Post-traumatic hematoma of the esophagus

A 20-year-old man was admitted after a traffic accident for a closed chest trauma. Initial evaluation showed a sternal fracture with a minor pneumomediastinum. Twenty-four hours later be experienced an acute respiratory failure, due to total left pulmonary atelectasis from indirect compression of the left main stem bronchus. Mediastinal widening at the postero-superior level was visualized by CT scan. The aortogram was normal. Thoracotomy showed a moderate left haemothorax, associated with an intramural haematoma of the low thoracic oesophagus which was respected. The time course was uneventful, except repetitive atelectases treated by fibrescopic aspiration. Oesophageal haematoma secondary to chest trauma is a rare injury, with around 10 cases reported in the literature. Compression of tracheobronchial axis is exceptional. Because of the delayed occurrence of such a complication after chest trauma, with sternal fracture, close clinical surveillance and CT scans are essential.     

Isolated middle lobe atelectasis: aetiology, pathogenesis, and treatment of the so-called middle lobe syndrome

Isolated atelectasis of the middle lobe has been known for many years as the "middle lobe syndrome". Several clinical studies have shown that it may bae caused by malignant tumours. A 10-year study of 135 patients with isolated middle lobe atelectasis is presented. Fifty-eight patients (43%) had malignant tumours. Of 38 who had a thoracotomy, lung resection was possible in 25. In 20 patients regional or systemic dissemination of the tumour had been diagnosed before operation. Seventy-seven patients had benign diseases, of which 74 were non-specific infections. Bronchography was performed in 46 of these cases, and all had abnormal findings in the middle lobe, eight revealing definite bronchiectasis. In three cases tuberculosis was found. In 16 cases the benign diagnosis was established at thoracotomy. Only three patients out of 58 with malignant tumours lived more than five years. Atelectasis of the middle lobe is always a sign of potential malignancy especially in patients with a previously normal chest radiograph.     

Scoliosis in Rett syndrome. Clinical and biological aspects

STUDY DESIGN: The natural history of progression of scoliosis was studied. The authors included a wide range of ages and correlated progression and progression rate to both age of the patient and the neurobiologic staging of the disease. OBJECTIVES: The authors studied information compiled by Hagberg and coworkers regarding Rett syndrome. The total number of patients was 78, with age ranging from 1 to 34 years. Standing or sitting anteroposterior roentgenograms were collected and measured. METHOD: The material was studied initially separately regarding orthopedic and radiologic analysis on one hand and neurobiologic staging on the other. Radiographic films were measured both retrospectively and prospectively, and scoliosis angle and progression and progression rate was calculated. Staging of patients with Rett syndrome was done according to Hagberg. RESULTS: When correlating curve magnitude and progression, the authors found that patients progressing > 15 degrees/year were classified as IV-A or IV-B stages. In the 0-5 year group, of the patients already having a curve of 15 degrees or more, all but one rapidly progressed to stage IV. The ten worst cases were characterized by early hypotonia, weakness, and gross motor disturbance. CONCLUSIONS: The scoliosis in Rett syndrome is of a neurogenic type, and it develops earlier than idiopathic scoliosis. The development of scoliosis is dependent more on stage of disease than on age. Curve progression is usually more rapid than in idiopathic scoliosis and in most other types of neurogenic scoliosis in childhood and occurs in a broader age span. Early hypotonia, weakness, and muscular insufficiency, and an early clinical referral to disease stages IV-A or IV-B are ominous factors. Clinical follow-up should begin early and be repeated regularly and frequently.     

