Posterior Vertebral Column Resection for VATER/VACTERL Associated Spinal Deformity: A Case Report

The VATER/VACTERL association is a syndrome notable for congenital vertebral malformations, anal atresia, cardiovascular anomalies, tracheoesophageal fistula, esophageal atresia, and renal or limb malformations. Vertebral malformations may include the entire spectrum of congenital spinal deformities, including kyphosis, as was seen in this case. A 14-year-old girl presented to our institution with severe rigid sagittal deformity in the thoracolumbar spine that had recurred following three prior spinal fusion surgeries: the first posterior only, the second anterior and posterior, and the third a posterior only proximal extension. These surgeries were performed to control progressive kyphosis from a complex failure of segmentation that resulted in a 66° kyphosis from T11 to L3 by the time she was 9 years old. Our evaluation revealed solid arthrodesis from the most recent procedures with resultant sagittal imbalance, and surgical options to restore balance included anterior and posterior revision spinal fusion with osteotomies, multiple posterior extension osteotomies with circumferential spine fusion, and posterior vertebral column resection with circumferential spine fusion. She was advised that multiple posterior extension osteotomies would likely be insufficient to restore sagittal balance in the setting of solid arthrodesis from anterior and posterior surgery, and that the posterior-only vertebral column resection would provide results equivalent to revision anterior and posterior surgery, without the morbidity of the anterior approach. She successfully underwent posterior vertebrectomy and circumferential spinal fusion with instrumentation and is doing well 2 years postoperatively. Severe rigid sagittal deformity can be effectively managed with a posterior-only surgical approach, vertebrectomy, and circumferential spinal fusion with instrumentation. An erratum to this article can be found at     

Laparoscopic ventral rectopexy for external rectal prolapse improves constipation and avoids de novo constipation

Objective Abdominal rectopexy is ideal for otherwise healthy patients with rectal prolapse because of low recurrence, yet after posterior rectopexy, half of the patients complain of severe constipation. Resection mitigates this dysfunction but risks a pelvic anastomosis. The novel nerve‐sparing ventral rectopexy appears to avoid postero‐lateral rectal dissection denervation and thus postoperative constipation. We aimed to evaluate our functional results with laparoscopic ventral rectopexy. Method Consecutive rectal prolapse patients undergoing laparoscopic ventral rectopexy were prospectively assessed (Wexner Constipation and Faecal Incontinence Severity Index scores) pre‐, 3 months postoperatively, and late (> 12 months). Results Sixty‐five consecutive patients with external rectal prolapse (median age 72 years, 34% > 80 years, median follow up 19 months) underwent laparoscopic ventral rectopexy. There was one recurrence (2%) and one conversion. Morbidity (17%) and mortality (0%) were low. Median operating time was 140 min and median length of stay 2 days. At 3 months, constipation was improved in 72% and  mildly induced in 2% (median pre‐and postoperative Wexner scores 9 vs 4, P < 0.0001). Continence was improved in 83% and mild incontinence was induced or  worsened in 5% (median pre‐ and postoperative incontinence score 40 vs 4, P < 0.0001). Significant improvement in both constipation and incontinence (P < 0.0001) remained at median 24 months late follow‐up. Conclusion Ventral rectopexy has a recurrent prolapse rate of < 5%, similar to that of posterior rectopexy. Its correction of preoperative constipation and avoidance of de novo constipation appear superior to historical functional results of posterior rectopexy. A laparoscopic approach allows low morbidity and short hospital stay, even in those patients over 80 years of age in whom a perineal approach is usually preferred for safety.     

Biomechanical comparison of single- and two-level cervical arthroplasty versus arthrodesis: effect on adjacent-level spinal kinematics

