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The authors reviewed 111 patients with neuromuscular disease who underwent anterior spine surgery for correction of scoliosis. An overall complication rate of 44.1% was found, 21.6% major and 22.5% minor. Pulmonary complications were the most common major complications, urinary tract infections the most common minor complications. The rate of complications was greater in patients with cerebral palsy, thoracoabdominal and transthoracic approaches, staged procedures, operative blood loss >1,000 mL, or previous spine surgery. In addition, statistical analysis confirmed that curve magnitude >100 degrees degrees was a risk factor for complications.

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The evaluation and management of acute spondylolysis remains unclear in part because of outcome data that are primarily subjective. The aim of this study was to evaluate and monitor these patients objectively using quantitative single-photon emission computed tomography (SPECT). Thirty-four patients were so observed clinically between 1987 and 1996 and were studied with an initial and at least one follow-up SPECT scintigram. Initial radiographs and planar bone scans failed to demonstrate the pars lesion in 53 and 19% of the patients, respectively. The average SPECT ratio before brace treatment was 1.45. After treatment, this ratio significantly decreased to 1.27 (p = 0.03). A subset of patients remained symptomatic at follow-up. Their reduction in SPECT ratio averaged only 2.8% as compared with 13% for the remainder of the patients (p = 0.01). Patients diagnosed and braced in the early, more active stage of the condition (with greater intensity on SPECT) had more predictable symptom relief. An initial SPECT ratio of >1.5 was associated with complete symptom resolution after brace treatment. Patients treated with activity restriction only (>3 months) before bracing were more likely to have persistent symptoms and more modest improvement on SPECT (p = 0.01). These data, which use SPECT scintigraphy, support prompt treatment with brace immobilization for acute spondylolysis in children and adolescents.

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We performed a retrospective review of 41 patients (ages 9-18 years) who underwent posterior spinal fusion with either Isola or Cotrel-Dubousset (CD) instrumentation to determine whether the presence of an apical hook on the thoracic convexity affected initial and long-term sagittal and coronal correction in adolescent idiopathic scoliosis surgery. A study group of 38 female and three male patients was evaluated (2-5 years of follow-up). Twenty-three patients (Group A) were treated with an up-going hook at the convex apex of the thoracic curve, and 18 patients (Group B) with similar curves were instrumented without an apical hook. Results showed that Group A's average preoperative coronal curve of 48 degrees decreased to 17 degrees , whereas Group B's preoperative average of 52 degrees decreased to 25 degrees . At follow-up, no statistical significance was noted in either coronal curve correction (p = 0.203) or sagittal kyphosis (p = 0.38) between Groups A and B. We conclude that omission of the up-going hook at the apex of the thoracic convexity can reduce postoperative discomfort in patients undergoing posterior spinal fusion, without sacrificing curve correction or balance.

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Monitoring of electrophysiologic function during intrapedicular fixation of the lumbosacral spine can be useful because this fixation technique has been associated with a significant number of postoperative radicular complications. Somatosensory evoked potentials (SEPs) traditionally have been used to monitor neurologic function during spinal instrumentation procedures. A case is presented of an intrapedicular fixation procedure that was monitored with SEPs and that resulted in false-negative SEP findings. This result suggests that SEPs may not be a sensitive enough monitoring tool for detecting compromise of single root function, and as a result, other monitoring techniques should be used. Dermatomal somatosensory evoked potentials (DSEPs) have been reported to be useful in this regard. To test their usefulness, 81 lumbosacral intrapedicular fixation procedures were monitored with DSEPs. Repeatable responses were obtained from all but one of the patients. The responses were sensitive to the compromise of root function. Predictions of postoperative outcome were dependent only on the responses at closing and not on changes that occurred during surgery.

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OBJECTIVE: Most studies evaluating the anterior cruciate ligament have focused on sagittal MR images for the diagnosis of injury. Limitations of sagittal images have been reported, however, including nonvisualization and incomplete visualization of the ligament. This study was undertaken to assess the value of adding coronal and axial MR images to sagittal images in the evaluation of the anterior cruciate ligament. MATERIALS AND METHODS: We reviewed oblique sagittal T1-weighted, coronal T2-weighted, and axial T2-weighted images to determine the status of the anterior cruciate ligament in 325 patients. All patients had arthroscopy. Sagittal images were initially interpreted alone and then in combination with coronal and axial images. RESULTS: Sagittal T1-weighted images alone had a 94% sensitivity and an 84% specificity for determining the status of the anterior cruciate ligament. A multiplanar evaluation of the anterior cruciate ligament resulted in a change in MR interpretation in 21 patients (6%), which led to an improved sensitivity of 98% and a specificity of 93%. Diagnostic confidence was improved in an additional 14 patients (4%). CONCLUSION: Our results show that the efficacy of MR imaging for the detection of anterior cruciate ligament tears is greater when axial and coronal images are used in combination with sagittal images than when sagittal images are used alone.

