Failure Of Conservative Treatment Research Articles

Endoscopy on the surgical intensive care unit

Endoscopy is most frequently performed in intensive care units (ICU) for gastrointestinal bleeding; however, there are other indications for performing an endoscopy on the ICU. This article shows the indications for this, the background and the peri-interventional and postinterventional management. The endoscopic placement of apostpyloric feeding tube is awell-established procedure. For anastomotic leakage in the esophagus and rectum, the endoscopic vacuum therapy is the treatment of choice. Gastrointestinal motility disorders are afrequent phenomenon in critically ill patients and are associated with increased mortality. With acecal diameter > 9-12 mm, endoscopic decompression can be performed; however, this is associated with an increased risk of perforation and should only be carried out after the failure of conservative treatment.

Clinical Predictors of Failed Medical Treatment in Patients with Tubo-Ovarian Abscess

<h3>Study Objective</h3> To estimate the risk of failed medical treatment in patients with tubo-ovarian abscess (TOA) and assess the external validity of a clinical risk score. <h3>Design</h3> External validation study. The probability of failed medical treatment predicted from the reference risk score was compared with the observed rates in a retrospective cohort of patients with TOA. <h3>Setting</h3> Safety-net teaching hospital system in Houston, Texas. <h3>Patients or Participants</h3> 169 consecutive patients admitted with TOA between 2011 and 2018 were included. Some were treated conservatively with IV antibiotics; others required a drainage procedure. <h3>Interventions</h3> Predictors of failed conservative treatment were captured. The previously published predictors by Fouks et al, included age>36, WBC ≥ 16000), abscess diameter (≥ 7 cm) and bilateral abscesses. A clinical risk score was calculated for each patient and correlated with the risk of failed medical treatment. A multivariate logistic regression using the patient characteristics was created, in addition to the prediction model using the risk score. Then the calibration, discrimination and accuracy of the model were evaluated to perform the external validation analysis. <h3>Measurements and Main Results</h3> Among 169 eligible patients, 50.2% were successfully treated with IV antibiotics and 49.8% needed drainage via minimally invasive or traditional surgery. Patients undergoing the intervention were more likely to be older, diabetic, to present with elevated white blood cell count, have fever and a large abscess size on univariate analysis. Large abscess size was found to be the strongest independent predictor for intervention in our cohort. The AUC curve for the adjusted model was 0.77 (0.71-0.84), indicating good discrimination. The Brier score was favorable (0.19) and the observed and predicted rates were similar ranging across different risk scores. <h3>Conclusion</h3> Our results provide external validation to a simple clinical risk score predicting failed medical treatment in patients with TOA. Large abscess size was found to be the strongest independent predictor for intervention.

A systematic review and meta-analysis of risk factors in the conservative treatment of cesarean scar pregnancy.

It is important to investigate the risk factors of the failure of conservative treatment for cesarean scar pregnancy in order to improve the success rate of treatment and preserve the fertility of patients. This article aims to investigate these factors by meta-analysis, so as to serve as a clinical reference. PubMed, MEDLINE, Embase, and the Cochrane Library databases were searched. Literatures related to the treatment of cesarean scar pregnancy (CSP) were selected. Literatures were screened according to the inclusion and exclusion criteria, and the quality was evaluated. RevMan 5.3.5 software was used to conduct the meta-analysis on the factors of treatment failure. A total of 7 articles were included in this study, involving 251 patients. Among them, there were 79 (31.5%) cases of conservative treatment failure. The results of the meta-analysis showed that more than 2 cesarean sections [OR =1.79, 95% CI: (0.94, 3.42), P=0.08], mass type CSP [OR =4.06, 95% CI: (2.11, 7.81), P<0.0001], serum β-hCG value <20,000 U/L [OR =1.81, 95% CI: (0.92, 3.54), P=0.09], and pregnancy time over 3 years from last cesarean section [OR =4.12, 95% CI: (1.29, 13.08), P=0.02] were the risk factors for the failure of conservative treatment of CSP. A total of 7 studies were included in this meta-analysis. The results showed that more than 2 cesarean sections, mass type CSP, serum β-hCG value <20,000 U/L, and pregnancy time over 3 years from last cesarean section were risk factors for the failure of conservative treatment of CSP. Patients with the above risk factors should be screened and informed of the possibility of conservative treatment failure in a timely manner, and different methods should be considered for treatment.

