To analyse the causes and factors associated with mortality in patients admitted to ASCI unit in a low- or middle-income country. The study was performed at a Tertiary Hospital at Groote Schuur Hospital, Cape Town South Africa Data between 1996 –2022 were retrospectively collected from hospital records of patients admitted to the ASCI Unit. There was approximately 3223 admissions for the study period. 682 patients were confirmed dead 87% were male and 64% were unemployed. The mean age was 46 years (ranging from 14 – 87 years). A 1/3 of injuries were caused by a MVA, a ¼ by a fall (low energy and from a height), and 1/5 by a gunshot wound. Average length of stay was 47 days (SD = 52 days), ranging from as short as 1 day to 512 days for one patient. Majority (65%) were admitted for more than a week but less than 2 months 32% were ventilated, and 17% with a CPAP facemask. 10% of patients had a pre-existing ulcer prior to admission. 65% of patients had surgery via the posterior approach, 33% via the anterior approach. On average patients died within 5 years of being admitted to hospital, ranging from dying in the same year as the injury to 20 years later. 73% of the deaths were classified as natural deaths and 20% as unnatural. There is a high mortality in patients with acute spinal cord injury, causes are multifactorial, and in depth critical analyses is required to improve clinical outcomes and rationalise resource allocation.
Specific and rapid detection methods for spinal tuberculosis, with sufficient sensitivity in HIV-1 co-infected individuals, are needed, to ensure early initiation of appropriate treatment to prevent physical disability and neurological fallout. In addition, understanding the systemic and local pathophysiology of spinal tuberculosis, and its interaction with HIV-1 infection, is crucial to guide future therapeutic interventions. We prospectively enrolled adult patients presenting with signs and symptoms of suspected spinal tuberculosis, at Groote Schuur Hospital, between November 2020 and December 2021. TB diagnostic testing was performed on open and CT-guided spinal biopsies using Xpert MTB/RIF Ultra compared to gold standards TB culture and histology. A highly sensitive droplet digital PCR assay for detecting and quantifying Mycobacterium tuberculosis complex (MTBC) and HIV-1 DNA was tested. Plasma inflammatory proteins were measured to assess systemic inflammation. Xpert Ultra had a high sensitivity of 94.7% and specificity of 100% for STB against TB culture and histology in both open and CT-guided biopsy samples. The ddPCR assay confirmed TB detection in 94% of patients with positive Xpert Ultra results. Four patients with negative TB diagnostic results had MTBC DNA detected by ddPCR. HIV-1 DNA was detected in the spinal tissues from all HIV-1-infected patients. MTBC DNA levels were significantly higher in HIV-1-co-infected spinal tissue samples (p< 0.01). We identified four biomarkers significantly associated with higher bacterial burden at the disease site (p< 0.01). Xpert Ultra and MTBC ddPCR improve the detection of STB. DdPCR can be utilized as an additional, highly sensitive tool for detecting and quantifying Mtb, in pathological samples that may be paucibacillary. These findings provide novel diagnostic and pathophysiologic insight into STB, in the context of HIV-1 infection, and provide rationale to include these tests in hospital and research settings for patients from communities burdened by TB and HIV-1.
