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Biomedical subjects

A H Crawford

Publications and source records attributed to A H Crawford.

At least 19 recordsLinked to original sources
PubMed2001

Tension pneumothorax as a complication of video-assisted thorascopic surgery for anterior correction of idiopathic scoliosis in an adolescent female.

STUDY DESIGN: This case report illustrates the occurrence of intraoperative tension pneumothorax, a previously unreported complication occurring during anterior instrumentation for correction of scoliosis by video-assisted surgery. OBJECTIVES: To demonstrate a consequence of overadvancement of a Steinmann pin (guide wire). SUMMARY OF BACKGROUND DATA: Although intraoperative tension pneumothorax is admitted to be a theoretical complication of video-assisted surgery for anterior correction of idiopathic scoliosis, there has yet to be a case reported in the literature. This report presents the first case of this complication. METHODS: A 13-year-old girl who had right thoracic scoliosis with a curve measuring 54 degrees underwent video-assisted surgery discectomy and anterior spinal fusion with instrumentation of T5 through T11. Single-lung ventilation had been achieved with a double-lumen tube and the right lung was deflated. After approximately 4.5 hours of complication-free surgery, intraoperative fluoroscopy showed an approximately 2-cm overadvancement of a guide wire into the opposite hemithorax. Approximately 5 minutes after the overadvancement was corrected, the patient experienced a gradual increase in heart rate and a corresponding gradual decrease in oxygen saturation and both systolic and diastolic blood pressures. Approximately 35 minutes later, it was determined that the patient had sustained a tension pneumothorax of the left hemithorax. RESULTS: The patient underwent urgent partial reinflation of the right lung and a tube thoracostomy of the left thoracic cavity. Vital signs quickly returned to stable levels, and the left lung easily reinflated with the chest tube suction. The patient remained stable after the procedure was resumed (by right lung deflation). The remainder of the surgery and the postoperative course were uneventful. CONCLUSIONS: Although video-assisted surgery continues to gain popularity in the management of spinal deformities, the surgical team must be certain to pay meticulous attention to detail throughout the procedure. The early detection and treatment of complications can be life-preserving.

Adolescent↗
PubMed2001

The effect of surgical timing on the perioperative complications of treatment of supracondylar humeral fractures in children.

BACKGROUND: The purpose of this study was to evaluate the perioperative complication rates associated with early surgical treatment (eight hours or less following injury) and delayed surgical treatment (more than eight hours following injury) of displaced supracondylar humeral fractures in children. METHODS: Fifty-two patients had early surgical treatment and 146 patients had delayed surgical treatment of a displaced supracondylar humeral fracture. The perioperative complication rates of the two groups were compared with the use of bivariate and multivariate statistical methods. RESULTS: There was no significant difference between the two groups with respect to the need for conversion to formal open reduction and internal fixation (p = 0.56), pin-track infection (p = 0.12), or iatrogenic nerve injury (p = 0.72). No compartment syndromes occurred in either group. Power analysis revealed that our study had an 86% power to detect a 20% difference between the two groups if one existed. CONCLUSIONS: We were unable to identify any significant difference, with regard to perioperative complication rates, between early and delayed treatment of displaced supracondylar humeral fractures. Within the parameters outlined in our study, we think that the timing of surgical intervention can be either early or delayed as deemed appropriate by the surgeon.

Adolescent↗
PubMed2001

Two cases of osteochondroma recurrence after surgical resection.

Osteochondromas are the most common bone tumor found in children. A review of 114 resected osteochondromas over a 10-year period revealed recurrence in 2 cases. The overall recurrence rate of these lesions is less than 2% and was found to be 1.8% in this review.

Adolescent↗
PubMed2000

Modulation of spinal deformities in patients with neurofibromatosis type 1.