Evidence for eosinophil activation in bronchiectasis unrelated to cystic fibrosis and bronchopulmonary aspergillosis: discrepancy between blood eosinophil counts and serum eosinophil cationic protein levels

The purpose of this prospective study was to evaluate the effect of prophylactic antibiotic treatment on postoperative antibiotic spinal wound infection after spinal surgery with instrumentation. Subjects consisted of 110 successive patients that underwent instrumented fusion with Cotrel-Dubousset (CD) or Miami Moss instrumentation. In 56 cases, the indication for surgery was painful spondylolisthesis. The remaining 54 patients were treated for idiopathic scoliosis. In total, 172 spinal procedures were performed and included in the study. Preoperative infection prophylaxis consisting of 2 g cefamandole was administered to all patients. Patients received three doses of 2 g/day cefamandole after surgery for 3 days. Follow-up ranged from 1 to 4 years. The study revealed an early infection in one (0.6%) of the 172 procedures in a patient with spondylolisthesis. A late infection occurred in one (0.6%) patient with the diagnosis of idiopathic scoliosis. In both cases, cultures were positive for Staphylococcus aureus.     

The benefits of school screening for scoliosis in the central part of The Netherlands

The Netherlands has well-organized school health services, and children are assessed on a regular basis for scoliosis among other disturbances and pathologies. The purpose of this study was to assess the benefits of an annual screening programme for scoliosis in the Netherlands. Three cohorts of 10,000 children sampled at 10, 12 and 14 years of age, respectively, were followed for 3 years. Children with a positive bending sign were referred to a second screening stage, in which external asymmetry was quantified. Children diagnosed via the programme (group 1) were compared with those children who had been referred for treatment independently of the screening (group 2). The total number of children in these groups combined was then compared with the number that would have been expected on the basis of accepted prevalence figures for idiopathic scoliosis given in current literature. Over 30,000 children were screened. Although the programme established a total of 57 cases of definite scoliosis (0.18%), the 34 cases (0.11%) already known, mainly detected by previous school health checks, were more severe regarding the risk of progression and treatment. The annual screening programme did not detect a single case that needed surgery. These figures provide the basis on which to decide for or against adopting an annual screening programme for scoliosis; the decision is a socio-political one. Based on this study, we expect all scoliotic patients needing treatment should be detected in time if periodic health checks will be maintained biennially. On medical grounds, it is our view, that screening for scoliosis should not be performed in the Netherlands annually.     

Review of 87 cases of scoliosis surgically treated

BACKGROUND: The authors compared the results and complications in surgical treatment of idiopathic scoliosis with Harrington's rod instrumentation with subtrasversal wires in dorsal treat. METHODS: A research on 87 cases operated on for idiopathic scoliosis from 1987 to 1995 is carried out. The 87 cases include 65 females and 25 males, 16 years old in average (range, 11 to 30). The curvature in Cobb's degrees and rotation of vertebrae with Raimondi's method on radiographs take just before, 15 days later and an year later on operation was measured. The patients have been divided into two groups: the first of 77 patients operated with Harrington's rod instrumentation; the second of 10 patients operated with Harrington's rod instrumentation and subtrasversal wires. RESULTS: In a general analysis without taking in to consideration the type and the seriousness of curvature it was obtained a better correction and derotation of vertebrae in patients of second group. The same group with wires had obtained a better correction and derotation of vertebrae in dorsal scoliosis from 40 degrees to 60 degrees and in the double scoliosis, while the first group obtained better results in dorsal scoliosis from 60 degrees to 80 degrees and in derotation of vertebrae on dorsal treat of double scoliosis. One case of pseudarthrosis in every group was observed. Any neurological complication were observed. CONCLUSIONS: The conclusions is drawn that the application of subtrasversal wire improves the Harrington's technique for the correction and derotation of dorsal and double scoliosis without neurological complications sometimes present with subliminar wires.     

