 32 trauma patients (16%), and 7 patients (23%) which were of other/outlying specialties were colonized with MRSA. 22 patients (6.6%) positive on admission, treated with eradication therapy, became negative on discharge. An additional 22 patients (6.6%) positive on admission became negative on discharge without receiving any treatment. During the audit period, 23 patients (6.9%) were negative for MRSA on admission and positive on discharge. 9 patients (39%) and 20 patients (62.5%) colonised in elective and trauma wards respectively, developed an MRSA infection, which required treatment. Conclusion: There is a relatively high prevalence of MRSA colonisation in patients admitted to orthopaedic and trauma wards. A proportion (22%) of patients are colonised with MRSA in the short time between testing and admission. Not all patients positive for MRSA following admission to hospital will have been colonised within the nosocomial environment.

Orthopaedic Proceedings, Jul 1, 2010

Purpose of Study: To observe the efficiency of the combined motor-somatosensory monitoring and so... more Purpose of Study: To observe the efficiency of the combined motor-somatosensory monitoring and somatosensory-alone monitoring to identify the intra-operative neurologic changes. Methods and Results: We retrospectively assessed 123 cases in our centre, who had complete neurophysiological report while undergoing corrective spinal deformity surgery with spinal monitoring, from 2004 to 2008. Combined motor-somatosensory, somatosensory-alone and motor-alone monitoring were applied in sixty five, fifty and eight operations, respectively. We also looked at the factors that could potentially affect the neuro-physiologic monitoring, such as preoperative neurological status, anaesthetic method, blood loss, competency level of the monitoring team and the reaction of the surgical team to a significant monitoring event. In total, there were only two cases of true positive event, defined as a significant intraoperative event and postoperative neurological deficit. Both of these cases had combined monitoring during their procedures. No case of false negative was observed. There were also five cases with a significant intraoperative event without post operative neurologic sequel (false positive). Four of these had combined monitoring, with complete normal sensory monitoring and abnormal motor monitoring, which prompted the operating team to the appropriate action. Conclusion: Based on this observation, it is felt that the combined monitoring during spinal deformity correction procedures is superior to the sensory-alone monitoring for identifying the impending neurologic deficits. This is in accordance with the previous reports and recommendations.

Orthopaedic Proceedings, Sep 1, 2005

Study Design : An analysis of patients admitted with cervical trauma, comparing: those managed wi... more Study Design : An analysis of patients admitted with cervical trauma, comparing: those managed with rigid collars until definitive management; rigid collar usage overnight; and no rigid collar usage from outset. Objectives: To determine the safety of omitting a rigid collar following cervical trauma, whilst awaiting definitive management. Summary of Background Data: The use of a rigid collar can result in pain, occipital sores, as well as raised intracranial pressure in head injured patients. Subjects : Fifty one patients with proven cervical fractures were analysed. Three groups of patients were identified with respect to their initial management after admission to the ward until definitive management: 1) Hard collar, sandbags and bed rest 2) Hard collar in situ overnight and then sandbags and bed rest. 3) Sandbags and bed rest. All patients had full spinal care and precautions, with rigid collars used for any transfers. The spectrum of injury severity was similar throughout all 3 groups. Outcome measures : Loss of alignment, neurological compromise and complications related to the rigid collar. Results: There was no loss of reduction or progression of neurological deficit in any group. There were compliance issues in the rigid collar group. Two patients developed occipital skin problems following rigid collar use. All groups proceeded to definitive management successfully. Conclusion: No significant adverse events were noted in any group. Management without a rigid collar depends on good nursing care. It is more comfortable for the patient and avoids the potential problems encountered with rigid collar use. In compliant patients not requiring immediate definitive management the omission of the rigid collar did not result in loss of reduction or neurological compromise. We feel such collars should be for transport and extrication only.

Orthopaedic Proceedings, May 1, 2006

Objective: To report a case of non-obstructive urinary retention secondary to cord compression du... more Objective: To report a case of non-obstructive urinary retention secondary to cord compression due to metastases from undiagnosed carcinoma of prostate in a middle aged patient. This is the first case to be reported of its kind. Case Report: A 58-year old brick layer, presented with urinary retention with overflow incontinence was referred by GP to A&E. No obstruction was felt during catheterisation and residual urine of 1.2 litres was drained. He also had dull low back pain since 5–6 weeks that was relieved by simple analgesia and he was able to work normally. He had no other symptoms or significant past medical history. Clinical examination including digital rectal examination (DRE) was normal. Laboratory investigations were normal except a rise in Alkaline phosphatase(194U/L) and ESR (43 mm/hr). X-rays of his spine were normal. MRI scan of the spine showed multiple metastatic lesions, bilateral end plate fractures and loss of vertebral body height of D12 with bulging of posterior vertebral body wall causing extradural compression of the conus. An urgent D12 decompression and biopsy of D12 was done with D10-L2 instrumentation. PSA levels were >500ng/ml.Histopathology showed moderately to poorly differentiated adenocarcinoma with a cribriform pattern. Immunohistochemistry showed a strong staining for PSA consistent with metastatic adenocarcinoma of the prostate. Post-operatively, he regained bladder control and was referred to oncologists for further management. Conclusion: Urinary retention may be the only presenting symptom of spinal cord compression due to metastasis from prostate cancer. High index of suspicion of prostate cancer in middle-aged and elderly male patients with urinary retention, especially when associated with back pain of any severity, even though prostate is normal on DRE is needed. PSA in patients complaining of low back pain who are at high risk for prostate cancer is recommended, even though DRE is normal.