Urologists' knowledge base and practice patterns in Peyronie's disease. A national survey of members of the italian andrology society.

Aim of our study was to explore the basic knowledge base and diagnostic and therapeutic practice patterns in Peyronie's disease (PD) of a large number of physicians belonging to the Italian Andrology Society (SIA). Our survey is based on two questionnaires which were e-mailed to the members of the SIA. The first questionnaire explored diagnostic and therapeutic practice patterns of SIA physicians, while the second questionnaire focused on their knowledge of the disease, as well as their training and level of experience in the specific field. We then planned to compare our outcomes with similar PD surveys from other countries. The first questionnaire was answered by 142 SIA physicians. The second questionnaire was answered by 83 SIA physicians. Most respondents (74.6%) chose penile ultrasonography as first-line diagnostic approach and 47.1% prefer to perform a color Doppler ultrasound after pharmaco-induced erection. Concerning the therapeutic practice patterns in active stage of the disease, most respondents (99.29%) prefer conservative medical therapy. Additionally, most respondents (64.78%), when failure of conservative treatment had been established, considered surgical treatment necessary, specifically corporoplasty, which may be associated with other techniques. The results of our survey show that, in comparison to their foreign counterparts, Italian SIA uro-andrologists have a more proactive diagnostic approach right from when patients first present. When PD is still in its active stage, SIA uro-andrologists mostly opt for medical therapy. In advanced disease or if conservative treatment fails, our survey indicates a greater preference for surgical treatment. Answers to the theoretical knowledge questions showed that SIA physicians have a good understanding of the disease's etiology, epidemiology, and clinical picture, and of the appropriate indications for treatment.

Suture Tape Augmentation in Lateral Ankle Ligament Surgery: Current Concepts Review.

Chronic lateral ankle instability (CLAI) is a condition that is characterized by persistent disability and recurrent ankle sprains while encompassing both functional and mechanical (laxity) instability. Failure of conservative treatment for CLAI often necessitates operative intervention to restore the stability of the ankle joint. The traditional or modified Broström techniques have been the gold standard operative approaches to address CLAI with satisfactory results; however, patients with generalized ligament laxity (GLL), prior unsuccessful repair, high body mass index, or high-demand athletes may experience suboptimal outcomes. Synthetic ligament constructs have been tested as an adjunct to orthopedic procedures to reinforce repaired or reconstructed ligaments or tendons with the hope of early mobilization, faster rehabilitation, and long-term prevention of instability. Suture tape augmentation is useful to address CLAI. Multiple operative techniques have been described. Because of the heterogeneity among the reported techniques and variability in postoperative rehabilitation protocols, it is difficult to evaluate whether the use of suture tape augmentation provides true clinical benefit in patients with CLAI. This review aims to provide a comprehensive outline of all the current techniques using suture tape augmentation for treatment of CLAI as well as present recent research aimed at guiding evidence-based protocols.

Ultrasonographic features can predict outcome of conservative management of acute appendicitis in children.

