2005 Scoliosis Research Society Asian Traveling Fellowship: report to the Education Committee.
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Education, Medical, Graduate↗
Biomedical subjects
Suken A Shah
Publications and source records attributed to Suken A Shah.
Low back pain in pediatric athletes with unilateral tracer uptake at the pars interarticularis on single photon emission computed tomography.
STUDY DESIGN: Retrospective clinical study with radiographic and medical chart review. OBJECTIVE: To study the clinical characteristics and outcome of pediatric athletes with low back pain and unilateral tracer uptake on single photon emission computed tomography (SPECT) at the pars interarticularis but no defect on radiographs. SUMMARY OF BACKGROUND DATA: Some pediatric athletes with low back pain have no findings on plain radiographs but a unilateral SPECT uptake at the pars interarticularis. However, little is known about these patients. METHODS: Twenty-two pediatric athletes who had low back pain with increased tracer uptake on SPECT unilaterally at the pars interarticularis but no defect on plain radiograph were evaluated. The following criteria were used for evaluation: age, male-to-female ratio, duration of symptoms, vertebral level, and presence of spina bifida occulta or scoliosis. RESULTS: The average age was 12.3 +/- 2.5 years. The male-to-female ratio was 1.2:1. The average duration of symptoms was 21 +/- 23 weeks. Nineteen (86%) had increased uptake at L5. Six (27%) had spina bifida occulta and 8 (36%) had scoliosis. Eighteen (82%) patients showed an excellent outcome. The patients who presented with a longer history of symptoms or a concomitant spina bifida occulta had an increased risk of having occasional aching with vigorous activity when compared with the patients who did not (P < 0.05). CONCLUSIONS: Athletes who have low back pain and increased tracer uptake unilaterally at the pars interarticularis on SPECT are younger than those previously reported patients with spondylolysis proven by a defect on radiographs. Some of these lesions do progress to "frank" spondylolysis seen on radiographs, but favorable clinical outcomes from nonoperative treatment can be expected. Patients with a longer pain history or concomitant spina bifida occulta may need careful follow-up because they are at increased risk of having occasional low back pain.
Adolescent↗
Loss of coronal correction following instrumentation removal in adolescent idiopathic scoliosis.
STUDY DESIGN: Retrospective radiographic analysis of patients with adolescent idiopathic scoliosis (AIS) status after instrumentation removal. OBJECTIVE: To evaluate the effect of instrumentation removal in surgically corrected AIS. SUMMARY OF BACKGROUND DATA: Spinal instrumentation is occasionally removed for various reasons, most commonly for postoperative pain or infection, in surgically corrected AIS. The fate of instrumentation removal in adults has been previously reported with documented loss of sagittal alignment. However, to our knowledge, the long-term follow-up after instrumentation removal in AIS has not been reported. METHODS: We retrospectively reviewed the preoperative, pre-instrumentation removal, postoperative following instrumentation removal, and latest follow-up radiographs of all patients with a primary diagnosis of AIS who underwent instrumentation removal after posterior spinal fusion. There were 21 patients (15 females, 6 males) from 2 institutions, at an average age of 14.8 years (range 9-19), who were originally treated between 1988 and 2002. Instrumentation removal occurred at an average of 2.4 years after surgery (range 8 months to 4 years, 2 months), with an average follow-up of 5.2 years (range 2-11). Fifteen patients underwent removal secondary to pain (2 of these with undetected infection) and 6 for known infection. Evaluation included coronal proximal thoracic, main thoracic, thoracolumbar/lumbar (TL/L), and sagittal T2-T5, T5-T12, T2-T12, T10-L2, T12-S1, and sagittal balance before surgery, before instrumentation removal, at immediate post-removal evaluation, and at latest follow-up. RESULTS: There were 12 main thoracic curves (Lenke type 1), 6 double thoracic curves (Lenke type 2), and 3 double major curves (Lenke type 3) in the series. Average proximal thoracic curve was 19.7 degrees (range 5 degrees -35 degrees ), the main thoracic curve 63.3 (range 42 degrees -112 degrees ), and the TL-L curve averaged 31.4 degrees (range 17 degrees -53 degrees ). There was an immediate loss of approximately 4 degrees (range 0 degrees -8 degrees ) in the main thoracic curve and 6 degrees (range 1 degrees -15 degrees ) in the TL/L curve after removal, with continued settling of an additional 6 degrees (10 degrees total, P = 0.002) in the main thoracic curve, and 3 degrees in the TL/L curve (9 degrees total, P = 0.01). There was also a significant difference in the group that underwent instrumentation removal <2 years after surgery compared to >2 years (main thoracic curve 13 degrees vs. 7 degrees , P = 0.017; TL/L 11 degrees vs. 7 degrees , P = 0.036). There were no significant changes in sagittal curvature or sagittal balance in either group (P > 0.39). CONCLUSIONS: Instrumentation removal in AIS is not always a benign process because the long-term follow-up of this cohort of patients shows a "settling" effect in the coronal plane of the main thoracic and TL/L curves after instrumentation removal. Interestingly, there was no change in the sagittal plane with time. Parents and patients should be counseled for this result when instrumentation removal is contemplated, and limited removal of focally symptomatic implants should be considered.