Orthopaedic Proceedings, Aug 1, 2008

Ossification of the posterior longitudinal ligament (OPLL) is a condition found predominantly in ... more Ossification of the posterior longitudinal ligament (OPLL) is a condition found predominantly in the oriental population and is rarely seen in non orientals. OPLL can present with cervical canal stenosis and myelopathy (including central cord syndrome), often following minor trauma. Co-existence of OPLL with diffuse idiopathic skeletal hyperostosis (DISH) is a rare condition and very few reports of such patients exist in literature. Here we report the case of a Caucasian with co-existing DISH and OPLL, presenting with acute central cord syndrome associated with fracture of the ossification. A 64 year old Caucasian farmer was transferred to our spinal unit with weakness in the right upper limb following a road traffic accident. On examination he had hyperaesthesia in both upper limbs and motor power of grade 4 in the right upper limb with a distal motor power of grade 3 in the hand. There was no motor deficit in the left upper limb or lower limbs. Radiographs revealed an ossification of the posterior longitudinal ligament with a break at C2 and C3 levels. He also had exuberant soft tissue ossification in the cervical and thoracic spines, suggestive of diffuse idiopathic skeletal hyperostosis (DISH). He recovered completely in 6 weeks with non operative treatment. Fracture of the posterior longitudinal ligament has not been widely reported, although it is possibly more prevalent than is recognised. We report this case in order to highlight the importance of recognising this condition in non oriental populations and to demonstrate that non operative treatment has a good prognosis.

Orthopaedic Proceedings, Aug 1, 2008

Introduction: Scheuermann’s disease is defined as thoracic kyphosis greater than 45° with greater... more Introduction: Scheuermann’s disease is defined as thoracic kyphosis greater than 45° with greater than 5° of anterior wedging in 3 consecutive vertebrae. We describe a new technique for the surgical treatment of thoracic kyphosis due to Scheuermann’s disease. Eleven patients were treated in our series. Results: The average preoperative kyphotic angle was 83.3 degrees (58 – 94 degrees). Multiple posterior closing wedge osteotomy was performed and four rods (two proximal and two distal) were contoured and fixed to pedicle screws and the deformity reduced by the cantilever technique. The average postoperative kyphotic angle was 41.1 degrees (range 25–54 degrees) giving an average correction of 42.2 degrees per patient. The average postop lumbar angle was 51.8 degrees (range 20–70 degrees). The average follow up time was 25.3 months (range 6–60 months). At follow up the kyphotic angle was found to be 42.8 degrees average (range 24–55 degrees) and the lumbar angle was 57.6 degrees average (range 42–70 degrees). This technique is superior as it avoids sudden stretching of the anterior vasculature and possible rupture of the anterior longitudinal ligament (ALL) and provides correction at multiple levels, avoiding build-up of stress at any single level. Conclusion: We find this technique simple and effective in reducing curves of high magnitude and the reduction was maintained in the long term. Our complication rate was comparable to that quoted in literature.

Scandinavian Journal of Urology and Nephrology, 2005

Urinary retention due to obstruction is a common presenting symptom of carcinoma of the prostate.... more Urinary retention due to obstruction is a common presenting symptom of carcinoma of the prostate. We report the first case in which non-obstructive urinary retention was the presenting symptom in a middle-aged patient with undiagnosed prostate cancer which had metastasized to the spine and caused cord compression.