To determine whether specific ultrasonographic features can predict failure of conservative treatment of acute appendicitis. A 2-year retrospective study was conducted on children admitted with acute appendicitis. Those with uncomplicated appendicitis diagnosed solely by ultrasound, and treated conservatively, were followed 18-24m to assess treatment outcome. Management was considered successful if recurrent acute appendicitis was not observed during follow-up. Appendix diameter, wall thickness, presence of mucosal ulceration, hyperechogenic fat, free fluid, and lymph nodes were evaluated as potential discriminatory ultrasonographic predictors. T-tests, chi-square, sensitivity, specificity, and odds ratios were calculated. Out of 556 consecutive patients that were admitted with acute appendicitis, 180 (32%) managed conservatively. One hundred eleven (62%) imaged by US only. Ninety-two out of 111 (83%) were followed 18-24m to assess treatment outcome, and 19/111 (17%) were lost to follow-up. Conservative management was successful in 72/92 (78.2%), with treatment failure in 20/92 (21.8%) (5/92 (5.4%) with recurrent acute appendicitis and 15/92 (16.3%) underwent appendectomy). Of the ultrasonographic features studied, mucosal ulceration demonstrated statistically significant predictive value. Fifteen out of 20 (75%) treatment failures had mucosal ulceration, compared to 21/72 (29.2%) of the patients with successful treatment (p < 0.001). This yielded a positive odds ratio of 7.3 (2.3-22.6, 95% CI), 70.8% (58.9-80.9, 95% CI) specificity, and 75% (50.9-91.3, 95% CI) sensitivity. Positive predictive value was 41.6% (31.5-52.5, 95% CI) while intact mucosa had negative predictive value of 91% (82.4-95.6, 95% CI) for conservative management success. The presence or absence of appendiceal mucosal ulceration at ultrasound can predict conservative management outcome in the setting of acute appendicitis, potentially improving pediatric patient selection for conservative management.

Correlates of post-dural puncture headache and efficacy of different treatment options: a monocentric retrospective study.

Post-dural puncture headache (PDPH) is a severe positional headache that appears usually within 72 hours after inadvertent dural puncture, secondary to cerebrospinal fluid leakage. It is treated first by conservative treatment (including bed rest, hydration, caffeine and simple analgesia) and then by invasive procedures such as blood patch. This study aims to evaluate factors associated with PDPH among a sample of Lebanese patients and assess the rate of success of different treatment modalities administered in a specific sequence: conservative treatment first, then ultrasound-guided bilateral greater occipital nerve block (GONB) if failure of conservative treatment and finally epidural blood patch (EBP) if failure of GONB. A retrospective case-control study was conducted between January 2015 and December 2019 in the Notre-Dame des Secours University Hospital. Out of a total of 10,051 procedures, 18 cases were diagnosed with PDPH and were matched based on gender, age and procedure type to a control group of patients who did not develop PDPH randomly selected (72 patients). Higher body mass index (adjusted odds ratio (ORa) = 0.77) was significantly associated with lower odds of PDPH, whereas the presence of previous chronic headache (ORa = 5.56) was significantly associated with higher odds of PDPH. Seven out of 18 (38.89%) had their pain symptoms/headache resolved on conservative treatment. Out of the remaining 11 patients, 6 (33.33%) had their symptoms resolved on GONB with a significant decrease in the pain score 48 hours after GONB compared to baseline (5.55 vs 9.73; p = 0.007). Five patients (27.78%) had their symptoms resolved using a blood patch, with a significant decrease in the pain score after blood patch compared to baseline (3.00 vs 9.80; p = 0.041). Our preliminary data suggest that ultrasound-guided GONB is a minimally risky and efficacious technique for those who fail to respond to conservative treatment.

THE EFFECT OF CRYOABLATION ON FUNCTIONING AND GAIT IN PATIENTS WITH LOW BACK PAIN

Introduction Low back pain and comorbid afflictions negatively influence the quality of life, postural control and gait. Facet joint syndrome is one of the causes of low back pain. Cryoablation is a minimal invasive percutaneuous technique for zygapophysial joint syndrome. Aim The aim of the study was to investigate the effectiveness of the cryoablation in patients with chronic low back pain on pain, disability and spatiotemporal gait parameters in the course of facet joint syndrome. Material and methods The study included 19 patients (13 women, 7 men) with chronic low back and facet arthropathic changes in MRI, and with failure in conservative treatment. The evaluation was performed before and with one-month follow-up after cryoablation and included pain assessment (Numeric Rating Scale), the evaluation of functional state and disability (Revised Oswestry Low Back Pain Disability Index, Roland-Morris Disability Questionnaire) and analysis of spatiotemporal gait parameters (treadmill). Results A significant improvement in pain, functioning and spatiotemporal gait parameters such as distance and the number of steps were found. Conclusions Cryoablation is an effective method for pain reduction in facet joint syndrome, which improves functioning and gait. Cryoanalgesia is a safe procedure for the treatment of low back pain related to facet joint syndrome if earlier conservative management failed. Keywords: cryoablation, low back pain, functional assessment, gait