STUDY DESIGN: A consecutive case retrospective chart and radiographic review. OBJECTIVES: To determine the incidence of nine radiographic dystrophic features acquired during the process of modulation, and to analyze the statistical correlation of these acquired dystrophic features with clinical progression of a spinal deformity. SUMMARY OF BACKGROUND DATA: In patients with neurofibromatosis, spinal deformities with seemingly few initial dystrophic features have shown a tendency to acquire dystrophic changes during long-term follow-up periods. Similarly, deformities with dystrophic changes can acquire further dystrophic features. This phenomenon is termed "modulation," a feature unique to spinal deformities in neurofibromatosis. These dystrophic changes may evolve slowly or aggressively, and may spread to other regions as well. METHODS: A review was done of the clinical records, photographs, radiographs, and other imaging studies of 457 patients referred between 1982 and 1995 with the diagnosis of neurofibromatosis Type 1. One hundred twenty-eight patients were diagnosed with a spinal deformity. Ninety-one patients who had a complete set of clinical and radiographic data were included in the study. Location and type of curve as well as the extent of spinal deformity were studied for their effect on the tendency for modulation. Initial spinal radiographs were analyzed for nine radiographic dystrophic features: rib penciling, vertebral rotation, posterior vertebral scalloping, anterior vertebral scalloping, lateral vertebral scalloping, vertebral wedging, spindling of the transverse process, widened interpedicular distance, and enlarged intervertebral foramina. Subsequent radiographs were analyzed critically for evolution, progression, or spread of these features. Correlation of acquisition in these dystrophic features with clinical progression in the spinal deformity, as measured in increments of scoliosis and kyphosis, was analyzed. RESULTS: In 81% of patients with spinal deformity diagnosed before 7 years of age and in 25% of patients with such a diagnosis after 7 years of age, evidence of modulation was observed. Location, side, and extent of the deformity and patient gender did not influence the propensity of the deformity to modulate. Correlation of modulation with clinical progression of the deformity showed rib penciling to be the only singular factor statistically influencing risk of progression. Of the deformities that acquired three or more penciled ribs, 87% showed significant clinical progression. No other radiographic dystrophic feature individually influenced progression. However, when three or more of the dystrophic skeletal features were acquired, the risk of progression reached statistical significance in 85% of patients. CONCLUSIONS: Spinal deformities in patients with neurofibromatosis 1 should be regarded as deformities in evolution. One should resist assigning these evolving deformities to either the dystrophic or nondystrophic end of the spectrum without considering the possibility of modulation across the spectrum. A spinal deformity that develops before 7 years of age should be followed closely for evolving dystrophic features (i.e., modulation). When a curve acquires either three penciled ribs or a combination of three dystrophic features, clinical progression is almost a certainty.

Adolescent↗
PubMed2000

Traumatic hip dislocation in children. Long-term followup of 42 patients.

To assess the impact of traumatic hip dislocations in the skeletally immature patient, 42 children younger than 16 years of age (average age, 9 years 10 months) who were treated at the authors' institution were studied. Data were collected from charts and radiographs and by completion of questionnaires. The average followup after injury was 10 years 1 month. The majority of dislocations (64%) were attributable to low energy injuries. Ipsilateral fractures about the hip occurred in 17% of patients. Avascular necrosis of the femoral head developed in 12% of patients, with the amount of time spent dislocated being the only statistically proven risk factor. Patients whose reduction was delayed greater than 6 hours had a 20 times higher risk of having avascular necrosis develop compared with patients whose hips were reduced in 6 hours or less. The use of computed tomography for joint asymmetry of 3 mm or greater and omission of bone scan screening were supported by this study. Functional outcomes were very good in this series with 95% of patients suffering mild (usually weather related) or no pain and 95% of patients suffering mild pain (intermittently noticeable) or no limp. A large percentage of the patients (78%) continued to participate in high demand activities such as football, soccer, and basketball.

Adolescent↗
PubMed1999

Intraoperative experience with neuromotor evoked potentials. A review of 60 consecutive cases.

STUDY DESIGN: A review of 60 surgical cases for correction of scoliosis, during which neuromotor evoked potentials and somatosensory evoked potentials were monitored. OBJECTIVES: To determine the validity and reliability of intraoperative neuromotor evoked potential monitoring in cases of scoliosis, where damage to the motor tracts of the spinal cord can occur. SUMMARY OF BACKGROUND DATA: Recently, the validity of neuromotor evoked potentials monitoring has been challenged, suggesting that the responses are not necessarily neuromotor evoked responses, but a combination of neuromotor and somatosensory evoked responses. This theory rendered the responses a potentially invalid measure of motor ability. However, despite controversy surrounding this topic, many professionals consider neuromotor evoked potential monitoring to be a successful and reliable measure of motor spinal cord function. METHODS: The results of neuromotor evoked potential testing were reviewed in 60 consecutive cases of children who underwent surgery for scoliosis. A standard protocol described in 1995 by Owen was used. RESULTS: Clinically useful neuromotor evoked potentials were obtained for 54 patients (90%). Inability to obtain neuromotor evoked potentials occurred in six patients (10%). CONCLUSIONS: This two-part study demonstrated the efficacy and reliability of neuromotor evoked potential monitoring during scoliosis surgery and examined the sources of difficulty in achieving accurate and valid results.