Tracheobronchial injuries in blunt thoracic trauma

Tracheobronchial lesions after blunt chest injury are seldom (0,5-0,7%). Diagnostic and therapeutic strategies in 16 own cases and a review of the literature are presented. Own experiences: Locations of the lesions were main bronchus (10), bronchus intermedius (2), and trachea (4). Rupture was total in five cases, and partial in seven. In four patients the mucosa only was ruptured. Initial symptoms: Subcutaneous emphysema (13), pneumothorax (9), respiratory insufficiency (5), lung lesion (5), but tracheal bleeding in five cases only. Diagnosis mainly by bronchoscopy (8 early, 4 late), but in 4 cases after thoracotomy. Treatment: In cases of total rupture, there were three anastomoses of the bronchus and one of the trachea, and one pneumonectomy. In all partial ruptures, there was suturing of the lesion. Mucosa lesions were treated conservatively. RESULTS: 1 empyema, 2 ex. leth. (bilateral pneumonia 7.d., multiple organ failure 20. d). FOLLOW UP: 9 patients free of symptoms, 5 patients with respiratory problems. The symptoms "mediastinal emphysema and continuous air leakage through the chest tube or persistent atelectasis of the lung" are indications for urgent bronchoscopy and early surgery. Long-term results are good in 70%-90% of the cases. Not diagnosed lesions can result in tracheobronchial stenosis and infections of the lung later on, to be treated by lung resection only. Total bronchial ruptures can result in strictures and non-infected atelectasis, resection of the stricture and reinflation of the lung being successful in 60%-70% of these late diagnosed cases.     

Treatment of idiopathic scoliosis in children

This is an update on the surgical and orthopedic management of scoliosis in children. After a review of the biomechanical factors underlying the scoliotic deformity in the three dimensions, methods and indications of conservative treatment combining physiotherapy and full-time or part-time bracing are discussed. Development of new segmental spinal instrumentation devices has modified the surgical treatment of scoliosis by allowing three-dimensional correction of deformities and obviating the need for postoperative immobilization in a cast or corset. Results of conservative treatment are analyzed in an original series of 56 children with progressive scoliosis treated when the angulation was still under 30 degrees. Mean follow-up since the end of treatment is 14 years. Results show that proper conservative treatment arrests progression and modifies the natural history of scoliosis. Outcome after surgical treatment is analyzed in an original and recent series composed of the 50 first children who had posterior surgery with the new Cotrel-Dubousset instrumentation. Results of anterior surgery (V.D.S. instrumentation), which is still indicated in some cases, are analyzed in an older series of 18 cases. When the deformities are too severe to allow conservative treatment, short segment fusion effectively corrects the scoliosis and reliably provides good cosmetic and functional results.     

Hand dominance and scoliosis in Duchenne muscular dystrophy

Twenty-three patients with Duchenne muscular dystrophy and scoliosis were studied. In all but one patient the major convexity was to the side of the dominant hand. The unsupported growing spine is easily unbalanced by asymmetrical forces imposed on it. From our observations we believe major use of a single upper extremity will result in scoliosis with the major convexity toward the side of the dominant hand. Management should include counterbalancing the postural abnormality imposed by hand dominance as well as unloading the spine frequently during the patient's waking hours.     

Cut-off point of the Scoliometer in school scoliosis screening

STUDY DESIGN: A large-scale study on school screening for scoliosis was conducted to assess the referral rate, prevalence rate, and positive predictive value using different angles of trunk rotation as criteria for referral. OBJECTIVE: To determine an ideal angle of trunk rotation cut-off point to be used for referral in school screening for scoliosis. SUMMARY OF BACKGROUND DATA: When using the Scoliometer (Orthopedic Systems, Inc., Hayward, CA) in school scoliosis screening, 5 degrees and 7 degrees angles of trunk rotation have been recommended as criteria for referral. Low positive predictive values and over-referral at these levels have been reported. METHODS: The Adams forward bend test and Scoliometer measurement were combined for school scoliosis screening in 33,596 girls from the fifth, sixth and seventh grades. Nurses were the primary screeners. Girls with trunk rotation angles of 5 degrees or more were referred for radiography. RESULTS: The referral rate was 5.2%. By selecting 6 degrees, 7 degrees, 8 degrees, 9 degrees or 10 degrees angles of trunk rotation as criteria for referral, the referral rate became 2.4%, 1.4%, 0.7%, 0.5%, or 0.3%, respectively. The prevalence rate for scoliosis equal to or larger than 10 degrees, 20 degrees, 30 degrees, or 40 degrees of the Cobb angle was 1.47%, 0.21%, 0.04% and 0.02%, respectively, by using a 5 degrees angle of trunk rotation as the criterion for radiography. The positive predictive value was 28.3% for scoliosis of 10 degrees or more, 4% for scoliosis of 20 degrees or more, 0.8% for scoliosis of 30 degrees or more, and 0.4% for scoliosis of 40 degrees or more with a 5 degrees angle of trunk rotation as the criterion for referral. By selecting angles of trunk rotation larger than 5 degrees as criteria for referral for radiography, the positive predictive value increased, but positive cases with larger Cobb angles also decreased markedly. CONCLUSION: The optimal cut-off point for referral when using the Scoliometer in school screening of scoliosis is still difficult to determine.     

