Hereditary multiple osteochondromas (HMO) is a common paediatric condition defined by the presence of multiple cartilage-capped bony lesions. Spinal osteochondromas affect up to 68% of HMO patients.1 Although most are asymptomatic, cord-encroaching osteochondromas can lead to significant neurological symptoms and morbidity.2 Limited guidelines exist regarding the use of advanced imaging as a screening modality for spinal osteochondromas. This study aims to evaluate the incidence of spinal osteochondromas detected via advanced imaging in the paediatric HMO population. A systematic review and meta-analysis was conducted following the Cochrane Handbook for Systematic Reviews of Interventions. A search was performed across MEDLINE, Embase, CENTRAL, and CINAHL databases for articles published between May 1, 1946 and May 31, 2024. Included studies reported on the use of advanced imaging, computer tomography (CT) or magnetic resonance imaging (MRI), in HMO patients under the age of 21. The primary outcome was spinal osteochondroma incidence determined by advanced imaging. Secondary outcomes included type of imaging, indication for imaging, symptoms on presentation, incidence of spinal encroaching lesions, incidence of patients requiring surgical intervention, and postoperative outcomes. A meta-analysis of single proportions was conducted to determine the pooled incidence of spinal osteochondromas, incidence of spinal canal-encroaching lesions, and incidence of spinal surgery in HMO patients. Of 415 eligible articles, seven met inclusion criteria. These studies included 198 HMO patients with a weighted mean age of 12 ± 1.0 years, and 47% were female. MRI was the primary imaging modality (99%) with 69% imaged secondary to institutional screening protocols. Approximately 21% had neurological symptoms at the time of imaging. Overall, the pooled incidence of spinal osteochondromas was 36% (Figure 1, 95% CI, 24–51%). Of these, 43% were located in the cervical spine, 38% in the thoracic spine, and 19% in the lumbar spine. Among HMO patients with spinal osteochondromas, 49% (95% CI, 37–61%) had canal-encroaching lesions and 21% (95% CI, 13–33%) underwent spinal surgery. Postoperatively, 47% of individuals had resolution of their symptoms, and no long-term complications were reported across six of the studies. Figure 1. Forest plot of incidence of spinal osteochondromas in HMO patients, demonstrating a rate of 36%. While spinal osteochondromas are prevalent amongst HMO patients, standardised screening protocols remain limited. Despite favourable surgical outcomes for symptomatic canal-encroaching lesions, initial and serial screening is needed to prevent irreversible neurological damage. Early baseline screening may also be warranted for asymptomatic HMO patients once sedation is no longer indicated. As global guidelines evolve, large multicentre prospective studies are needed to identify optimal timing for spinal osteochondroma screening in HMO patients. For any figures or tables, please contact the authors directly.
Introduction:La douleur chronique demeure un enjeu majeur, particulièrement en soins primaires où l'accès à des services appropriés et coordonnés est limité. Pour y répondre, le Plan d'action ministériel québécois en douleur chronique 2021-2026 vise à améliorer l'accès à des soins intégrés grâce à de nouveaux projets de services interprofessionnels en soins primaires. Objectif:Documenter la mise en œuvre de ces projets en analysant les processus décisionnels, organisationnels et cliniques, ainsi que les innovations et défis observés. Méthodes:Une étude de cas multiméthode a été menée dans cinq projets. Dix gestionnaires et responsables ont participé à des entretiens semidirigés et rempli une enquête organisationnelle. Les données qualitatives et quantitatives ont été analysées pour identifier les facilitateurs et les obstacles à l'implantation. Résultats:Tous les projets ont implanté des modèles interprofessionnels, mais avec une hétérogénéité importante selon les ressources disponibles. Le triage est principalement assuré par les infirmières, avec une implication médicale limitée. Des pratiques collaboratives dynamiques et qui renforcent la continuité des soins et services ont émergé. Malgré tout, les équipes font face à des défis organisationnels majeurs, dont le financement temporaire, la pénurie de personnel et une coordination intersectorielle fragile. Conclusion:Ces services représentent une avancée significative, mais leur pérennité requiert un soutien institutionnel et un financement durable.
Se verificaron y analizaron los indicadores de dosis para estudios de cabeza con tomograf´ıa computarizada, como el ´Indice de Dosis en Tomograf´ıa Computarizada volum´etrico (CTDIvol) realizados a pacientes pedi´atricos. Se realizaron simulaciones de estudios usando t´ecnicas de exposici´on cerebral en el equipo de tomograf´ıa computarizada del Instituto Nacional de Salud del Ni˜no (INSN). Para esto, se utiliz´o un fantoma de cabeza de PMMA (polimetilmetacrilato), un material que tiene una densidad y capacidad de atenuaci´on similar a la del tejido humano. Para medir c´omo se distribuye la dosis de radiaci´on en puntos espec´ıficos del fantoma, se us´o una camara de ionizaci´on de tipo l´apiz conectada a un electr´ometro digital, que se carg´o autom´aticamente con factores de correcci´on para calibrar sus detectores externos. El promedio del indicador CTDIvol, para los rangos de edad de 0-3 a˜nos, 3-5 a˜nos, 5-10 a˜nos, 10-15 a˜nos, 15-18 a˜nos, son 26.08 mGy, 26.57 mGy, 34.99 mGy, 35.20 mGy, 53.40 mGy respectivamente. Estos resultados son cercanos a los de estudios realizados en pa´ıses de Am´erica del Norte, Europa, Asia y ´Africa. El estudio identific´o que los valores del indicador de dosis CTDIvol de cerebro para pacientes pedi´atricos del rango 15-18 a˜nos es cercano al CTDIvol en pacientes adultos. Se subraya la necesidad de implementar y aplicar tecnicas de exposici´on optimizadas para reducir las dosis de radiaci´on que reciben los pacientes pedi´atricos.