Acta Orthopaedica Belgica, Apr 1, 2009

The Spine Journal, May 1, 2007

Further evidence of the importance of segmental vessel ligation in the development of neurologica... more Further evidence of the importance of segmental vessel ligation in the development of neurological complications has been recently published. The more levels the ligation encompasses, the higher the risk of spinal cord damage. Therefore, caution should be taken when several segmental arteries are to be ligated in the clinical setting. To prevent ligation of segmental vessels during convex growth arrest surgery and thus decrease the risk of spinal cord ischemia and neurological injury. A report of a modified technique of convex growth arrest surgery used in two consecutive patients in our unit. In two consecutive patients the segmental vessels were mobilized, elevated, and protected by using surgical slings. The rib graft was then slid beneath the elevated vessels into the prepared vertebral body channel and punched into place. The pleura then closed over the rib graft and spared vessels. Three of the five segmental vessels in the first patient were spared. All five segmental vessels were spared in the second patient. No neurological complications occurred. We report a straightforward technique, which obviates the need for segmental vessel ligation, and therefore decreases the risk of neurological injury in an already high-risk group.

Injury-international Journal of The Care of The Injured, Apr 1, 2005

Methicillin resistance to Staphylococcus aureus is an established cause of hospital infection wor... more Methicillin resistance to Staphylococcus aureus is an established cause of hospital infection worldwide, 1,2 and is increasingly seen in the immunocompromised in the community. Ilio-psoas abscess are rarely encountered pyogenic infections in the immunocompetent with an annual worldwide incidence estimated to be around twelve cases per year. 3 We report the first case of spontaneous, incidentally discovered ileo-psoas and disc abscesses caused by methicillin-resistant Staphylococcus aureus (MRSA) in a patient not immunocompromised or with any other predisposing causes. He was not septic, presenting with back pain and immobility after a fall, and was presumed to have a fracture. This case reinforces the need to explore all diagnostic possibilities and not to assume that all problems after falling are from fractures.

Global Spine Journal, Mar 27, 2020

Study Design: Systemic review and meta-analysis. Objectives: Several studies have reported the im... more Study Design: Systemic review and meta-analysis. Objectives: Several studies have reported the impact of accidental dural tears (DT) on the outcome of spinal surgery, some with conflicting results. Therefore, the aim of this study was to carry out a systemic review and meta-analysis of the literature to establish the overall clinical outcome of spinal surgery following accidental DT. Method: A systemic literature search was carried out. Postoperative improvement in Oswestry Disability Index (ODI), Short-Form 36 survey (SF36), leg pain visual analogue scale (VAS), and back pain VAS were compared between patients with and without DT at different time intervals. Results: Eleven studies were included in this meta-analysis. There was a slightly better improvement in ODI and leg VAS score (standardized mean difference of À0.06, 95% confidence interval [CI] À0.12 to À0.01, and À0.06, 95% CI À0.09 to À0.02, respectively) in patients without DT at 12 months postsurgery, but this effect was not demonstrated at any other time intervals up to 4 years. There were no differences in the overall SF36 (function) score at any time interval or back pain VAS at 12 months. Conclusion: Based on this study, accidental DT did not have an overall significant adverse impact on the short-term clinical outcome of spinal surgery. More studies are needed to address the long-term impact and other outcome measures including other immediate complications of DT.

The Spine Journal, Dec 1, 2011

BACKGROUND CONTEXT: Lumbar spondylolysis is a well-recognized condition occurring in adolescents ... more BACKGROUND CONTEXT: Lumbar spondylolysis is a well-recognized condition occurring in adolescents because of repetitive overuse in sports. Multiple-level spondylolysis involving consecutive lower lumbar segments are rare. Several authors have reported failure of conservative treatment in the management of multiple-level pars fractures. STUDY DESIGN: A case report and review of previous literature is presented. OBJECTIVE: The objectives of this case report were to present a rare case of pars fracture involving nonconsecutive segments and discuss image findings and treatment. METHODS: The patent's history, clinical examination, computed tomography (CT), magnetic resonance imaging (MRI) findings, and treatment are reported. We also discuss the pathogenesis, various treatment options, and review the literature. RESULTS: We present the fourth case of bilateral pars fractures involving nonconsecutive lower lumbar spine segments of L3 and L5, in a 16-year-old young adolescent footballer who presented with 4-month history of constant low back pain. After 1 year of conservative management, the more acute fractures at L3 showed complete bony union, symptomatic pain relief, and return to full sporting activity. CONCLUSION: We report a rare case of bilateral pars fractures involving nonconsecutive segments. Multiplane reconstruction of CT images and MRI are very useful in planning treatment and follow-up. Conservative management may be used to treat multilevel nonconsecutive pars fractures.