Background ContextThe use of motion-preserving spinal implants versus conventional arthrodesis instrumentation systems, which stabilize operative segments, necessitates improved understanding of their effect on spinal kinematics and the biomechanically optimal method for surgical reconstruction.PurposeThe primary objective of this study was to measure operative- and adjacent-level kinematics after single- and two-level cervical arthroplasty and compare them with those after anterior cervical arthrodesis. A secondary objective was to locate the centers of intervertebral rotation at the operative and adjacent levels after arthroplasty and compare them to those after arthrodesis.Study DesignThis biomechanical study used an in vitro human cadaveric model to compare the multidirectional flexibility kinematics of single- versus two-level cervical disc arthroplasty reconstructions.MethodsEight cadaveric cervical spines (C2–T2) were biomechanically evaluated between Levels C4 and T1 in the intact condition and under the following reconstructions: single-level arthroplasty (C6–C7) using porous coated motion (PCM) device; single-level arthrodesis (C6–C7) using interbody cage with anterior plate; two-level arthroplasty (C5–C7) using PCM devices; two-level hybrid treatment of arthroplasty (C5–C6) using PCM device and arthrodesis (C6–C7) using cage/plate; and two-level arthrodesis (C5–C7) using cage/plate. Multidirectional flexibility testing used the Panjabi hybrid testing protocol, including pure moments for the intact condition with overall spinal motion replicated under displacement control for subsequent reconstructions. Unconstrained intact moments of ±3.0 Nm were used for axial rotation, flexion-extension, and lateral bending testing with quantification of the operative- and adjacent-level range of motion (ROM) and neutral zone. The calculated centers of intervertebral rotation were compared for all intervertebral levels under flexion-extension conditions.ResultsAxial rotation loading demonstrated a significant decrease in the C6–C7 ROM for the single-level arthrodesis group compared with the intact spine and the single-level arthroplasty group (p<.05). No differences were observed between the intact and single-level arthroplasty groups (p>.05). For the two-level hybrid treatment group, the C5–C6 ROM significantly increased compared with the intact, single-level arthroplasty, and two-level arthrodesis groups (p<.05). Moreover, a significant increase was observed in the adjacent-level (C7–T1) ROM for the two-level arthrodesis group compared with all other treatment groups (p<.05). Under flexion-extension, no differences were observed in C6–C7 ROM between the intact spine and single-level arthroplasty groups (p>.05). However, as expected, the single-level arthrodesis and two-level hybrid treatment groups demonstrated a decreased ROM at C6–C7 versus the intact spine and arthroplasty treatments (p<.05). In terms of adjacent-level effects, two-level arthrodesis (C5–C7) led to increased ROM in the inferior level (C7–T1) in axial rotation and flexion-extension compared with the intact spine and all other treatment groups (p<0.05). Lateral bending loading conditions demonstrated no significant difference among the treatment groups (p>.05). In flexion-extension, the centers of intervertebral rotation for the intact spine and single-level arthroplasty groups were localized in the central to posterior one-third of the inferior vertebral body for each motion segment: C5–C6, C6–C7, and C7–T1. The single-level arthrodesis group produced more diffuse centers of rotation, particularly at the operative (C6–C7) and inferior adjacent levels (C7–T1).ConclusionsThis study highlights the biomechanical effects of single- and two-level cervical arthroplasty versus single- and two-level arthrodesis on four functional spinal levels (C4–T1). Operative-level ROM was preserved with single- and two-level arthroplasty under all loading modes. The distal adjacent level (C7–T1) demonstrated the greatest increase among the four levels in ROM compared with the intact condition after two-level arthrodesis. These kinematic findings were corroborated by changes in the adjacent-level centers of rotation after arthrodesis and may suggest a biomechanical cause of adjacent-level disease secondary to cervical arthrodesis.     

Paradigm shift in gastrointestinal surgery − combating sarcopenia with prehabilitation: Multimodal review of clinical and scientific data

A growing body of evidence has demonstrated the prognostic significance of sarcopenia in surgical patients as an independent predictor of postoperative complications and outcomes. These included an increased risk of total complications, major complications, re-admissions, infections, severe infections, 30 d mortality, longer hospital stay and increased hospitalization expenditures. A program to enhance recovery after surgery was meant to address these complications; however, compliance to the program since its introduction has been less than ideal. Over the last decade, the concept of prehabilitation, or “pre-surgery rehabilitation”, has been discussed. The presurgical period represents a window of opportunity to boost and optimize the health of an individual, providing a compensatory “buffer” for the imminent reduction in physiological reserve post-surgery. Initial results have been promising. We review the literature to critically review the utility of prehabilitation, not just in the clinical realm, but also in the scientific realm, with a resource management point-of-view.     

An evaluation of the use of retrospectively acquired preoperative AOFAS clinical rating scores to assess surgical outcome after elective foot and ankle surgery

The use of retrospectively acquired preoperative AOFAS rating scores in clinical research to assess the outcomes of elective foot and ankle surgery has not been validated. The data obtained utilizing this methodology may misrepresent the results and lead to spurious conclusions. This investigation compared preoperative AOFAS Ankle-Hindfoot scores obtained before and after surgery from patients who had undergone elective surgery to determine if retrospectively acquired scores match those collected prospectively. Only two out of 47 patients (4%) recalled identical AOFAS scores. The mean difference between the preoperative scores (preoperative score obtained after surgery minus preoperative score obtained before surgery) was -5.3 points. Fifteen patients (32%) had preoperative scores that differed by 20 points or more. Kappa statistics found little agreement among the five elements that comprised the two preoperative scores when responses obtained before and after surgery were compared to one another. The results suggest that preoperative clinical rating scores obtained after elective surgery are a poor predictor of the patient's preoperative condition and that studies which employ retrospectively acquired preoperative AOFAS clinical rating scores may overestimate the benefit of surgery.     