Adolescent↗
Elastic intramedullary nails.
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Bone Nails↗
Dynamic scapholunate dissociation in a child.
We describe a case of dynamic scapholunate dissociation in a skeletally immature ten-year-old girl. The patient presented for pain in the anatomical snuffbox and swelling over the dorsum of the wrist and hand. Standard static and dynamic radiographs of the wrist did not reveal any pathology. Magnetic resonance imaging was inconclusive. The scapholunate dissociation was diagnosed by wrist arthroscopy, reduced, and stabilised using standard techniques. Full and pain-free motion of the wrist was restored.
Arthroscopy↗
Lumbar spondylolysis in pediatric and adolescent soccer players.
BACKGROUND: Lumbar spondylolysis in young soccer players has not been studied extensively. PURPOSE: The purpose of this study was to review lumbar spondylolysis in young soccer players, describe the causes, and report the results of nonoperative treatment emphasizing the cessation of activity for 3 months. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The authors reviewed 57 child and adolescent soccer players (35 boys and 22 girls) with lumbar spondylolysis who came to their outpatient clinic for back pain evaluation. These patients received different modalities of nonoperative treatment, including cessation of sports and wearing a thoracolumbosacral orthosis. Soccer skills, field position, side of dominant leg, age, initiating event of low back pain, duration of symptoms, and nonoperative treatment were reviewed. Clinical outcome of treatment was assessed by the Steiner-Micheli criteria at the most recent follow-up (minimum 2 years). The Fisher exact test was used to compare all the data. RESULTS: Of the patients, 43% noticed that pain started after a high-velocity kick. Thirty-three (58%) of 57 patients had excellent results with no pain during sports, 20 (35%) good, 3 (5%) fair, and 1 (2%) poor. Subjects who ceased playing soccer for 3 months had better results than those who did not comply with this restriction. CONCLUSION: The authors recommend stopping sports for at least 3 months in cases of lumbar spondylolysis in young soccer players who hope to return to their previous level of play without back pain.
Adolescent↗
Cytokine release, pancreatic injury, and risk of acute pancreatitis after spinal fusion surgery.
Acute pancreatitis after posterior spinal fusion in children is associated with high intraoperative blood loss. Inflammation, oxidative stress, and pancreatitis markers were assessed during this period. Five of the 17 patients studied developed acute pancreatitis 3-7 days after surgery. Intraoperative blood loss (4850 +/- 2315 vs 1322 +/- 617 ml) and peak tumor necrosis factor alpha levels (15.29 +/- 5.3 vs 8.27 +/- 4.6 pg/ml) in the immediate postoperative period were significantly higher in these five patients than in controls, respectively. No differences were noted in serum interleukin 8, interleukin 6, pancreatis-associated protein, or urine malondialdehyde levels. Urine trypsin-associated peptide, elevated initially in all patients, was significantly higher in the acute pancreatitis group at diagnosis. Length of stay was significantly longer in the acute pancreatitis group. Greater blood loss and peak tumor necrosis factor alpha are associated with subsequent risk of acute pancreatitis, suggesting a role of ischemia-reperfusion injury.
Acute Disease↗
Tension-sided femoral neck stress fracture in a skeletally immature patient. A case report.