Journal of the Neurological Sciences, 2009

Background: MEP is the most appropriate technique to assess the functional integrity of the whole... more Background: MEP is the most appropriate technique to assess the functional integrity of the whole motor pathway, particularly during scoliosis surgery. Objectives: The object of this prospective study is to assess the impact of preoperative clinical, electrophysiological (EMG, NCV, SSEPs) studies and intra-operative recording of MEPs using multi-pulse transcranial electrical stimulation on the outcome of 15 operations adolescent idiopathic scoliosis. Methods: The selected 15 cases had diverse grades of scoliosis severity according to Lenke classification of adolescent idiopathic scoliosis (AIS). All patients were under the age of 18 years old (14.3±2.46), 10 females and 5 males. Preoperative clinical, routine laboratory, electrophysiological studies and intra-operative recording were done for all patients who met all study criteria. Post-operative and electrophysiological assessments were carried out for all cases. Patients with a history of epilepsy or skull fracture were excluded. Results: Post-operative follow up for all cases was continued for 6-month and revealed nonexistence of new motor deficits either clinically or electro-physiologically. This is owing to that the cases had normal preoperative studies (n=15) as well as intraopaerative MEPs. Apart from considerable intra-operative transient MEP changes in two patients, no new EPs or clinical deficits were documented. Regarding post-operative SSEP, it remained unaltered and even it demonstrated better recovery in 7 patients, on top no complications were raised. Conclusion: All patients who had reproducible MEPs (100%) during the whole surgery procedures via APB, ADM, AH and TA recordings had had excellent clinical and electrophysiological outcomes.

Orthopaedics and Trauma, Oct 1, 2016

Thoracic and thoracolumbar fractures range from low impact osteoporotic compression injuries to h... more Thoracic and thoracolumbar fractures range from low impact osteoporotic compression injuries to high-energy fracture/dislocations with spinal cord injury. Assessment can be broadly divided into two sections. Primary assessment should follow the principles of Advanced Trauma Life Support. The secondary assessment should relate to the spinal fracture itself. In determining the optimal treatment, the stability of the injury must be assessed by following a complete clinical and radiographic evaluation. The thoracolumbar junction (T10eL2) is a transitional region between the rigid thoracic spine and the more flexible lumbar spine and hence is susceptible to injury. The thoracic spine (T1eT9) is relatively protected area, due to the rib cage; when injuries do occur they commonly involve visceral and spinal cord injury. Many classifications exist, however the AO and Thoracolumbar Injury Classification and Severity (TLICS) systems are the most clinically useful. Although they are based on thoracolumbar injuries they are commonly extended to thoracic fractures. The majority of fractures can be managed non-operatively with early mobilization and bracing. Surgical stabilization is indicated in unstable fractures. Posterior stabilization with pedicle screws is the most widely used technique; simultaneous decompression can also be achieved with this approach. Anterior surgery has biomechanical advantages and has been shown to be equally effective.

Orthopaedics and Trauma, Dec 1, 2017

Adolescent idiopathic scoliosis is the most common type of spinal deformity seen in the paediatri... more Adolescent idiopathic scoliosis is the most common type of spinal deformity seen in the paediatric population. The deformity affects otherwise normal functioning teenagers with no underlying pathological condition, no neurological abnormalities and normal imaging of the neuraxis. It produces a cosmetic deformity occasionally associated with muscular back pain and respiratory compromise in severe degrees of deformity. The aetiology is likely multifactorial and the risk of curve progression depends on the age of the patient at initial presentation, amount of remaining spinal growth and initial size of the curvature. Patients should be assessed with a thorough clinical evaluation including radiographic and often magnetic resonance imaging. Observation is recommended in growing patients with small curves up to 20e25. Bracing can stop or slow down curve progression in growing patients with curves up to 40. Surgical treatment is indicated in the presence of a severe deformity which is producing pain or pulmonary symptoms and is associated with cosmetic dissatisfaction. Most commonly this is performed through a posterior spinal fusion with the use of instrumentation and bone graft. The aim of the surgery is to stabilize the spine, correct the deformity and prevent deterioration. This has to be performed safely minimizing the risks of neurological/vascular/visceral injury, infection or non-union with instrumentation failure.

International Sportmed Journal, 2007

Spinning exercise cycle machines are becoming increasingly popular. They provide the health benef... more Spinning exercise cycle machines are becoming increasingly popular. They provide the health benefits of cycling without the injury risks of road usage. This is the report of a unique case of cervical spine fracture sustained whilst exercising in a gym on a stationary Spinning® bike.