RELATIONSHIP BETWEEN URODYNAMIC PARAMETERS AND LEVEL OF SPINAL CORD INJURY

Introduction Low back pain and comorbid afflictions influence negatively on the quality of life, postural control and gait. Facet joint syndrome is one of the causes of low back pain. Cryoablation is a minimal invasive percutaneuous technique for zygapophysial joint syndrome. Aim The aim of the study was to investigate the effectiveness of the cryoablation in patients with chronic low back pain on pain, disability and spatiotemporal gait parameters in the course of facet joint syndrome. Material and methods The study included 19 patients (13 women, 7 men) with chronic low back and facet arthropathic changes in MRI, and with failure in conservative treatment. The evaluation was performed before and with one-month follow-up after cryoablation and included pain assessment (Numeric Rating Scale), the evaluation of functional state and disability (Revised Oswestry Low Back Pain Disability Index, Roland-Morris Disability Questionnaire) and an analysis of spatiotemporal gait parameters (treadmill). Results A significant improvement in pain, functioning and spatiotemporal gait parameters such as distance and the number of steps were found. Conclusions Cryoablation is an effective method for pain reduction in facet joint syndrome, which improves functioning and gait. Cryoanalgesia is a safe procedure for the treatment of low back pain related to facet joint syndrome if earlier conservative management failed. Keywords: cryoablation, low back pain, functional assessment, gait

REHABILITATION PROTOCOL AFTER HIP ARTHROSCOPY

Introduction Pain in the hip joint area related to the femoro-acetabular impingement syndrome, local cartilage damage, or labrum tear is an increasingly common cause of orthopedic consultations. In the case of failure of conservative treatment, the treatment of choice is the arthroscopic treatment of the lesions and arthroplasty. As after any surgical procedure, an important aspect is subsequent rehabilitation, which may increase the positive effect of the treatment. Aim This article aims to present the original rehabilitation procedure after hip arthroscopy. Material and methods The presented rehabilitation program lasts about 5–9 months and consists of four stages. The first stage, lasting two weeks, mainly focuses on protecting the treated structures, reducing pain, and preventing adhesions and blood clots. Stage two, which lasts up to 4–6 weeks, is to restore the correct gait pattern and progress exercises from stage one. In the third stage, which lasts up to 12 weeks, rehabilitation focuses on regaining the full range of motion, muscle strength, and endurance similar to the non-operated leg. After a positive functional assessment, the patient progresses to the fourth stage, which prepares him to return to the entire sports activity. The decision to return to sport is based on the relevant results of the functional assessment and clinical examination. Results This work presents the original protocol of rehabilitation after arthroscopic procedures of the hip joint. Comparing the rehabilitation process, criteria for progression, and the time to return to sport, the protocol proposed by us is in line with the currently accepted rehabilitation trends in the world. Conclusions The rehabilitation protocol proposed by our team was based on the authors’ experience and the available literature. The rehabilitation process has been divided into 4 phases with precise criteria for progression. Biomechanical Functional Assessment plays an important role in the control of the entire course of rehabilitation. Keywords: hip arthroscopy, rehabilitation protocol, functional evaluation

Vertebral Endplate Changes Correlate with Presence of Cartilaginous Endplate in the Herniated Disc Tissue: Factor Predicting Failure of Conservative Treatment.