Adolescent idiopathic scoliosis (AIS) is a complex three-dimensional deformity of the spine characterized by a Cobb angle of at least 10 degrees. The goal of surgery is to not only prevent progression but restore sagittal and coronal balance, protecting cardiopulmonary function and improving cosmesis. We reviewed the impact of deformity correction surgery in terms of radiology and patient reported outcome(PROMs). The senior authors prospectively maintained database from 2003 –2022 was retrospectively analysed in terms of pre- and post-operative patient reported outcome measures (SRS 22) as well as radiological parameters. 44 patients with AIS were identified with pre and post op PROMS. The average age at surgery was 15yrs with 84% female. 38% had a Lenke 1 curve and 3 patients had Lenke 6 curves. 73% had posterior surgery. There was a total improvement in SRS 22 scores by 7.8%. Patients reported significant satisfaction with treatment 4.8/5 and improvement in self-image with a change of 0.4 (p<0.001). However, no difference in function, pain and mental health were recorded. Overall, proximal thoracic (PT) curves improved from 24 degrees to 11 degrees (p<0.001), Main thoracic (MT) curve 55 degrees to 19 degrees and Thoracolumbar/Lumbar curves (TL/L) 45 degreesto 11 degrees. Pre-operative flexibility and post-operative correction were 0.40 and 0.41 respectively for PT curve. MT was 0.32 and 0.67. That for TL/L was 0.57 and 0.71 respectively. Surgery yields significant main curve correction correlating with high patient reported satisfaction rate. Although total SRS 22 score yielded 7.8% improvement, sub-analysis of self-image showed the most significant improvement.
Adolescent idiopathic scoliosis is a three-dimensional deformity of the spine, affecting 1–3% of the population. Most cases are treated conservatively. Curves exceeding 45° in the thoracic spine and 40° in the lumbar spine may require correction and fusion surgery, to limit the progression of the curve and prevent restrictive pulmonary insufficiency (curves above 70°). When fusion is required, it may be performed either by posterior or anterior approaches. Posterior is useful for thoracic (Lenke I) curves, notably to correct the thoracic hypokyphosis frequently observed in AIS. Anterior approaches by thoraco-lombotomies allow an effective correction of thoraco-lumbar and lumbar curves (Lenke V and VI), with fewer levels fused than with posterior approaches. However, the approach requires diaphragm splitting and one may be concerned about the long-term pulmonary consequences. The literature provides conflicting insight regarding the consequences of the approach in anterior scoliosis correction, the interpretation of the results being difficult knowing that the correction of the scoliosis itself may improve pulmonary function. This is a retrospective observational study done at a Tertiary Institution. The HRQOL scores have been collected as a prospective cohort. Clinical and radiographic data was collected from patients charts and analysed by two senior surgeons A cohort of 64 patients were operated in the given time period. 50 patients met the inclusion criteria. No major complications were reported. The Union rate was 100% and no post operative complications were noted. Pre and post SRS scores improved in all patients. The Anterior approach for Lenke V AIS gives great surgical exposure and allows for excellent correction of Cobb angle with minimal risk to the patient.
Severe kyphosis in myelomeningocoele patients results in seating problems, early satiety and ultimately pressure sores over the prominence. Kyphectomy and sagittal correction can improve these morbidities. To evaluate the outcome of kyphectomy surgery in meningomyelocoele children.Background:
Aim:
GeneXpert, a new, rapid molecular diagnostic test is recommended as the first line investigation for suspected pulmonary TB in areas of high HIV prevalence or drug resistance, yet it has not been validated for the diagnosis of musculoskeletal TB. The aim of this study was to assess the accuracy of GeneXpert for extraspinal musculoskeletal TB.Background:
Aim:
Cervical spine injured patients often require prolonged ventilatory support due to intercostal paralysis and recurrent chest infections. This may necessitate tracheotomy. Concern exists around increased complications when anterior cervical spine surgery and tracheotomies are performed. The primary aim of this study was to evaluate the effect of tracheostomy in anterior cervical surgery patients in term of complications. In addition, the aetiology of trauma and incidence of anterior surgery and ventilation in this patient group was assessed.Background:
Objective:
Spinal deformity surgery carries the risk of loss of neurological function which may be permanent. Although the overall the incidence is low it is much higher in complex congenital deformities or those with pre-existing myelopathy. Intra-operative spinal cord monitoring allows this risk to be reduced by providing feedback to the surgeon while the corrective manoeuvres are performed. Although ideally a trained technician with multimodal monitoring is recommended, it is often not an option in a resource limited environment and surgeon operated technology is used. to evaluate the use of surgeon operated trans-cranial motor evoked potentials (tcMEP) in spinal deformity surgeryBackground:
Aim:
To review the outcome of multilevel (≥4) instrumented lumbar fusion to sacrum / pelvis performed for degenerative conditions Clinical data of 47 consecutive patients from 2002 to 2012 were reviewed retrospectively. Inclusion criteria included fusion from at least L2 to S1 / pelvis, i.e. minimum of 4 levels. Imaging was assessed for restoration of normal sagittal profile as well as subsequent fusion. EQ5D, OSD and VAS scores pre-op and at 6 months post op were analysed. Average age at surgery was 64 years (50–78). Thirteen cases were primary and 34 revisions. Indications were axial back pain either associated with sagittal imbalance (40%) or leg pain (36%) and leg pain alone in 10%.Purpose
Methods
Trauma is endemic in South Africa. The upper thoracic spine is extremely difficult to image and assess clearly with frontline x-rays resulting in up to 22% of proximal fractures being missed. To review a series of patients with proximal thoracic fractures.Introduction:
Aim:
Circumferential arthrodesis of the spine may be achieved by posterior-only or anterior and posterior surgery. Posterior-based interbody fusions have significant limitations including unreliable improvement of segmental lordosis and variable rates of post-operative radiculopathy. Combined anterior and posterior surgery introduces significant cost and peri-operative morbidity. The purpose of this paper is to report the radiographic and clinical outcomes of posterior-based circumferential arthrodesis using a novel expandable interbody cage. A prospective pilot clinical trial with one year follow-up of the only expandable cage approved by the FDA for interbody application. Clinical outcomes measured include ODI and VAS for back and leg. Radiographic outcomes include arthrodesis rates based upon CT scan. Statistical significance for change in health status was calculated using Student's t-test.Introduction:
Methods:
Historically, anterior decompression followed by posterior fusion has been the surgical management of choice in spinal tuberculosis. Due to theatre time being at a premium, we have evolved to performing anterior only debridement, allograft strut reconstruction and instrumentation for tuberculosis in the adult thoracic spine. The aim of this study is to review the safety and the efficacy of this treatment. Twenty-eight adult thoracic tuberculosis patients were identified where anterior only surgery had been performed. These were all in the mid-thoracic spine as circumferential surgery is still favoured in thoracolumbar disease. The surgery was performed by a single surgeon at a tertiary hospital. Following transthoracic aggressive debridement, allograft humeral shafts were cut to size and inserted under compression and the spines instrumented with the use of screw-rod constructs into the body above and below. A retrospective review of clinical notes and radiological studies was performed.Aim:
Methods:
The aim is to assess the use of non-fusion instrumentation “growth rods” in early onset scoliosis (EOS). A retrospective review of 12 consecutive patients who had undergone a growth rod procedure for EOS was performed. Six patients had neuromuscular scoliosis, 5 had juvenile idiopathic scoliosis while one had a congenital aetiology. Growth constructs were predominately constructed from modular commercially available sets using hooks, screws and connection blocks. One VEPTR was used in a severe kyphoscoliosis. Patients returned to theatre at 6 monthly intervals for a lengthening procedure. Patients were assessed with regards to age at presentation, age at surgery, indications for surgery, initial Cobb angle, post- operative Cobb angle, number of lengthening's done, instrumentation used, amount of spine growth achieved and complications.Purpose of study
Methods
To determine whether MRI done prior to reduction altered the surgeon's choice of reduction method. One hundred and four patients were included in this retrospective review. The first component of this study identified the presence of uncontained, herniated discs in this patient group. The MRI scans were reviewed by two teams including a radiology team and orthopaedic team. These scans were assessed without clinical information and the teams did not have access to the patient notes. An Interrater agreement assessment was applied to the data and the most reliable inter-observer variables of disc injury were chosen to identify the presence of a herniated uncontained intervertebral disc. The second part of this study entailed a detailed clinical note review specifically looking at type of reduction, whether it was intended and the reason why a certain type of reduction was chosen. These naturally divided the 104 patients into 5 cohorts including; closed reduction, Intended open reduction due to the documented presence of a ‘dangerous disc’, open reduction following failed closed reduction, open reduction with no documented reason and open reduction due to delay in presentation. Since closed reduction would not be considered in delayed presentations this cohort was removed from data analysis. Additionally the pre and post reduction neurological status was noted.Purpose