Orthopaedic Proceedings, Feb 21, 2018

The current trend in kyphosis correction is for “every level” instrumentation to achieve intraope... more The current trend in kyphosis correction is for “every level” instrumentation to achieve intraoperative stability, correction, fusion and implant longevity. We evaluate the medium term follow up of a low implant density (LID) construct. All patients with adolescent kyphosis (idiopathic or Scheurmann9s) on our deformity database were identified. Radiographs and records were analysed for neurological complications, correction and revision. The constructs included were all pedicle screw anchors with multiple apical chevron osteotomies and a proximal and distal “box” of 6 to 8 screws. A four rod cantilever reduction manoeuvre with side to side connectors completed the construct. Kyphosis for any other cause was excluded. Follow up less than 12 months was excluded. 23 patients were identified with an average follow up 27 months (72 to 12 months) and a mean implant density of 1.1 (53.5% of “available” pedicles instrumented). There was 1 false positive neurophysiological event without sequelae (4%). There were no proximal junctional failures (0%). There were no pseudarthroses or rod breakages (0%). There was 1 loss of distal rod capture (early set screw failure) (4%). This was revised uneventfully. There were 4 infections requiring debridement (early series). Average initial correction was 44% (77.7 degrees to 43.5 degrees) with a 1% loss of correction at final follow up (43.5 to 44.0 degrees). The fulcrum bending correction index was 107% (based on fulcrum extension radiographs). 85% of curves had a fulcrum flexibility of less than 50%. The average cost saving compared to “every level “instrumentation was £5700 per case. This paper shows that a LID construct for kyphosis has technical outcomes as good as high density constructs. The obvious limitation of the study is the small number of patients in the cohort. The infection rates have improved with changes to perioperative process in the later series of patients. We do not believe these are a consequence of the construct itself.

Orthopaedic Proceedings, Aug 1, 2008

The use of blood transfusion in elective spinal surgery still remains a topic of debate in spite ... more The use of blood transfusion in elective spinal surgery still remains a topic of debate in spite of several guidelines on transfusion in orthopaedic surgery. We report on a study done to look at the transfusion practice in 64 patients who underwent scoliosis correction surgery in our institution. There were 16 males and 48 females, with an average age of 19.8 years (range 3–70 years). There were 50 patients with idiopathic scoliosis, seven with degenerative scoliosis, five with neuromuscular scoliosis, and one each of congenital and neurologic scolioses. 31 of the patients underwent posterior correction and 13 patients underwent anterior surgery and 11 patients underwent posterior surgery with costoplasty and 5 patients underwent front and back surgery while 4 patients had front and back surgery with costoplasty. 10 patients underwent iliac crest bone grafting. The mean preop haemoglobin was 13.1 g % (range11.3–16.2 g %) and the mean postop haemoglobin was 8.9 g % (5–14.9 g %). The average amount of intraoperative fluids infused was 4100 ml (range: 300–11000 ml). The mean blood loss was 803.3 ml (range: 300–1800 ml). Sixteen patients were transfused in all requiring 32 units of blood, with an average of 2 units per patient. The average duration of hospital stay was 10.1 days (5–45 days). The mean blood loss through drains was 396 ml (10–2000 ml).

Introduction: Scheuermann9s kyphosis is a fixed round back deformity characterised by wedged vert... more Introduction: Scheuermann9s kyphosis is a fixed round back deformity characterised by wedged vertebrae seen on radiograph. It is known patients presented with a negative sagittal balance before operation. Few studies investigated the outcome after operation, especially the change in the lumbar hyperlordosis. Aim: To investigate the change in sagittal profile after correction surgery. Method: This is a retrospective review of cases from 2001 to 2012. Our centre uses a posterior, four rod cantilever reduction technique for all Scheuermann9s Kyphosis correction. 36 cases are identified. They include 24 males and 12 females with an average age of 20 and follow up of 27 months. First 8 cases used the stainless steel hybrid implants. The remaining 28 had titanium all pedicle screw system. All had intra-operative spinal cord monitoring. Results: The target of thoracic kyphosis correction is around the accepted upper end of normal limit (40°). The average thoracic kyphosis Cobb angle was 78.5°. The immediate post-op angle was 43.2° and at final follow up, 43.6°. The average lumbar lordosis changed from 65.7° pre-op to 48.8° post-op, which is now bigger than the thoracic kyphosis. The result is the transfer of average sagittal balance (C7 plumb line) from −2.2 cm to −3.5 cm, which remains posterior to the posterior corner of S1 after the surgery. Discussion: Surgery can improve the roundback deformity but not the overall sagittal profile. We have no explanation to this phenomenon. This could imply the pathology of Scheuermann9s Kyphosis involves the whole spine, not just the wedging thoracic segment. Conflict Of Interest Statement: No conflict of interest.