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Adolescent↗
Preserving ambulatory potential in pediatric patients with cerebral palsy who undergo spinal fusion using unit rod instrumentation.
STUDY DESIGN: A retrospective study investigated 24 ambulatory pediatric patients with spastic cerebral palsy and neuromuscular scoliosis. OBJECTIVE: To evaluate the effect of spinal fusion from T1-T2 to the sacrum with pelvic fixation using unit rod instrumentation on the ambulatory potential of these patients. SUMMARY OF BACKGROUND DATA: Spinal deformities in patients with cerebral palsy and good ambulatory capacity are infrequently associated with pelvic obliquity, so instrumented spinal fusions traditionally do not extend to the pelvis. METHODS: The medical charts and radiographs were reviewed, and the patients' ambulatory ability was assessed clinically with videotape or complete gait analysis. A questionnaire assessing patients' functional improvement was given to the caretakers. RESULTS: The study group included 17 female and 7 male patients, among whom were 19 quadriplegics and 5 diplegics. The mean age at surgery was 15.4 years. Of the 24 patients, 20 underwent posterior spinal fusion and 4 had combined anteroposterior procedures. The patients were evaluated clinically before surgery and after surgery. Follow-up evaluations of ambulatory function occurred at a mean of 2.86 years after surgery. No alteration in the ambulatory status of the patients was found, except in one patient who experienced bilateral hip heterotopic ossification and gradually lost her ability to ambulate. Preoperative and postoperative gait analysis was performed for 12 patients, showing no change in their ambulatory function. The surgical outcome survey demonstrated significant improvement in the patients' physical appearance, head and trunk balance, sitting ability, and respiration, with no change in ambulatory capacity. CONCLUSIONS: Spine surgery with fusion extending to the pelvis in ambulatory patients with cerebral palsy provided excellent deformity correction and preserved their ambulatory function.
Adolescent↗
Transphyseal fracture-dislocation of the femoral neck: a case report and review of the literature.
We describe a case of transphyseal hip fracture-dislocation in a 7.5-year-old patient who was treated initially by open reduction and internal fixation. Soon after the injury, the femoral head developed avascular necrosis. The treatment was focused on maintaining adequate hip range of motion and providing femoral head containment with a combined subtrochanteric femoral osteotomy and shelf acetabuloplasty. The patient's young age and good hip remodeling potential contributed to the favorable clinical outcome 3 years after the injury. The long-term prognosis remains guarded, however.
Accidents, Traffic↗
The duPont kyphosis brace for the treatment of adolescent Scheuermann kyphosis.
The purpose of this study was to evaluate the effectiveness of a newly designed brace in the treatment of adolescent Scheuermann thoracic kyphosis. Twenty-two children who met the roentgenographic criteria of Scheuermann kyphosis and were compliant with treatment were followed until skeletal maturity. Sixteen patients (73%) showed nonprogression of their kyphosis (nine patients demonstrated an improvement, seven patients remained unchanged), and had a mean improvement of 9 degrees (64 degrees to 55 degrees). Six patients (27%) demonstrated progression of the kyphosis and had a mean increase in their kyphosis of 9 degrees (59 degrees to 68 degrees). One patient underwent posterior spinal fusion for progressive thoracic kyphosis despite bracing. It was recommended that this brace be worn until skeletal maturity; in this study this time period was determined to be at least 16 months to induce improvement or halt progression of this disease. Flexible curves are a positive predictor of a successful outcome of bracing with the kyphosis brace. These results are comparable to previous reports in the literature describing the effectiveness of the modified Milwaukee brace in the treatment of Scheuermann thoracic kyphosis prior to skeletal maturity, and the kyphosis brace has the advantage of concealability under normal attire.
Adolescent↗
The effect of a 5-day space flight on the immature rat spine.