Study DesignCross-sectional comparative.PurposeTo characterize the scores of disc degeneration, inflammation, and nerve density in herniated disc samples and associate findings with the presence of vertebral endplate (VEP) changes on magnetic resonance imaging (MRI).Overview of LiteratureConsidering the role of disc composition in spontaneous regression and persistence of pain during conservative management, it is important to identify the influencing factors. VEP changes are highly associated with disc degeneration, but their correlation with herniated disc composition has not yet been reported.MethodsFifty-one discs were obtained from patients undergoing surgery for herniated disc. Their ages ranged from 19–65 years, and 31/51 were male. Pre-surgical T1 and T2 weighted lumbar-spine MRIs were analyzed to observe Pfirrmann grade, VEP defects, herniation type, Modic changes, and high-intensity zones (HIZ) at the affected level. Five-micron thick sections were stained with hematoxylin and eosin, Alcian blue periodic acid–Schiff stain; examined for histological degeneration scores (HDS; 0–15), inflammation (0 [absence]–3 [severe]), and presence of cartilaginous endplate (CEP). Three-micron thick sections were stained with protein-gene-product 9.5 and expression was counted/mm2. Data was analyzed, and p<0.05 was considered to indicate statistical significance.ResultsVEP defects, Modic changes, and HIZ were respectively observed in 30/51, 16/51, and 6/51 of the samples. CEP was observed in 26/51 samples and in 23/51 with endplate defects. Discs with adjacent VEP defects showed increased HDS (p<0.001) and inflammation (p<0.001). Discs with adjacent Modic changes also revealed increased HDS (p=0.01). Histological sections with CEP showed increased HDS (p<0.001) and inflammation (p<0.001), and nerve density was significantly positively correlated with HDS (r=0.27, p=0.02).ConclusionsVEP changes can modulate degeneration and inflammation of herniated discs. Presence of these changes is highly predictive of the occurrence of CEP in herniated discs, which leads to slow resorption and persistent clinical symptoms.

Median nerve injury after local injection

Background, Iatrogenic median nerve injuries after local injection of carpal tunnel syndrome occur via direct injury. Complete or partial injury was observed. Surgeon should know the risk factors and how to prevent this case. Aim of the work. To overview the incidence, commonest drugs, our expertise in treating injection-related injuries, the functional recovery and how to prevent this injuries. Patient and methods. A retrospective analysis of management of 8 cases of injection-related iatrogenic median nerve injury from 2015 to 2020, Clinical presentation, neurological, and electrophysiological, were done. Failure of Conservative treatment is indicator for surgery, in the form of exploration, microscopic assessment of the nerve, neuroma excision and direct repair or nerve grafting. Results. The Mean age was, 3 Male (37.5%) and 5 Female (62.5%), with mean follow up 10.75-6.7 ms. median nerve is a common site for injury after local injection as it a common procedure. The conservative management for all patients, were followed by surgical treatment in 6 cases which had no recovery. Prognosis was depending on many factors, exact site of injection, intrafacicular or not, amount of drug which was injected, time between injury and surgical management. Conclusion. Iatrogenic nerve injuries resulting from injections are a common occurrence. The Surgeons must understand the 3 D anatomical approaches to the median nerve and its abnormal anatomy. The key to improvement is still early diagnoses and treatment planning. The motor function stills the problem to regain with good sensory recovery.

Accessory medial cuneiform bone in a child: unreported site and review of literature

&lt;p&gt;Accessory ossicles of the foot are not uncommon finding in foot radiographs which has confused radiologists and orthopedic surgeons from time immemorial. Occasionally these bones are symptomatic, hindering daily activities of patients. We present a case report of an eleven years old girl with a symptomatic accessory medial cuneiform on the dorsal aspect of left foot. The child was evaluated radiologically and after a trial of failed conservative treatment, she was operated upon. Intraoperatively a superficial nerve on dorsum of this accessory ossicle was found, and the extra bone was excised. This accessory bone was found to be related to medial cuneiform bone at its dorsal and distal surface making to suggest its name as "Os cuneo-I metatarsale-I dorsale". Detailed radiological evaluation is mandatory for identification and exact anatomical localization of the extra bone before proceeding to excision, when non operative treatment fails to relieve the symptoms.&lt;/p&gt;&lt;p&gt;&lt;strong&gt; &lt;/strong&gt;&lt;/p&gt;

Incidence and risk factors for failure of conservative treatment for valgus impacted femoral neck fractures in elderly patients with high-risk comorbidities–A bi-center retrospective observational study