Orthopaedic Proceedings, Mar 1, 2006

Objective: To describe the prevalence and incidence of methicillin resistant Staphylococcus aureu... more Objective: To describe the prevalence and incidence of methicillin resistant Staphylococcus aureus (MRSA) colonisation in patients in the Trauma and Orthopaedic wards of the University Hospital of North Staffordshire. Design Prospective audit. Patients and methods: Over a three month period from 1st March to 31st May 2003 359 patients attending the elective orthopaedic outpatient department for major joint surgery were screened at the pre-operative assessment clinic; 105 of these patients were screened again on the elective orthopaedic wards. 197 patients were screened on the trauma wards. 31 patients of other/outlying specialities were screened. Patients whose stay was expected to be for 48 hours or more were included in the audit. Patients were screened for MRSA colonization on admission, transfer and discharge. Colonised patients were treated according to the local infection control policy. Results: 31 elective orthopaedic patients (29%); 46 trauma patients (23%) and 8 other/outlying patients (26%) were colonized with MRSA. On admission, 23 elective orthopaedic patients (22%), 32 trauma patients (16%), and 7 patients (23%) which were of other/outlying specialties were colonized with MRSA. 22 patients (6.6%) positive on admission, treated with eradication therapy, became negative on discharge. An additional 22 patients (6.6%) positive on admission became negative on discharge without receiving any treatment. During the audit period, 23 patients (6.9%) were negative for MRSA on admission and positive on discharge. 9 patients (39%) and 20 patients (62.5%) colonised in elective and trauma wards respectively, developed an MRSA infection, which required treatment. Conclusion: There is a relatively high prevalence of MRSA colonisation in patients admitted to orthopaedic and trauma wards. A proportion (22%) of patients are colonised with MRSA in the short time between testing and admission. Not all patients positive for MRSA following admission to hospital will have been colonised within the nosocomial environment.

Orthopaedic Proceedings, Jul 1, 2010

Purpose of Study: To observe the efficiency of the combined motor-somatosensory monitoring and so... more Purpose of Study: To observe the efficiency of the combined motor-somatosensory monitoring and somatosensory-alone monitoring to identify the intra-operative neurologic changes. Methods and Results: We retrospectively assessed 123 cases in our centre, who had complete neurophysiological report while undergoing corrective spinal deformity surgery with spinal monitoring, from 2004 to 2008. Combined motor-somatosensory, somatosensory-alone and motor-alone monitoring were applied in sixty five, fifty and eight operations, respectively. We also looked at the factors that could potentially affect the neuro-physiologic monitoring, such as preoperative neurological status, anaesthetic method, blood loss, competency level of the monitoring team and the reaction of the surgical team to a significant monitoring event. In total, there were only two cases of true positive event, defined as a significant intraoperative event and postoperative neurological deficit. Both of these cases had combined monitoring during their procedures. No case of false negative was observed. There were also five cases with a significant intraoperative event without post operative neurologic sequel (false positive). Four of these had combined monitoring, with complete normal sensory monitoring and abnormal motor monitoring, which prompted the operating team to the appropriate action. Conclusion: Based on this observation, it is felt that the combined monitoring during spinal deformity correction procedures is superior to the sensory-alone monitoring for identifying the impending neurologic deficits. This is in accordance with the previous reports and recommendations.

Orthopaedic Proceedings, Sep 1, 2005

Study Design : An analysis of patients admitted with cervical trauma, comparing: those managed wi... more Study Design : An analysis of patients admitted with cervical trauma, comparing: those managed with rigid collars until definitive management; rigid collar usage overnight; and no rigid collar usage from outset. Objectives: To determine the safety of omitting a rigid collar following cervical trauma, whilst awaiting definitive management. Summary of Background Data: The use of a rigid collar can result in pain, occipital sores, as well as raised intracranial pressure in head injured patients. Subjects : Fifty one patients with proven cervical fractures were analysed. Three groups of patients were identified with respect to their initial management after admission to the ward until definitive management: 1) Hard collar, sandbags and bed rest 2) Hard collar in situ overnight and then sandbags and bed rest. 3) Sandbags and bed rest. All patients had full spinal care and precautions, with rigid collars used for any transfers. The spectrum of injury severity was similar throughout all 3 groups. Outcome measures : Loss of alignment, neurological compromise and complications related to the rigid collar. Results: There was no loss of reduction or progression of neurological deficit in any group. There were compliance issues in the rigid collar group. Two patients developed occipital skin problems following rigid collar use. All groups proceeded to definitive management successfully. Conclusion: No significant adverse events were noted in any group. Management without a rigid collar depends on good nursing care. It is more comfortable for the patient and avoids the potential problems encountered with rigid collar use. In compliant patients not requiring immediate definitive management the omission of the rigid collar did not result in loss of reduction or neurological compromise. We feel such collars should be for transport and extrication only.