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The anterior cruciate ligament (ACL) is an important stabilizer of knee motion. Injury of the ACL can lead to substantial disability; an accurate diagnosis of ACL injury is vital in both short-term and long-term patient care. Magnetic resonance (MR) imaging has emerged as the study of choice to evaluate the status of the ACL and other associated structures in the knee. Sagittal MR images have been commonly used in the evaluation of the ACL. However, the authors believe that coronal and axial imaging planes can add useful information about ACL injury and, thus, lead to improved accuracy and confidence regarding diagnosis. Multiplanar imaging can readily demonstrate meniscal, ligamentous, and bone marrow injuries that commonly occur with the most frequent mechanisms of ACL injury. These mechanisms, in order of frequency, include internal rotation and valgus stress, hyperextension, and varus stress with external rotation. An understanding of these mechanisms is helpful in the MR diagnosis of ACL injury.

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The progression of congenital lumbar kyphosis in myelomeningocele is a well-known problem, but rates of progression are not well documented in the literature. Fifty-one children with congenital kyphosis and myelomeningocele were followed for an average of 4.8 years. Minimum follow-up was 1 year. Group I (35 patients) had initial radiographs at 1 year of age or less. Group II (16 patients) had radiographs taken after the age of 1 year. Curves less than or equal to 90 degrees in Group I progressed 7.7 degrees/yr; those greater than 90 degrees progressed 12.1 degrees/yr. Curves less than or equal to 90 degrees and greater than 90 degrees progressed at similar rates, regardless of initial curve magnitude: 6.4 degrees/yr and 6.7 degrees/yr, respectively. No correlation existed among the rate of curve progression, the frequency of shunt revisions, or the presence of vertebral anomalies, aside from the dysraphism.

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Vascular lesions of the shoulder may be misinterpreted as one of the more familiar shoulder abnormalities by a treating physician. We are reporting on 13 athletes who were found to have symptoms related to compression of the subclavian or axillary artery or their tributaries. Nine were amateur or professional baseball pitchers. Severe arm fatigue or finger ischemia, secondary to embolization, were presenting symptoms. Arm fatigue was noted in all pitchers. After complete history and physical examination, including auscultation for bruits in functional positions, all athletes were evaluated by noninvasive tests (Doppler and Duplex scanning). Arteriography was performed with positional testing, recreating overhead activity, and complete radiographic visualization of the dye to the digital arteries. Two patients were found to have subclavian artery aneurysm. The remaining athletes were found to have compression of the subclavian artery beneath the anterior scalene muscle (five patients), the axillary artery beneath the pectoralis minor (two patients), both arterial segments (two patients), and one was found to have arterial compromise at the level of the humeral head. Branch artery compression was also noted. One pitcher occluded the posterior circumflex humeral artery with embolization to the digit. The two patients with subclavian aneurysms underwent saphenous vein bypass with cervical rib resection. All of the other athletes except one underwent resection of a 2 to 3 cm segment of the anterior scalene muscle or pectoralis minor muscles. All returned to their previous level of activity except one patient who developed impingement type symptoms and required acromioplasty. He is currently undergoing rehabilitation. Proper recognition of vascular compromise in the upper extremity of athletes is essential to avoid the catastropic complications of arterial thrombosis.

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Vascular lesions of the hand may be seen in athletes exposed to repetitive blunt trauma. Thirteen athletes seen from 1983 to 1988 experienced symptoms related to hand ischemia. Nine were professional baseball catchers. The majority of patients complained of chronic symptoms, including cold hypersensitivity (four patients), finger numbness (one), finger coolness (three), and finger blanching (three). Two patients had acute symptoms with sudden posttraumatic hand ischemia with finger and palmar pain. Diagnosis was established by history and physical examination and confirmed by noninvasive testing. Testing included use of Doppler examination and cold tolerance examination with thermistors. Two athletes required angiographic evaluation because of severe ischemia and continuous pain. All patients in this group were managed nonoperatively. Those with chronic complaints were counseled regarding cold avoidance and instructed to increase their glove padding. The two patients with acute symptoms required vasodilator (papaverine chloride) infusion, followed by intravenous heparin and dextran. All baseball catchers returned to their sport with dissipation of symptoms.

