Congenital scoliosis is a complex spinal problem associated with many other anomalous findings. Treatment options are diverse but enable optimization of management and care of these children.
Osteomyelitis is an infection of the bone that can involve the vertebral column. A rare cause of vertebral osteomyelitis is Mycobacterium bovis after intravesical Bacillus Calmette-Guerin (BCG) therapy for transitional cell carcinoma of the bladder. In this report, we describe the case of a 64-year-old male presenting with constitutional symptoms, progressive thoracic kyphosis, and intractable T11 and T12 radiculopathies over the proceeding six months. A CT scan revealed erosive, lytic changes of the T12 and L1 vertebrae with compression of the T12 vertebra. An MRI demonstrated T11-12 osteomyelitis with intervening discitis and extensive paraspinal enhancement with a corresponding hyperintensity on a short tau inversion recovery (STIR) sequence. A needle aspiration grew out Mycobacterial tuberculosis complex that was pansensitive to all antimicrobial agent therapies, except pyrazinamide on culture, a finding consistent with an M. bovis infection. The patient’s infection and neurologic compromise resolved after transthoracic T11-12 vertebrectomies with decompression of the spinal cord and nerve roots as well as T10-L1 instrumented fusion and protracted antimicrobial therapy. The epidemiology and natural history of M. bovis osteomyelitis are reviewed and the authors emphasize a mechanism of vertebral inoculation to explain the predilection of M. bovis osteomyelitis in males after intravesical BCG therapy.
BACKGROUND Burnout is a negative workplace syndrome of emotional exhaustion, cynicism, and perceived professional inefficacy that risks the patient-provider relationship, patient care, and physician well-being. OBJECTIVE To assimilate the neurosurgical burnout literature in order to classify burnout among domestic and international neurosurgeons and trainees, identify contributory factors, and appraise the impact of wellness programs. METHODS A scoping review identified the available literature, which was reviewed for key factors related to burnout among neurosurgeons. Two researchers queried PubMed, Embase, Google Scholar, Cochrane, and Web of Science for articles on burnout in neurosurgery and reduced 1610 results to 32 articles. RESULTS A total of 32 studies examined burnout in neurosurgery. A total of 26 studies examined prevalence and 8 studies detailed impact of wellness programs. All were published after 2011. Burnout prevalence was measured mostly through the Maslach Burnout Inventory (n = 21). In 4 studies, participants defined their own understanding of “burnout.” Domestically, burnout prevalence was 11.2% to 67% among residents and 15% to 57% among attendings. Among trainees, poor operative experience, poor faculty relationships, and social stressors were burnout risks but not age, sex, or marital status. Among attendings, the literature identified financial or legal concerns, lack of intellectual stimulation, and poor work-life balance as risks. The impact of wellness programs on trainees is unclear but group exercises may offer the most benefit. CONCLUSION Noticeable methodological differences in studies on trainee and attending burnout contribute to a wide range of neurosurgery burnout estimates and yield significant knowledge gaps. Environment may have greater impact on trainee burnout than demographics. Wellness programs should emphasize solidarity.
OBJECTIVE The authors performed a study to identify clinical characteristics of pediatric patients diagnosed with Chiari I malformation and scoliosis associated with a need for spinal fusion after posterior fossa decompression when managing the scoliotic curve. METHODS The authors conducted a multicenter retrospective review of 44 patients, aged 18 years or younger, diagnosed with Chiari I malformation and scoliosis who underwent posterior fossa decompression from 2000 to 2010. The outcome of interest was the need for spinal fusion after decompression. RESULTS Overall, 18 patients (40%) underwent posterior fossa decompression alone, and 26 patients (60%) required a spinal fusion after the decompression. The mean Cobb angle at presentation and the proportion of patients with curves > 35° differed between the decompression-only and fusion cohorts (30.7° ± 11.8° vs 52.1° ± 26.3°, p = 0.002; 5 of 18 vs 17 of 26, p = 0.031). An odds ratio of 1.0625 favoring a need for fusion was established for each 1° of increase in Cobb angle (p = 0.012, OR 1.0625, 95% CI 1.0135-1.1138). Among the 14 patients older than 10 years of age with a primary Cobb angle exceeding 35°, 13 (93%) ultimately required fusion. Patients with at least 1 year of follow-up whose curves progressed more 10° after decompression were younger than those without curve progression (6.1 ± 3.0 years vs 13.7 ± 3.2 years, p = 0.001, Mann-Whitney U-test). Left apical thoracic curves constituted a higher proportion of curves in the decompression-only group (8 of 16 vs 1 of 21, p = 0.002). CONCLUSIONS The need for fusion after posterior fossa decompression reflected the curve severity at clinical presentation. Patients presenting with curves measuring > 35°, as well as those greater than 10 years of age, may be at greater risk for requiring fusion after posterior fossa decompression, while patients less than 10 years of age may require routine monitoring for curve progression. Left apical thoracic curves may have a better response to Chiari malformation decompression.
Background/Aims: To characterize the impact of cranial asymmetry and age at initiation of therapy on final cranial asymmetry in infants with deformational plagiocephaly treated with helmet orthotics. Methods: We conducted a single-center retrospective review of 45 pediatric patients <12 months of age with deformational plagiocephaly who underwent STARband cranial orthotic helmet treatment. Cranial asymmetry was measured using a 3-dimensional laser surface scanner and defined as a cranial vault asymmetry index (CVAI) >3.5%. Results: Twenty-one patients (47%) were <6 months of age at the start of helmet therapy. A greater initial CVAI or age at therapy initiation correlated with a greater final CVAI (univariate analysis, r = 0.53, p < 0.001; r = 0.42, p = 0.004). Subgroup analysis of 18 patients beginning therapy at 4-5 months of age and 20 patients beginning therapy at 6-8 months of age revealed that only a change in the initial CVAI was associated with a change in the final CVAI (r = 0.43, p = 0.007). Conclusion: In a comparison of patients who initiated helmet therapy at 4-5 and 6-8 months of age, only cranial asymmetry at the outset of therapy was correlated with final cranial asymmetry (r = 0.43, p = 0.007).
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