Adolescent↗
PubMed1999

Video-assisted thoracoscopy.

New therapeutic modalities for disorders of the pediatric spine must include video-assisted thoracoscopy. The endoscopic approach to the spine has involved an evolutionary approach. What began as an isolated drainage of a vertebral abscess was continued as a method of single discectomy; release of the annulus fibrosis with or without ligation of segmental vessels; rib resection for costoplasty; rib harvesting for intervertebral fusion; and most recently, insertion of correctional implants and fusion.

Adolescent↗
PubMed1999

Pediatric vertebral and spinal cord tumors: a retrospective study of musculoskeletal aspects of presentation, treatment, and complications.

Fifty-two pediatric patients with documented vertebral and spinal cord tumors were reviewed to evaluate the musculoskeletal manifestations of presentation, treatment, and management of complications. Diagnoses included 16 malignant and 36 nonmalignant vertebral and spinal cord tumors. Mean age at diagnosis was 8 years 1 month, and the male-to-female ratio was 1.7:1. Overall, there was an average delay in diagnosis of 12 months for this group of patients. Mean clinical follow-up was 5 years. The two most common reasons for presentation were pain (67%) and spinal deformity (46%). Initial plain radiographs were positive in 82% of patients. Postlaminectomy spinal deformity occurred at a rate of 45% in patients undergoing laminectomies, and 60% of those with deformity required spinal fusion. Overall, 67% of the 52 patients underwent spinal fusion, with a 9% asymptomatic pseudarthrosis rate. Complications were common, with 1.9 complications per patient; 59% of complications required surgical management. There were no perioperative deaths. At follow-up, 19% of patients had neurologic deficits ranging from neurogenic bladder to lower extremity weakness and difficulty walking to quadriplegic. Eighty-six percent of patients were ambulating without difficulty at follow-up. The survival rate was 94% and the local recurrence rate was 27% at most recent follow-up.

Adolescent↗
PubMed1998

Endoscopic discectomy increases thoracic spine flexibility as effectively as open discectomy. A mechanical study in a porcine model.

STUDY DESIGN: Two surgical techniques for anterior discectomy were compared biomechanically. The surgical procedures were performed in live, anesthetized, skeletally immature pigs. Spine flexibility was measured in vitro. OBJECTIVE: To determine whether endoscopic techniques for discectomy are as effective as open procedures in increasing spine flexibility. SUMMARY OF BACKGROUND DATA: Although studies have verified that discectomy increases spine flexibility, no study has confirmed whether endoscopic techniques increase flexibility as effectively as standard thoracotomy, which is a substantially different procedure. METHODS: The intervertebral disc between vertebrae T8 and T9 was resected from 30 live, anesthetized, adolescent pigs. In 15 pigs, the chest was opened via thoracotomy of the eighth rib, and the disc was excised. In the other 15 pigs, the disc was removed endoscopically. These motion segments and six intact controls were tested mechanically in side bending, flexion-extension, and axial rotation. RESULTS: No statistically significant differences in flexibility were found between open and endoscopic groups in any loading direction. The statistical power to detect a 20% difference between surgical groups was > or = 95%. CONCLUSIONS: Endoscopic and open techniques were equally effective in increasing spine flexibility. Because endoscopy may reduce surgical morbidity compared with open discectomy, these results support the use of endoscopy for the surgical correction of scoliosis before instrumentation.

Animals↗
PubMed1997

The role of preoperative pulmonary function tests in patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion.

STUDY DESIGN: A retrospective review of the case records and radiographs of 133 patients with adolescent idiopathic scoliosis who underwent posterior spinal fusion and instrumentation between 1986 and 1992. OBJECTIVES: To evaluate the incidence of abnormal results on preoperative pulmonary function tests and their correlation to immediate postoperative pulmonary impairment in patients with adolescent idiopathic scoliosis who had posterior spinal fusion. SUMMARY OF BACKGROUND DATA: It has been stated that preoperative pulmonary function tests are essential to assess surgical risk in a patient with scoliosis because of the possibility of further compromising the pulmonary function. Authors of previous studies have reported on the increased incidence of postoperative pulmonary complications in patients undergoing anterior spinal surgery. METHODS: The case records and radiographs of 133 patients with either a thoracic or a double-major curve, who underwent posterior spinal fusion, were reviewed. The presence of any preoperative or postoperative cardiopulmonary symptoms and increased requirement of postoperative ventilatory support were noted. Results of preoperative pulmonary function tests were classified as normal, restrictive, or obstructive disease. Postoperative chest radiographs were examined to note the presence of atelectasis, infiltrates, pneumothorax, hemothorax, or pneumonia. RESULTS: The majority of patients (72.9%) had normal results on pulmonary function tests. The mean coronal Cobb angle of the thoracic curve was 48 degrees, and the mean angle of kyphosis was 26 degrees. None of the patients had any increased requirement of postoperative ventilatory support. The overall incidence of postoperative pulmonary complications was 2.3%. CONCLUSIONS: Performance of a thoracoplasty was the only risk factor for postoperative pulmonary complications in patients undergoing posterior spinal fusion. There was no correlation between deterioration of preoperative pulmonary function and the risk of postoperative pulmonary complications. It appears that performance of preoperative pulmonary function tests in patients with moderate adolescent idiopathic scoliosis-scheduled for posterior spinal fusion is not necessary.