Orthopaedic Proceedings, May 1, 2006

Objective: To report a case of non-obstructive urinary retention secondary to cord compression du... more Objective: To report a case of non-obstructive urinary retention secondary to cord compression due to metastases from undiagnosed carcinoma of prostate in a middle aged patient. This is the first case to be reported of its kind. Case Report: A 58-year old brick layer, presented with urinary retention with overflow incontinence was referred by GP to A&E. No obstruction was felt during catheterisation and residual urine of 1.2 litres was drained. He also had dull low back pain since 5–6 weeks that was relieved by simple analgesia and he was able to work normally. He had no other symptoms or significant past medical history. Clinical examination including digital rectal examination (DRE) was normal. Laboratory investigations were normal except a rise in Alkaline phosphatase(194U/L) and ESR (43 mm/hr). X-rays of his spine were normal. MRI scan of the spine showed multiple metastatic lesions, bilateral end plate fractures and loss of vertebral body height of D12 with bulging of posterior vertebral body wall causing extradural compression of the conus. An urgent D12 decompression and biopsy of D12 was done with D10-L2 instrumentation. PSA levels were >500ng/ml.Histopathology showed moderately to poorly differentiated adenocarcinoma with a cribriform pattern. Immunohistochemistry showed a strong staining for PSA consistent with metastatic adenocarcinoma of the prostate. Post-operatively, he regained bladder control and was referred to oncologists for further management. Conclusion: Urinary retention may be the only presenting symptom of spinal cord compression due to metastasis from prostate cancer. High index of suspicion of prostate cancer in middle-aged and elderly male patients with urinary retention, especially when associated with back pain of any severity, even though prostate is normal on DRE is needed. PSA in patients complaining of low back pain who are at high risk for prostate cancer is recommended, even though DRE is normal.

Orthopaedic Proceedings, Aug 1, 2008

Ossification of the posterior longitudinal ligament (OPLL) is a condition found predominantly in ... more Ossification of the posterior longitudinal ligament (OPLL) is a condition found predominantly in the oriental population and is rarely seen in non orientals. OPLL can present with cervical canal stenosis and myelopathy (including central cord syndrome), often following minor trauma. Co-existence of OPLL with diffuse idiopathic skeletal hyperostosis (DISH) is a rare condition and very few reports of such patients exist in literature. Here we report the case of a Caucasian with co-existing DISH and OPLL, presenting with acute central cord syndrome associated with fracture of the ossification. A 64 year old Caucasian farmer was transferred to our spinal unit with weakness in the right upper limb following a road traffic accident. On examination he had hyperaesthesia in both upper limbs and motor power of grade 4 in the right upper limb with a distal motor power of grade 3 in the hand. There was no motor deficit in the left upper limb or lower limbs. Radiographs revealed an ossification of the posterior longitudinal ligament with a break at C2 and C3 levels. He also had exuberant soft tissue ossification in the cervical and thoracic spines, suggestive of diffuse idiopathic skeletal hyperostosis (DISH). He recovered completely in 6 weeks with non operative treatment. Fracture of the posterior longitudinal ligament has not been widely reported, although it is possibly more prevalent than is recognised. We report this case in order to highlight the importance of recognising this condition in non oriental populations and to demonstrate that non operative treatment has a good prognosis.

Orthopaedic Proceedings, Aug 1, 2008

Introduction: Scheuermann’s disease is defined as thoracic kyphosis greater than 45° with greater... more Introduction: Scheuermann’s disease is defined as thoracic kyphosis greater than 45° with greater than 5° of anterior wedging in 3 consecutive vertebrae. We describe a new technique for the surgical treatment of thoracic kyphosis due to Scheuermann’s disease. Eleven patients were treated in our series. Results: The average preoperative kyphotic angle was 83.3 degrees (58 – 94 degrees). Multiple posterior closing wedge osteotomy was performed and four rods (two proximal and two distal) were contoured and fixed to pedicle screws and the deformity reduced by the cantilever technique. The average postoperative kyphotic angle was 41.1 degrees (range 25–54 degrees) giving an average correction of 42.2 degrees per patient. The average postop lumbar angle was 51.8 degrees (range 20–70 degrees). The average follow up time was 25.3 months (range 6–60 months). At follow up the kyphotic angle was found to be 42.8 degrees average (range 24–55 degrees) and the lumbar angle was 57.6 degrees average (range 42–70 degrees). This technique is superior as it avoids sudden stretching of the anterior vasculature and possible rupture of the anterior longitudinal ligament (ALL) and provides correction at multiple levels, avoiding build-up of stress at any single level. Conclusion: We find this technique simple and effective in reducing curves of high magnitude and the reduction was maintained in the long term. Our complication rate was comparable to that quoted in literature.

Scandinavian Journal of Urology and Nephrology, 2005

Urinary retention due to obstruction is a common presenting symptom of carcinoma of the prostate.... more Urinary retention due to obstruction is a common presenting symptom of carcinoma of the prostate. We report the first case in which non-obstructive urinary retention was the presenting symptom in a middle-aged patient with undiagnosed prostate cancer which had metastasized to the spine and caused cord compression.