Method
To demonstrate that instrumented fusion of the paediatric cervical spine is possible and can be performed safely. A retrospective review of paediatric patients who had instrumented fusion of the cervical spine.Objectives
Study Design
Posterior vertebral column resection (PVCR) is indicated in the management of severe rigid spine deformities. It is a complex surgical procedure and is only performed in a few spine centres due to the technical expertise required and associated risk. The purpose of this study is to review the indications, surgical challenges and outcomes of patients undergoing PVCR. 12 patients with severe spinal deformities who underwent PVCR were retrospectively reviewed after a follow-up of 2 years. Surgery was performed with the aid of motor evoked spinal cord monitoring and cellsaver when available. The average surgical duration was 310 minutes (100–490). The average blood loss was 1491 ml (0–3500). The indication for PVCR was gross deformity and myelopathy which was due to congenital spinal deformities and one case of old tuberculosis. Clinical records and the radiographic parameters were reviewed.Objective
Methods
Transarticular screw fixation offers acceptably high fusion rates but is not possible in 18% of patients due to a high riding vertebral artery. It also requires pre-operative anatomical reduction which is not always possible. The Harms' technique utilises a posterior C1 lateral mass and C2 pedicle screw. This allows easier access due to the angle of drilling and has become an increasingly popular surgical technique. The aim of this study is to review and compare the above techniques with regard to surgery, complications and outcome. This study is a retrospective chart and radiographic review of patients undergoing posterior C1-2 fusion in a single institution in the period 2003 to 2011. The most common aetiology was rheumatoid arthritis and post-traumatic instability. All atlanto-axial instability patients that came to surgery are included in this study, and only cases with less than six months follow-up were excluded. We report on surgical indications, surgical outcomes, complications and radiographic outcomes.Purpose of study
Description of methods
To investigate anterior instrumented corrective fusion for thoracolumbar or lumbar scoliosis. A retrospective review of medical records and radiographs of 38 consecutively managed patients who underwent anterior spine surgery for thoracolumbar curves by a single surgeon between 2001 and 2011. The cohort consisted of 28 female and 10 male patients with idiopathic scoliosis as the commonest aetiology. Data collated and analysed included patient demographics, surgical factors, post-operative management and complications. In addition, radiographic analysis was performed on pre-operative and follow-up x-rays.Aim
Methods
The aim of the study was to review the surgical management of Neuromuscular Scoliosis (NMS) and its outcome. NMS patients who underwent surgery between 2001 and 2012 were identified. Case notes, surgical data, complications and radiographic results were reviewed retrospectively. The families were contacted telephonically. Sitting posture status and whether the parents and patients would opt to have the surgery again if given the opportunity, was assessed.Purpose of the study
Method
To perform an Interrater reliability study determining the agreement between an Orthopaedic team and a Radiology team on the MRI features of prolapsed uncontained cervical discs in Flexion-Distraction injuries of the cervical spine. This leads us to determine how many patients demonstrated evidence of a ‘dangerous’ disc: an uncontained disc herniating posteriorly that may be drawn into the spinal canal during closed reduction. One hundred and ten patients who had pre-reduction MRI scans managed during the last 10 years were included. Variables were chosen and defined by the senior Author and explained to both teams prior to reviewing the scans. The review was performed by each team independently and without any access to clinical information. Data collection and interpretation was designed by a statistician to reduce risk of data entry errors. Interrater reliability/agreement was determined using the Cohen Kappa value.Purpose
Methods