Background–Establishing the ideal indications for conservative treatment for elderly patients with valgus impacted femoral neck fractures is difficult because few studies have identified predictive factors for the failure of this treatment method. This study aimed to report the outcomes of conservative treatment for elderly patients with valgus impacted femoral neck fractures and determine risk factors that lead to treatment failure. Methods–From January 2009 to December 2018, 206 patients with valgus impacted femoral neck fracture were identified at two institutions. Elderly patients with valgus impacted femoral neck fractures corresponding to an Orthopedic Trauma Association/AO Foundation (OTA/AO) classification of 31-B1.1 or 31-B1.2 who were treated conservatively were included in the study. The following data was collected to compare the preoperative characteristics of patients with valgus impacted femoral neck fractures: age, sex, bone mineral density, medical comorbidities (hypertension, diabetes mellitus, ischemic heart disease, arrhythmia, chronic kidney disease [CKD], and stroke), medial cortex displacement, valgus angle, posterior tilt, and retroversion. These data were used to assess the independent predictors for failure of conservative treatment using multiple logistic regression analysis. Results–The failure rate after conservative treatment for valgus impacted femoral neck fracture in the enrolled patient group was 27.3% (15 of 55). CKD, presence of medial cortex displacement, high posterior tilt, and high retroversion were all identified as independent predictors for failure. The cut-off values for retroversion and posterior tilt that predicted treatment failure were 12.5° (area under curve [AUC] 0.768, p = 0.002, 95% confidence interval [CI] 0.632–0.903, sensitivity 0.733, 1-specificity 0.300) and 7.5° (AUC 0.712, p = 0.016, 95% CI 0.542- 0.881, sensitivity 0.667, 1-specificity 0.325), respectively. Conclusions–The present study showed that a high union rate could be obtained if the indications for conservative treatment in for elderly patients with valgus impacted femoral neck fractures are well-defined. Thus, we believe that conservative treatment can be a viable option for valgus impacted femoral neck fractures when elderly patients with high-risk comorbidities have acceptable fracture angulation, no medial cortex displacement, and no CKD. Level of Evidence–Level III, retrospective cohort study.

Are injectable regenerative therapies effective in the treatment of degenerative disc disease? A systematic review.

Degenerative disc disease is a major health concern in spine surgery. The aim of this systematic review was to summarize the current knowledge about injectable regenerative therapies (mesenchymal stem cells [MSC] or platelet rich plasma [PRP]) in degenerative disc disease. A research and analysis of the literature on Pubmed, Medscape, Medline, Google Scholar and Cochrane databases was performed, in accordance with the Preferential Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flowchart. Only peer-reviewed randomized controlled trials (RCTs), prospective single-arm trials, case series, and cohort studies were included. A total of 17 studies were included. All were homogeneous regarding indications to the procedure: discogenic low-back pain for at least 3-6 months, failure of conservative treatment, MRI evidence of disc degeneration. A total of 182 patients were treated with MSC and 198 patients were treated with PRP. Considering the efficacy, the studies were heterogeneous in clinical evaluation systems; however, they all reported significant improvement in clinical and functional scores. Neither major complications nor adverse effects were reported by any author. As for radiographical outcome none of the studies reported a disc height improvement after treatment. Degenerative disc disease is a major health concern. Regenerative therapies could play a role in the treatment of its symptoms, as they have been proven to be clinically effective, cheap, and safe. Nevertheless, further studies are needed, in order to establish evidence based standardized treatments.

Current Concepts on Subtalar Instability.

Subtalar instability remains a topic of debate, and its precise cause is still unknown. The mechanism of injury and clinical symptoms of ankle and subtalar instabilities largely overlap, resulting in many cases of isolated or combined subtalar instability that are often misdiagnosed. Neglecting the subtalar instability may lead to failure of conservative or surgical treatment and result in chronic ankle instability. Understanding the accurate anatomy and biomechanics of the subtalar joint, their interplay, and the contributions of the different subtalar soft tissue structures is fundamental to correctly diagnose and manage subtalar instability. An accurate diagnosis is crucial to correctly identify those patients with instability who may require conservative or surgical treatment. Many different nonsurgical and surgical approaches have been proposed to manage combined or isolated subtalar instability, and the clinician should be aware of available treatment options to make an informed decision. In this current concepts narrative review, we provide a comprehensive overview of the current knowledge on the anatomy, biomechanics, clinical and imaging diagnosis, nonsurgical and surgical treatment options, and outcomes after subtalar instability treatment.

