When is a spine fused?

The ability to correctly diagnose spinal non-union is vital to our ability to diagnose and treat patients with new or recurrent symptoms following spine fusion and to accurately assess the efficacy of spine fusion techniques and technologies. Surgical exploration has traditionally been the gold-standard investigation for spinal non-union. As routine surgical exploration is impractical in the majority of patients the use of non-invasive radiologic methods of spine fusion assessment is necessary. The purpose of this paper is to outline the most common radiologic methods of spine fusion assessment including the strengths and limitations associated with each imaging modality. In addition we will review the best-available evidence for the use of radiologic investigations to diagnose spine non-unions. We will then provide recommendations for what we believe to be the best methods of diagnosing successful union of cervical interbody, lumbar interbody and lumbar posterolateral fusions that can be used by spine clinicians and researchers alike.     

When is a pneumothorax not a pneumothorax?

The authors report on a 13-year-old boy who, after exercise, had respiratory distress and left upper quadrant abdominal pain. Initially, a mistaken diagnosis of pneumothorax was made, and a chest tube was inserted. A nasogastric tube was then visualized on chest x-ray in the left hemithorax. He underwent a laparotomy and had herniation of spleen, stomach, and large and small bowel in the left pleural space passing through a traumatic defect in the hemidiaphragm. The laparoscopic Nissen fundoplication 3 years prior was felt to have contributed. A timely and correct diagnosis is essential to avoid the sequelae associated with these injuries and with inappropriate tube thoracostomy.     

When is it a diagnosis of overlap syndrome?

The connective tissue diseases comprise a group of syndromes of unknown etiology affecting as many as 1 person in 40, often with a predilection for the female sex. Included are: systemic lupus erytematosus (SLE), polymyositis and dermatomyositis, Sj?gren syndrome, scleroderma and the vasculitis (polyarteritis nodosa, Wegener's, giant cell arteritis). There are patients who are not easily defined; having features overlapping with those of other connective tissue diseases. A variety of terms such as mixed connective tissue disease, undifferentiated connective tissue syndrome and overlap syndrome have emerged to describe such patients. Although many of these overlap syndromes are unlikely to have life-threatening consequences, they may be extremely debilitating and distressing, significantly reducing quality of life for the patient and his or her family. We present the case of a patient initially diagnosed with dermatomyositis and who eventually evolved to overlap syndrome by developing SLE.     

Gomco circumcision: When is it safe?

BACKGROUND/PURPOSE: The Gomco clamp is used most commonly for neonatal circumcisions in the United States with reported rates of complication as low as 0.2%. Often, however, circumcision is delayed beyond the neonatal period because of illness, parental concerns, or physician bias with patients presenting for elective circumcision in the first few years of life. In neonates and infants, the "bloodless" Gomco circumcision is cost effective, can be performed with minimal anesthesia and gives good cosmetic results. However, the optimal age at which to perform this procedure remains controversial. We reviewed the experience of one pediatric urologist with Gomco circumcision in neonates and infants to determine the optimal age at which this procedure should be performed. METHODS: One hundred thirty patients underwent Gomco circumcision by 1 pediatric urologist between 1996 and 1998. Ninety-eight patients underwent Gomco circumcision as neonates or during early infancy at a mean age of 17 days (range, 4 to 30 days). Thirty-two patients underwent circumcision after early infancy at a mean age of 6.5 months (range, 90 days to 8.5 months). All patients younger than 1 month of age underwent circumcision while fully awake using a dorsal penile nerve block. Patients greater than 3 months of age were circumcised under general anesthesia. Gomco circumcision was performed using 1.1- to 2.1-cm bells. Patients were assessed with regard to outcome. RESULTS: None of the 98 patients in the early infancy group had postcircumcision complications. Of the 32 patients in the older group, 12 (30%) had postoperative bleeding requiring suture repair or fulguration. The skin edges separated in 2 patients, 1 less than 1 month of age and 1 in the older group. Neither patient required further intervention, and both healed spontaneously. There was no correlation between size of clamp and development of complications. CONCLUSION: Although safe and effective for circumcision in the neonatal period and in early infancy, use of the Gomco clamp for circumcision beyond early infancy (3 months of age) has substantial morbidity, and alternative methods of circumcision should be sought.     

When is a urodynamic investigation indicated for overactive bladder?

Ohne Zusammenfassung     

When is a varicocele repair indicated: the dilemma of hypogonadism and erectile dysfunction?

In the past, the indications for varicocelectomy are primarily for infertility with abnormal semen parameters, testicular hypotrophy/atrophy in adolescents, and/or pain. The surgical treatment of varicocele for hypogonadism is controversial and debated. Recently, multiple reports in the literature have suggested that varicocele is associated with hypogonadism and varicocele repair can increase testosterone levels. Men with hypogonadal symptoms should have at least two serum testosterone levels. Microsurgical varicocelectomy may be beneficial for men with clinically palpable varicoceles with documented hypogonadism. In this review, we summarize the most recent literature linking varicocele to hypogonadism and sexual dysfunction and the impact of repair on serum testosterone levels. We performed a search of the published English literature. The key words used were “varicocele and hypogonadism” and “varicocele surgery and testosterone.” We included published studies after 1998. We, also, evaluated the effect of surgery on the changes in the serum testosterone level regardless of the indication for the varicocele repair.