Addressing pre-operative expectations is important for realistic surgical outcomes, enhance satisfaction, support informed decisions, and ensure valid informed consent. Here, we determine if there are differences in pre-operative expectations (specifically in the domains of pain relief and overall functional wellbeing) between primary and revision surgery groups in adult Canadian elective lumbar spinal surgery patients. This multicenter, retrospective cohort study analyzed adult elective lumbar spine surgery patients enrolled in Canadian Spine Outcomes and Research Network from 2017 to 2023. Two cohorts of interest 1) Patients undergoing posterior decompression alone and 2) those undergoing posterior decompression with fusion. These were further divided into primary and revision surgery groups. Exclusion criteria included patients undergoing surgery for trauma, tumors, infection, or those who underwent anterior-only approaches. Expectation scores were divided into two dimensions: overall functional well-being (independence, physical activity, mental well-being, social contacts, and general physical) and pain relief (leg and back pain). For each category, patients rated expected outcomes on a scale from 0 (no change) to 3 (much better). Each score was calculated by summing points for items in each dimension, divided by the total possible maximum, where higher scores indicate higher pre-operative expectations. Propensity score matching (PSM) was used to create a balanced comparison between primary and revision surgery groups within both cohorts, adjusting for confounders such as age, sex, labor force status, number of comorbidities, depressive symptoms, primary pathology, physical activity, leg and back pain, and self-rated health status . Greedy algorithm with nearest neighbor matching and 0.2 caliper was used to balance baseline covariates between groups. Our total patient population was 6,353 patients, with 3,050 undergoing decompressions alone, of which 2,843 are primary surgery patients and 207 are revision surgery patients. The remaining patients underwent decompression and fusion, of which 2,825 were primary surgery patients, and 478 were revision surgery patients. After matching, in the decompression alone cohort there was no significant difference in pain relief expectation scores between primary (n=181) [mean = 2.49 (±0.63)] and revision surgery patients (n=181) [mean 2.45 (±0.63], p=0.3455), nor in overall functional wellbeing scores (primary mean = 2.22 (±0.63); revision mean =2.19 (±0.62), p=0.469). Additionally, in the decompression and fusion cohort there was no significant difference in overall functional wellbeing expectation scores between (n=180) in primary surgery patients (n=432)(mean = 2.24 (±0.66); n = 180) and in revision surgery patients (432) (mean = 2.12 (±0.68), p=0.095; n = 178), nor in pain relief scores (primary mean = 2.53 (±0.63); revision mean =2.41 (±0.69), p=0.469). There were no differences seen in pre-operative expectations between primary and revision patients, despite the revision patients having previous experience with surgery. Surgeons should maintain consistent pre-operative discussions for both primary and revision surgery patients.
Vertebral Body Tethering (VBT) aims to gradually correct scoliosis by utilizing patients' growth, while preserving spine motion. VBT has shown early satisfactory results, while having low complication rates. However, the clinical results and complication profile need to be further defined. We report outcomes at five years post VBT and surgical complications in skeletally immature patients. We reviewed 74 idiopathic scoliosis patients who underwent VBT at a single centre, with a minimum of five-year follow-up. Patients had preoperative, first erect, six-months, one-year, two-year and five-year annual X-rays thereafter. Postoperative data at each of these visits were analyzed. Any interval increases in coronal curve angle equal to or greater than five degrees from the smallest recorded postoperative measure to any other postoperative interval underwent segmental interscrew angle measurements to identify tether breakage. Breakage was suspected when the interscrew angle increased by five degrees or more. Means and standard deviation of specific parameters were calculated. All 74 patients were skeletally immature, the mean age at surgery is 11.8 ± 1.3 years and the mean follow-up time is 63.4 ± 8.4 months. VBT was performed on an average of 7.4 vertebral levels. Instrumented Cobb angle was 48.7° ± 9.2° preop, 17.1° ± 12.3° at the 2-year postop and 25.7° ± 14.0° at the five-year postop. Revision surgery was performed in 12 patients (16.2%). Four patients needed either partial or complete release of the tether due to overcorrection. Two patients needed revision of VBT due to curve progression. Four patients required posterior spinal fusion (PSF) due to curve progression despite VBT. One patient needed a revision of VBT followed by PSF. One patient developed a small dural tear recognized postoperatively, initially treated by a blood patch. This patient complicated by developing an iatrogenic Chiari-like malformation and then needed revision surgery for screw reposition. Forty-nine patients (66%) had a suspected broken tether at the last follow up. The mean time of the first tether breakage is 38.1 ±15 months. In our cohort 66% (49 patients) had a suspected radiological tether break after five years, and 6.8% (five patients) required PSF. VBT offers a significant correction in the coronal and transverse planes postoperatively with a reoperation rate of 16.2 %.