BACKGROUND CONTEXT: Spaceflight has many reported effects upon the musculoskeletal system structure and function. This study was designed to determine the effect of a 5-day flight on the rat spine. METHODS: In September 1991, 8 neonatal rats were flown aboard the Space Shuttle Columbia flight STS-48 during a 5-day mission. Upon return to earth, the spines were dissected, frozen and shipped to our laboratory. Matched ground-based rats were used as controls. The spines were radiographed and then slowly thawed. Individual vertebrae were subjected to compressive biomechanical testing using an Instron tester (Instron Corp, Canton, MA, USA) and then processed for determination of calcium and phosphorus content. The intervertebral discs were placed in physiological saline and the stress-relaxation characteristics measured. The discs were then lyophilized and assayed for collagen and proteoglycan content. Disc height on radiographs was measured by image analysis. RESULTS: After space flight, the heights of the discs were found to be 150 to 200 microns greater, although the values were not statistically significant. There was no difference in the resiliency of the thoracic discs as determined by stress-relaxation. However, in the lumbar discs, space flight increased the resiliency (p<.01). There was no difference in water content. In both the thoracic and lumbar discs there was a 3.3-fold increase in hydroxyproline-proteoglycan ratio after space flight. However, because of the small sample size, these values were not statistically significant. In the vertebrae, there was no difference in calcium-phosphate ratio or compressive strength. CONCLUSIONS: These data suggest that even after a short 5-day flight, the spine begins to undergo biomechanical and biochemical changes. In addition, the weightless environment in space may provide a good model to study the effects of immobilization on earth.
Animals↗
The associated effects of untreated unilateral hip dislocation in cerebral palsy scoliosis.
INTRODUCTION: The presence of a unilateral hip dislocation in children with cerebral palsy (CP) may cause problems with sitting imbalance, pressure ulcers, and hip pain. There is a dynamic interplay between hip dislocation, pelvic obliquity (PO), and scoliosis. The effect of an untreated unilateral hip dislocation on the rate of curve progression of CP scoliosis has not been defined in the literature. The purpose of this study is to investigate the effect of unilateral hip dislocation on PO and the rate of curve progression in children with spastic quadriplegic CP. METHODS: Patients with spastic quadriplegic CP who had spine radiographs at the time of initial presentation with scoliosis and at the latest follow-up were evaluated. Twenty-three children with spastic CP who had an untreated unilateral hip dislocation and scoliosis constituted the study group. The control group consisted of 83 quadriplegic CP patients with scoliosis and well-located hips. The rate of curve progression, incidence of PO, and the rate of PO progression at follow-up were compared between the 2 groups. RESULTS: The mean ages of patients with a unilateral dislocation and with well-located hips at initial radiograph were 10.4 and 10.5 years, respectively. The mean follow-up was 3.5 years. The mean rate of scoliosis curve progression in patients with a unilateral hip dislocation was 12.9 degrees per year. In the control group, the mean progression rate was 12.2 degrees per year. The incidence of PO at follow-up was 74% in scoliotic patients with a dislocation and 63% in scoliotic patients with normal hips. Using repeated-measures analysis of variance, unilateral hip dislocation was found to have no significant effect on scoliosis progression; however, progression of PO was significantly increased in the hip dislocation group (P < 0.05). Pelvic obliquity was corrected after posterior spinal fusion to the sacrum with pelvic fixation, without reducing the hip(s) at the same surgery. CONCLUSION: Unilateral hip dislocation causes a significant increase of PO but does not affect the rate of scoliosis curve progression.
Adolescent↗
Acquired atlantoaxial instability in children with spastic cerebral palsy.
The development of nontraumatic atlantoaxial instability in children with spastic cerebral palsy has not been reported. The authors present three patients with severe spastic quadriplegia who developed C1-C2 instability and cervical myelopathy at mean age 12.6 years. These patients demonstrated a similar clinical picture with symptoms attributed to cervical myelopathy in varied severity including apneic episodes, opisthotonus, alteration in muscle tone, torticollis, respiratory problems, hyperreflexia, and bradycardia. Patient 1 was scheduled for surgery but died due to an apneic episode. Patient 2 refused surgery and has been followed for 3 years while his neurologic condition remains unchanged. Patient 3 underwent occipitocervical decompression and fusion, recovered neurologically, and resumed his previous functional skills. Patients demonstrating considerable functional deterioration or insidious change in their established neurologic status should undergo detailed screening to rule out developing upper cervical instability. Early surgical intervention consisting of spinal decompression and fusion may prevent the development of myelopathy.
Adolescent↗