Glomerular complement regulation is overwhelmed in passive Heymann nephritis

BACKGROUND: An injection of anti-Fx1A antibodies in rats leads to passive Heymann nephritis (PHN), a model of membranous nephropathy. Fx1A is a crude extract of renal cortex that contains megalin as a principal component. However, when rats are given anti-megalin antibodies, abnormal proteinuria does not occur. Because of the established complement dependence of PHN, we hypothesized that antibodies neutralizing complement regulatory proteins in the rat glomerulus also were required to induce PHN. Two likely targets are Crry and CD59, proteins abundant on the rat podocyte and contained within Fx1A that inhibit the C3 convertase and C5b-9 assembly, respectively. METHODS: Rats were injected with anti-megalin monoclonal antibodies, followed by anti-Crry and/or anti-CD59 F(ab')(2) antibodies five days later. In a second group of experiments, rats were injected with anti-Fx1A or anti-Fx1A immunodepleted of reactivity against Crry and/or CD59. RESULTS: In the setting of podocyte-associated anti-megalin monoclonal antibodies, simultaneous neutralization of Crry and CD59 function led to the development of significant proteinuria (11.0 +/- 2.1 mg/day, P < 0.001 vs. all other groups). In contrast, animals that had neither or only one of these complement regulators inhibited had normal urinary protein excretion (< or =6 mg/day). In animals given anti-Fx1A depleted of anti-Crry and/or anti-CD59, all groups developed typical PHN, characterized by heavy proteinuria and extensive glomerular deposition of C3 and C5b-9. CONCLUSION: Crry and CD59 play an important role in restraining complement-mediated injury following subepithelial immune complex deposition; however, in PHN, their regulatory capacity is overwhelmed.     

Haemophilus influenzae associated scleritis

AIMS: To describe the clinical course and treatment of Haemophilus influenzae associated scleritis. METHODS: Retrospective case series. RESULTS: Three patients developed scleritis associated with ocular H influenzae infection. Past medical history, review of systems, and laboratory testing for underlying collagen vascular disorders were negative in two patients. One patient had arthritis associated with an antinuclear antibody titre of 1:160 and a Westergren erythrocyte sedimentation rate of 83 mm in the first hour. Each patient had ocular surgery more than 6 months before developing scleritis. Two had cataract extraction and one had strabismus surgery. Nodular abscesses associated with areas of scleral necrosis were present in each case. Culture of these abscesses revealed H influenzae in all patients. Treatments included topical, subconjunctival, and systemic antibiotics. Scleral inflammation resolved and visual acuity improved in each case. CONCLUSION: H influenzae infection may be associated with scleritis. Accurate diagnosis and treatment may preserve ocular integrity and good visual acuity.     

Dyskeratosis congenita in an adolescent girl with associated choanal atresia

Dyskeratosis congenita is a rare, progressive, degenerative disorder characterized by cutaneous and mucosal involvement in the first decade of life with malignant changes and bone marrow failure in the second and third decades. The primary inheritance pattern is X-linked recessive, with the majority of cases presenting in boys. We report dyskeratosis congenita in an adolescent girl with choanal atresia, a previously unreported association.     

Attitudes about sexual disclosure and perceptions of stigma and shame

OBJECTIVES: To determine the association between stigma and shame about having a sexually transmitted disease and adolescents' past STD related care seeking; between stigma, shame, and perceptions about disclosure of sexual behaviours to a doctor or nurse; and whether the association of stigma, shame, and care seeking was moderated by perceptions about disclosure. METHODS: A household sample of 142 sexually active African-American youths, 13-19 years old, was questioned about STD related stigma (alpha = 0.89), STD related shame (alpha = 0.90), and perceptions about disclosure of sexual behaviours to a doctor or nurse (alpha = 0.81). RESULTS: Among females, stigma was associated with increased anticipation of negative reactions to disclosure of sexual behaviours to a doctor or nurse (odds ratio (OR) = 0.319; 95% confidence interval (CI) =0.12 to 0.85) while shame was not. Stigma was also independently associated with STD related care seeking in the past year (OR = 0.296; 95% CI = 0.09 to 0.94) while shame was not. There was no association between stigma and shame with perceptions about disclosure or past care seeking in males. Perceived outcomes of disclosing sexual behaviours did not moderate the association of stigma, shame, and past STD related care seeking. CONCLUSIONS: Stigma about STDs may influence how female adolescents perceive reactions to disclosure of their sexual behaviour to healthcare providers. It may also be an important factor in their decision seek to STD related care. Perceptions about disclosure of sexual behaviour to a doctor or nurse do not change the relation of stigma or shame to past STD related care seeking.