Natural history of scoliosis in spastic cerebral palsy

BACKGROUND: Although the frequent occurrence of scoliosis in patients who have spastic cerebral palsy is well known and surgical treatment has often been recommended for these patients, little is known about the natural history of scoliosis in this population. We aimed to clarify the natural history of scoliosis from childhood through to adulthood and provide objective data on proper surgical indications for such patients. METHODS: The participants were 37 institutionalised patients with severe spastic cerebral palsy and scoliosis. All the participants had a series of radiographs taken, starting at a mean age of 7.8 years; they were followed up for an average of 17.3 years. We retrospectively reviewed radiographs and assessed the effect of five factors on progression of scoliosis: sex, degree of spasticity, initial physical capability, pattern of spinal curve, and location of curve. FINDINGS: Scoliosis usually started before the age of 10 years and progressed rapidly during the growth period. In many cases, even after growth had ended, continuous progression was seen. The mean magnitude of the curves at final examination was 55 degrees (Cobb angle). In 11 (85%) of 13 patients who had a spinal curve of more than 40 degrees before age 15 years, the scoliosis progressed to more than 60 degrees by the time of the final examination. Meanwhile, in only three (13%) of 24 patients who had a curve of less than 40 degrees at age 15 years, did the scoliosis progress to more than 60 degrees. Severe scoliosis (> or = 60 degrees) developed predominantly in those who had total body involvement (67%), were bedridden (100%), or had throacolumbar curves (57%). INTERPRETATION: The risk factors for progression of scoliosis in spastic cerebral palsy are: having a spinal curve of 40 degrees before age 15 years; having total body involvement; being bedridden; and having a thoracolumbar curve. Patients with these risk factors might benefit from early surgical intervention to prevent progression to severe scoliosis.     

Morphologic discrimination among healthy subjects and patients with progressive and nonprogressive adolescent idiopathic scoliosis

STUDY DESIGN: A prospective and controlled comparative study. OBJECTIVES: To identify variables that would allow discrimination among patients with progressive adolescent idiopathic scoliosis, patients with nonprogressive adolescent idiopathic scoliosis, and control subjects. SUMMARY OF BACKGROUND DATA: In a previous study, the correlation was demonstrated between morphologic somatotypes and adolescent idiopathic scoliosis. METHODS: One hundred forty-six subjects were evaluated anthropometrically and were classified according to their morphologic somatotype. Of these subjects, 52 were adolescent girls with progressive idiopathic scoliosis, whereas 32 girls had nonprogressive idiopathic scoliosis. The control group was composed of 62 healthy adolescent girls. Somatotype values for ectomorphism, mesomorphism, and endomorphism were obtained according to a technique based on Sheldon's method, and 77 anthropometric measurements of segments of the thorax, head, and limbs were taken. RESULTS: The discriminant analysis realized on a subset of 18 variables allowed the correct identification of each subject's group in 84% of the cases. CONCLUSIONS: It is possible to differentiate healthy adolescent subjects, patients with nonprogressive adolescent idiopathic scoliosis, and patients with progressive idiopathic scoliosis by using anthropometric measurements and morphologic classification. These findings may be useful in the early detection of children at risk for progression of scoliosis and may allow earlier application of treatment methods without waiting for a significant increase in the curve.     