Acta Orthopaedica Belgica, Apr 1, 2009

The Spine Journal, May 1, 2007

Further evidence of the importance of segmental vessel ligation in the development of neurologica... more Further evidence of the importance of segmental vessel ligation in the development of neurological complications has been recently published. The more levels the ligation encompasses, the higher the risk of spinal cord damage. Therefore, caution should be taken when several segmental arteries are to be ligated in the clinical setting. To prevent ligation of segmental vessels during convex growth arrest surgery and thus decrease the risk of spinal cord ischemia and neurological injury. A report of a modified technique of convex growth arrest surgery used in two consecutive patients in our unit. In two consecutive patients the segmental vessels were mobilized, elevated, and protected by using surgical slings. The rib graft was then slid beneath the elevated vessels into the prepared vertebral body channel and punched into place. The pleura then closed over the rib graft and spared vessels. Three of the five segmental vessels in the first patient were spared. All five segmental vessels were spared in the second patient. No neurological complications occurred. We report a straightforward technique, which obviates the need for segmental vessel ligation, and therefore decreases the risk of neurological injury in an already high-risk group.

Injury-international Journal of The Care of The Injured, Apr 1, 2005

Methicillin resistance to Staphylococcus aureus is an established cause of hospital infection wor... more Methicillin resistance to Staphylococcus aureus is an established cause of hospital infection worldwide, 1,2 and is increasingly seen in the immunocompromised in the community. Ilio-psoas abscess are rarely encountered pyogenic infections in the immunocompetent with an annual worldwide incidence estimated to be around twelve cases per year. 3 We report the first case of spontaneous, incidentally discovered ileo-psoas and disc abscesses caused by methicillin-resistant Staphylococcus aureus (MRSA) in a patient not immunocompromised or with any other predisposing causes. He was not septic, presenting with back pain and immobility after a fall, and was presumed to have a fracture. This case reinforces the need to explore all diagnostic possibilities and not to assume that all problems after falling are from fractures.

Global Spine Journal, Mar 27, 2020

Study Design: Systemic review and meta-analysis. Objectives: Several studies have reported the im... more Study Design: Systemic review and meta-analysis. Objectives: Several studies have reported the impact of accidental dural tears (DT) on the outcome of spinal surgery, some with conflicting results. Therefore, the aim of this study was to carry out a systemic review and meta-analysis of the literature to establish the overall clinical outcome of spinal surgery following accidental DT. Method: A systemic literature search was carried out. Postoperative improvement in Oswestry Disability Index (ODI), Short-Form 36 survey (SF36), leg pain visual analogue scale (VAS), and back pain VAS were compared between patients with and without DT at different time intervals. Results: Eleven studies were included in this meta-analysis. There was a slightly better improvement in ODI and leg VAS score (standardized mean difference of À0.06, 95% confidence interval [CI] À0.12 to À0.01, and À0.06, 95% CI À0.09 to À0.02, respectively) in patients without DT at 12 months postsurgery, but this effect was not demonstrated at any other time intervals up to 4 years. There were no differences in the overall SF36 (function) score at any time interval or back pain VAS at 12 months. Conclusion: Based on this study, accidental DT did not have an overall significant adverse impact on the short-term clinical outcome of spinal surgery. More studies are needed to address the long-term impact and other outcome measures including other immediate complications of DT.

The Spine Journal, Dec 1, 2011

BACKGROUND CONTEXT: Lumbar spondylolysis is a well-recognized condition occurring in adolescents ... more BACKGROUND CONTEXT: Lumbar spondylolysis is a well-recognized condition occurring in adolescents because of repetitive overuse in sports. Multiple-level spondylolysis involving consecutive lower lumbar segments are rare. Several authors have reported failure of conservative treatment in the management of multiple-level pars fractures. STUDY DESIGN: A case report and review of previous literature is presented. OBJECTIVE: The objectives of this case report were to present a rare case of pars fracture involving nonconsecutive segments and discuss image findings and treatment. METHODS: The patent's history, clinical examination, computed tomography (CT), magnetic resonance imaging (MRI) findings, and treatment are reported. We also discuss the pathogenesis, various treatment options, and review the literature. RESULTS: We present the fourth case of bilateral pars fractures involving nonconsecutive lower lumbar spine segments of L3 and L5, in a 16-year-old young adolescent footballer who presented with 4-month history of constant low back pain. After 1 year of conservative management, the more acute fractures at L3 showed complete bony union, symptomatic pain relief, and return to full sporting activity. CONCLUSION: We report a rare case of bilateral pars fractures involving nonconsecutive segments. Multiplane reconstruction of CT images and MRI are very useful in planning treatment and follow-up. Conservative management may be used to treat multilevel nonconsecutive pars fractures.