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Between 1983 and 1986, 23 athletes were evaluated for arm and hand complaints. Eleven players had symptoms of thoracic outlet compression. Severe arm fatigue (eight patients) and finger ischemia (three patients) were the presenting symptoms. In the remaining 12 athletes, symptoms of hand ischemia were predominant. Noninvasive testing with Doppler ultrasonography and duplex scanning (positional testing and finger systolic pressure recording) and cold immersion were used to aid in diagnosis. In the 11 athletes with thoracic outlet compression, arteriography confirmed the finding with compression of the subclavian artery in five, the axillary artery in one, both subclavian and axillary arteries in two, posterior humeral circumflex artery in one, and subclavian aneurysm in two. Compression of the suprascapular artery was identified in four, the subscapular artery in two, and the posterior humeral circumflex artery in one. Thrombosis of a first baseman's ulnar artery and occlusion of the palmar arch in a frisbee player were documented by arteriography. Decompression of the thoracic outlet consisted of anterior scalenectomy in five, pectoralis minor muscle division in one, and resection of both muscles in two. Removal of cervical rib with interposed vein graft was performed in the two players with arterial aneurysm. Hand ischemia in the remaining athletes was treated conservatively with Dextran-heparin infusion for acute ischemia. Repeat noninvasive study of all players demonstrated absence of compression in their playing position, and all have resumed their playing careers. Hand ischemia in athletes can be evaluated noninvasively and treated conservatively. Resection of hypertrophied muscles to decompress the thoracic outlet together with release of branch artery compression in selected athletes promotes perfusion to arm and shoulder muscles and helps to avoid the catastrophic complication of repetitive trauma leading to sudden arterial thrombosis.

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In a retrospective analysis of 62 adult scoliotic patients with an average age of 34 years, 39 patients were treated by single-stage posterior fusions, 19 by Harrington instrumentation, and 20 by Luque instrumentation. Twenty-three patients had staged scoliotic procedures. Overall there was a 47% incidence of complications, with the lowest rate, 20%, found in those patients undergoing single-stage posterior fusion with Luque instrumentation. A 16.7% incidence of pseudarthrosis was found in those patients undergoing posterior fusion with Harrington instrumentation. Pseudarthrosis was not found in patients fused posteriorly with Luque instrumentation or with staged anterior and posterior instrumentation.

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Radiological assessment of surgical fusion of fractures and dislocations of the cervical, thoracic, and lumbar spine are an integral part of management of spinal cord injury patients. A meaningful assessment of such fusions can be done properly only when there is adequate knowledge of the types of surgical fusions, the biological material used, and metallic devices applied. Early surgical reduction and internal fixation of the traumatized spine facilitate rapid restoration of spinal alignment, make nursing care less difficult, and sometimes lead toward improvement of neurological function. Complications can occur in all types of surgical fusions. They can affect the fusion material, the metallic device, or the alignment of the spine. Most of those complications are radiologically detected.

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Chymopapain has been approved for intradiscal injection in the United States and is expected to be used in approximately 100,000 patients per year. The need to identify the population at risk for anaphylaxis is obvious. Both in vivo and in vitro methods are available for measurement of IgE against chymopapain. This is a report of two cases of chymopapain allergy. One case discusses a 25-year-old woman who had rhinitis, asthma, and urticaria associated with occupational health hazards who was rejected for chemonucleolysis. The other case describes a 59-year-old man who had a predictably severe anaphylactic reaction to chymopapain and responded to treatment with epinephrine. Both patients had IgE antibody against chymopapain.

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In this study, the authors review the records of 63 graduates of Northwestern University Medical School who were residents in its graduate medical education programs of anesthesia and orthopedic surgery. They examine the relationship among college grades, medical school performance, and the results of assessment by annual, nationwide, medical specialty in-training examinations. For the anesthesia group, the best predictors of in-training examination performance were the Medical College Admission Test (MCAT) Verbal Ability score, the college grade-point average for nonscience subjects, and the MCAT Science, General Information, and Quantitative Ability scores. For the orthopedic group, the best predictors were the MCAT Verbal Ability score, the college grade-point average in nonscience subjects, the MCAT Science score, and the National Board of Medical Examiners Part I and Part II examination scores. The previous academic records for the 63 residents contained little to presage results in the in-training examination. The correlation obtained between nonscience college subjects and the in-training examination results was negative.

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A retrospective review of 206 consecutive thoracic and lumbar fusions revealed a variety of surgical procedures performed for instability and malalignment after severe trauma. Stabilization procedures included insertion of 103 Harrington distraction and 15 Harrington compression rods, 84 Weiss spings, six Luque rods, and 10 miscellaneous plates and wires as single or multiple devices in combination with anterior and/or posterior fusions. Complications of surgical fusion included nine unhooked rods, six fatigue fractures of rods and springs, five overdistractions of vertebrae, four cases of severe kyphosis, and two failures of reduction. A meaningful postoperative radiologic evaluation can be accomplished only when indications for surgical techniques, their radiologic appearance, and possible complications are known.

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The affective behavior of orthopedic residents may be the most important indicator of their ability to function as orthopedic surgeons. Seven years of personal observations were combined with the experience of more than 300 participants in the Basic Course for Orthopaedic Educators, and recorded from the results of a recent questionnaire answered by members of the Association of Orthopaedic Chairmen. The affective domain was found to supply the answers to most of the problems of orthopedic residents. An evaluation of affective behavior early in the residency program may help to determine residents' suitability for a career in orthopedic surgery.

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