Chronic dopamine D1, dopamine D2 and combined dopamine D1 and D2 antagonist treatment in Cebus apella monkeys: antiamphetamine effects and extrapyramidal side effects

STUDY DESIGN: This study involved weekly radiographic examination of pinealectomized rats, hamsters, and chickens to observe the development of scoliosis. OBJECTIVES: To determine whether pinealectomy produces scoliosis in animals more closely related phylogenetically to humans than to chickens, namely rats and hamsters, which are representative of mammals. SUMMARY OF BACKGROUND DATA: Pinealectomy in 3-day-old chickens has consistently resulted in the development of scoliosis with many characteristics similar to those seen in patients with adolescent idiopathic scoliosis. It has not been determined whether this phenomenon is restricted solely to chickens or is applicable to other animals, especially those more closely related to humans. METHODS: The pineal gland was removed from young rats, hamsters, and chickens. All animals underwent radiography weekly to detect the development of any scoliosis. Weight and length measurements were also taken weekly, and serum melatonin levels were determined at the time the animals were killed. RESULTS: Scoliosis was not observed in either the rats or the hamsters. In contrast, scoliosis developed in 10 of 21 chickens. Serum melatonin levels in all pinealectomized animals were zero. CONCLUSIONS: In contrast to the chickens, pinealectomy does not seem to cause scoliosis in either young rats or hamsters. The reasons for this discrepancy may include differences in the physiology and spinal morphology of the rat and hamster in comparison with the chicken. In the pinealectomized chickens, the results also suggest that future scoliosis development might be indicated by a significant increase in size when they are compared with pinealectomized chickens that do not develop scoliosis. Such differences in growth rates also distinguish patients with adolescent idiopathic scoliosis.     

Long-term effects of bicycle-ergometry training on exercise endurance and dyspnea in patients with chronic pulmonary emphysema]

OBJECTIVE: To evaluate prenatal diagnosis of limb-body wall complex (LBWC) by ultrasonography in eight cases. STUDY DESIGN: The diagnosis was based on two of the following: exencephaly/encephalocele with facial clefts, thoracoschisis and/or abdominoschisis and limb defect. The ultrasonographic findings were compared with the autopsy findings in each case. RESULTS: The average weeks of gestation at which malformations were diagnosed by ultrasonography was 21.7 +/- 4.7 (mean +/- SD, n = 8). All eight fetuses were diagnosed as having characteristic abnormalities and six of them as having scoliosis by ultrasonography. Four of the eight were examined for maternal serum alpha-fetoprotein (MSAFP); the levels exceeded 2.5 multiples of the mean according to the standard value at our hospital. Chromosomal analysis was performed for six cases and revealed that they were normal in karyotype. All eight cases showed abdominoschisis, scoliosis and abnormalities of the lower extremities. A single umbilical artery was present in seven cases (87.5%), and a short umbilical cord was present in seven (87.5%). CONCLUSION: Ultrasonographic detection of abdominoschisis, scoliosis abnormalities of the lower extremities, a single umbilical artery and a short umbilical cord is important for the prenatal diagnosis of LBWC. An extremely elevated level of MSAFP is also indicative of the complex.     