Adolescent↗
PubMed1997

Thoracic tumors in children with neurofibromatosis-1.

Thoracic tumors have been infrequently reported as a complication of neurofibromatosis-1 (NF1). To determine the prevalence and clinical features of thoracic tumors seen in children with NF1, we reviewed medical records and imaging studies for a group of 260 pediatric patients with NF1 followed in a multidisciplinary NF Center. Extrapleural thoracic tumors were seen in nine patients with NF1, corresponding to a prevalence of 3.5% in this hospital-based series of patients. Pathological studies of the tumors demonstrated plexiform neurofibroma in four cases and neurofibrosarcoma in one case. The remaining four cases were suspected to be plexiform neurofibroma based on clinical features but have not been confirmed histologically. Three patients presented with symptoms of chest pain, syncope, or wheezing; six patients were asymptomatic at the time of diagnosis of the tumors. Physical findings frequently found in patients with thoracic tumors were scoliosis (especially focal scoliosis) and visible plexiform neurofibromas of the neck. We conclude that NF1 patients presenting with any of these signs and symptoms should be screened for thoracic tumors with chest X-ray and magnetic resonance imaging as needed. It is unknown whether screening asymptomatic NF1 patients with chest X-rays on a regular basis will result in an improved outcome.

Adolescent↗
PubMed1997

Video-assisted thoracoscopic surgery (VATS). Endoscopic thoracoplasty technique.

STUDY DESIGN: The study of two patients whose rib deformity was treated using a new endoscopic thoracoplasty technique is reported. OBJECTIVES: To report a new endoscopic thoracoplasty technique for the treatment of rib deformities associated with idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: Thoracoplasty has traditionally been performed as an open procedure, often necessitating additional incisions and/or tissue dissection. METHODS: Two children with significant rib humps associated with idiopathic scoliosis were treated with a new endoscopic thoracoplasty technique. RESULTS: Both children showed dramatic cosmetic improvement of their rib deformity. CONCLUSIONS: The indications for the use of video-assisted thoracoscopic surgery in the treatment of pediatric spinal deformity are expanding. We have extended our video-assisted thoracoscopic surgery repertoire to include endoscopic thoracoplasty for treatment of rib deformities associated with idiopathic scoliosis. The technique for endoscopic thoracoplasty is discussed, and illustrative cases are presented.

Adolescent↗
PubMed1997

Multiple noncontiguous injuries of the spine in a child: atlantooccipital dislocation and seat-belt injury of the lumbar spine.

Multiple noncontiguous injuries of nonadjoining regions of the spine in children are rare. Such injuries can be overlooked as the neurological deficit caused by one injury can be masked by the other. The combination of atlantooccipital dislocation and a seat-belt injury of the spine in children is rare. We describe an unusual case of atlantooccipital dislocation in combination with a seat-belt injury of the lumbar spine in a surviving child. Early halo-vest immobilization was an effective treatment in this patient. Although survival with atlantooccipital injuries is becoming common, severe and persistent neurological deficits can result in high morbidity. A brief description of the pathomechanics, diagnosis and treatment of the atlantooccipital dislocation and lumbar seat-belt injury is given.

Atlanto-Occipital Joint↗
PubMed1997

Hyphenated history: the Phelps-Baker test.

The language of orthopedics is filled with eponyms. Orthopedic surgeons speak cryptically to one another using code words and "orthopedic pig-Latin." Certain hyphenated eponyms are particularly interesting, because they represent people who came to be partners in orthopedic history. The derivation of the Phelps-Baker test, an important component of the hip examination of children who suffer from cerebral palsy, named in honor of Winthrop Morgan Phelps and Lenox D. Baker, is described in this report.

Eponyms↗
PubMed1996

Video-assisted thoracoscopic releases of scoliotic anterior spines.

Anterior thoracic discectomy procedures with endplate ablations and posterior spinal fusions are advocated for patients with severe scoliosis. These surgical procedures traditionally are accomplished through extensive open thoracotomy incisions. At Children's Hospital Medical Center, Cincinnati, surgical team members have used a minimally invasive procedure, video-assisted thoracoscopic surgery (VATS), to release the anterior spines of patients with scoliosis. This surgical technique has many benefits, including reduced blood loss, decreased postoperative pain, and improved postoperative pulmonary function. Perioperative nurses play key roles in the team approach to patient care through provision of preoperative education programs for patients and family members, organization of OR equipment, anticipation of possible intraoperative complications, and postoperative patient care planning. The implementation of a VATS program within an institution requires a significant financial investment and a long-term commitment to the ongoing education of OR personnel.

Child↗
PubMed1996

Role of osteotomy in the treatment of slipped capital femoral epiphysis.

The treatment of severe slipped capital femoral epiphysis (SCFE) remains problematic. Treatment of most mild and moderate cases has been simplified, not by our increasing knowledge of physiology or molecular genetics, but by the advances in radiographic imaging, metallurgy, and the development of cannulated screw technology. Most centers agree that the placement of a single pin or screw across the center of the epiphysis, stabilizing the unreduced epiphysis and keeping the implant out of the joint space until physeal closure is achieved, is the most efficient and effective method for the majority of slips. Despite this knowledge and improvement in early results, the problems of avascular necrosis and chondrolysis have not been eliminated. Of more concern for patients whose severe unreduced SCFE has been pinned in situ is the secondary problem of the altered biomechanics of the lower extremity, leaving the hip in extension, the limb externally rotated and shortened. Most series show poor long-term results of realignment osteotomies; however, most series also show poor long-term results of severe slips treated by any means. These population groups are historically the same. Current radiographic imaging and implant design may eliminate most of the technical problems encountered with the accuracy and stability of realignment osteotomies, thereby allowing earlier motion, which may improve our results. The current status of realignment osteotomies is reviewed.

Epiphyses, Slipped↗
PubMed1996

Open fracture of the tibia in children.

The records of eighty-three children who had had an open fracture of the tibial metaphysis or diaphysis between January 1983 and July, 1993 were studied retrospectively. The average duration of follow-up was fourteen months (range, two to seventy-five months). There were twenty-four grade-I, forty grade-II, thirteen grade-IIIA, six grade-IIIB, and no grade-IIIC fractures, according to the classification scheme of Gustilo et al. Sixty patients (72 per cent) had sustained the fracture when they were struck by an automobile, and forty-eight patients (58 per cent) had other associated major injuries. All fractures were treated with irrigation and débridement, and antibiotics were administered parenterally for a minimum of forty-eight hours. Thirty-two patients were managed with immobilization in a cast only; forty, with transcutaneous fixation with an average of two Steinmann pins followed by immobilization in a cast; nine, with external fixation; one, with open reduction and internal fixation with two screws and two pins; and one, with delayed intramedullary nailing. Fifty-seven wounds were closed primarily (forty-four, over a Penrose drain, and thirteen, without a drain), ten were treated with delayed closure, four were allowed to heal by secondary intention, seven were covered with a soft-tissue flap, and five were treated with skin-grafting (a split-thickness skin graft was used for four, and a split-thickness and a full-thickness skin graft were used for one). The average time to union was fifteen weeks (range, five to sixty-one weeks), with the fracture healing by sixteen weeks in sixty-four patients (77 per cent). Eighteen patients (22 per cent) had delayed union, and only one patient (1 per cent) had non-union. Secondary procedures were necessary to achieve union in only two patients. Two patients had a superficial wound infection, and no patient had osteomyelitis. One patient, who had been managed with external fixation, had a pin-track infection; none of the patients who had had transcutaneous fixation had a pin-track infection. Two patients had a compartment syndrome, and two patients had a transient stretch injury of a nerve (the peroneal nerve in one and the sciatic nerve in the other). Four fractures healed with an angulatory deformity of more than 10 degrees in any plane. Five patients had overgrowth of the limb of one centimeter or more. Physeal arrest did not occur in any patient. We concluded that treatment of unstable open fractures of the tibia in children with débridement and transcutaneous fixation followed by immobilization in a cast leads to good anatomical and functional results. We prefer this technique to external fixation, which is associated with several potential complications. Loose closure of a clean open wound over a Penrose drain is effective and can be safely utilized in selected children.

Adolescent↗