Active or passive chest drainage after oesophagectomy in 101 patients: a prospective randomized study

BACKGROUND: This study evaluates the efficiency and safety of two methods of chest drainage after uncomplicated oesophagectomy. METHODS: A prospective randomized study between active suction drainage and passive chest drainage was carried out in 101 patients who underwent gastric pull-up oesophagectomy. RESULTS: No difference in the prevalence of pneumothorax during treatment was noted between the active (nine of 55) and the passive (four of 46) drainage groups (P=0.20). Nor was there any difference in the size (P=0.46) and duration (P=0.53) of the pneumothorax. There was no significant difference in right (P=0.84) and left (P=0.61) basal atelectases and the amounts of right (P=0.10) and left (P=0.24) pleural effusions. There were significantly more basal atelectases (P < 0.001) and pleural effusions (P<0.001) in the non-operated left side compared with the operated right side. Postoperative hospital stay was the same in both groups (median 13 days; P=0.86). The hospital mortality rate was two of 101, and was not affected by the type of drainage. CONCLUSION: Passive drainage did not reduce hospital stay, but was as safe and effective as the active system in draining the pleural cavity after uncomplicated oesophagectomy.     

Pedicle screw placement using image guided techniques

Clinical evaluation of a computer assisted spine surgical system is presented. Eighty pedicle screws were inserted using computer assisted technology in thoracic and lumbar vertebrae for treatment of different types of disorders including fractures, spondylolisthesis, and scoliosis. Fifty-two patients with severe fractures, spondylolisthesis, or pseudoarthrosis of T10 to L5 were treated using a computer assisted technique on 1/2 the patients and performing the screw insertion manually for the other 1/2. At the same time, 28 pedicle screws were inserted in T12 to L4 vertebrae for scoliosis with the help of the computer assisted technique. Surgery was followed in all cases (66 vertebrae; 132 pedicle screws) by postoperative radiographs and computed tomographic examination, on which measurements of screw position relative to pedicle position could be done. For fractures, spondylolisthesis, or pseudarthrosis, comparison between the two groups showed that four screws in 52 (8%) vertebrae had incorrect placement with computer assisted technique whereas 22 screws in 52 (42%) vertebrae had incorrect placement with manual insertion. In patients with scoliosis, four screws in 28 (14%) vertebrae had incorrect placement. In all of the patients (132 pedicle screws) there were no neurologic complications. These results show that a computer assisted technique is much more accurate and safe than manual insertion.     

Intermittent distracting rod for correction of high neurologic risk congenital scoliosis

STUDY DESIGN: Report of three cases of severe congenital scoliosis corrected by a new device. OBJECTIVES: To show a new, safe alternative for treatment to achieve and maintain correction of the most severe spinal deformity. SUMMARY OF BACKGROUND DATA: Because of neurologic risk, severe congenital scoliosis is usually not instrumented. Gradual correction seems to be safer for the spinal cord and to produce more efficient results because of the viscoelastic properties of the spine. METHODS: A new device was used in three patients with congenital scoliosis. This device is placed by a posterior approach and permits correction of the scoliosis by slow, intermittent distraction. The gear of the elongation mechanism is activated by an extender placed subcutaneously. The correction takes place in the conscious patient, under rigorous neurologic control. RESULTS: At the end of the distraction procedure, corrections of the scolioses in the three patients were from 118 degrees to 45 degrees, 104 degrees to 47 degrees, and 137 degrees to 71 degrees, respectively CONCLUSIONS: The new device has proved useful for correcting, efficiently and without neurologic damage, severe scoliosis in three patients, and may be helpful in those curves with high neurologic risk.     

Results of allogeneic bone transplants in spondylodesis of the spine

The use of allogeneic bone bank bone was evaluated in 67 patients, operated for disorders of the spine. In 26 patients with paralytic scoliosis a pseudarthrosis developed three times and there was one infection. In 28 patients with other causes of scoliosis there were also three cases with pseudarthrosis. In the group of posterolateral arthrodesis of the lumbar spine we saw four patients out of 13 with pseudarthrosis. The results are in accordance with the literature. The use of allogeneic bone in scoliosis surgery is justified in view of the acceptable pseudarthrosis rate and the low incidence of infection. In the lumbar spine group, however, the use of bone bank bone gives less satisfactory results. The use of autologous bone is recommended for this group. There were no signs of transmission of infectious diseases in the total group of patients.     

P450RAI (CYP26A1) maps to human chromosome 10q23-q24 and mouse chromosome 19C2-3

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.