Halo vest immobilization – an institutional review of safety in acute cervical spine injury from 2013 to 2017

Objective: Halo vest immobilization (HVI) remains an important treatment option for occipital-cervical injuries. It provides the surgeon with a safe and effective medical treatment options for challenging patients. The aim of this study was to evaluate the safety of HVI in these patients. Methods: This retrospective study identified adult patients treated with Halo vests immobilization (HVI) for acute cervical spine injury at our metropolitan level 1 trauma center from 2013 to 2017. This heterogenous cohort included 67 consecutive patients with acute cervical spine injury secondary to trauma or iatrogenic injury following surgical intervention with a mean age of 52 and a mean injury severity score (ISS) of 18. Forty-six percent of patients were treated with HVI as an adjunct therapy to surgical fixation (both short- and long-term immobilization), 45% of patients were treated with HVI as a primary medical treatment, and 9% of patients were treated with HVI instead of failed conservative medical treatment, such as cervical braces. Results: Pneumonia during the initial hospital stay was the most common complication (25%), followed by the correction of loose pins (22%) and pin site infections (18%). Overall, 51% of patients experienced at least one of these complications. There were significant associations between low initial GCS scores and the development of pneumonia (p < 0.001), high ISS scores and the development of pneumonia (p < 0.01), and duration of HVI and the occurrence of loose pins (p < 0.05). Four patients initially treated with HVI as primary medical treatment was converted to surgical treatment due to an intolerance of HVI or non-healing injuries. Conclusions:The HVI is a safe and effective treatment modality in a subset of patients with complex cervical junction and subaxial cervical spine pathology.

Exomphalos with intestinal fistulation: Case series and systematic review for clinical characterization, management and embryopathogenesis

IntroductionExomphalos with intestinal fistulation (EIF) is a rare variant of exomphalos with intestine opening to the surface of an intact sac, and may result in a diagnostic challenge. We report 3 new cases and conducted a systematic review of the literature, to characterize its association with the type of exomphalos and vitellointestinal duct (VI) as well as to evaluate its management and outcomes. MethodsA literature search from PubMed using keywords pertaining to exomphalos and fistulation was used to identify all unique cases reported between 1950 and 2020, in addition to the case series reported here, to establish the clinical presentation, histological findings, management and outcomes. ResultsWe found a total of 28 cases of EIF, of which 25 had been reported in 70 years from 19 reports. There was a male predominance (4-to-1 ratio). The majority presented as an exomphalos minor (n = 23, 82%) with a prolapsing patent VI duct (n = 16, 57%), most had evidence of Meckel's diverticulum (n = 25, 89%). All but one case were managed by fistula excision with or without ileal resection and anastomosis, followed by primary closure of the abdominal wall defect. All patients, except one with Trisomy 13 who received only palliative care, underwent surgery. Post-operative complications occurred in 7 patients (25%). Congenital anomalies were present in 12 (43%) and none had Beckwith-Wiedemann syndrome. Mortality occurred in 4 patients (14%) between 3 and 17 days. One EIF with exomphalos major failed early conservative treatment due to sac disintegration and sepsis, requiring staged closure, but had a good outcome. DiscussionEIF is a rare entity usually associated with exomphalos minor and vitelline duct involvement. EIF presentation is variable but primary surgery is the mainstay of treatment with generally good outcomes. Common features of EIF suggest a different embryopathogenesis to other forms of exomphalos.

Indocyanine Green Angiography for Use in Robotic Spermatic Cord Denervation

Introduction: Chronic orchialgia continues to be a challenge for urologists to treat and for patients to live with. Currently, conservative treatment (rest, anti-inflammatory drugs, physical therapy, and antidepressants) is the first-line therapy for men struggling with chronic orchialgia.1 However, when these approaches fail, alternative therapies are required. Before resorting to orchiectomy, microsurgical spermatic cord denervation (MSCD) has been shown to significantly decrease pain with few side effects for the correctly selected patient.2 Accurate microsurgical technique and especially avoidance of arterial injury is critical, especially for novice surgeons as well as in cases with aberrant anatomy. In this video presentation, we describe the novel use of indocyanine green (ICG) angiography in correlation with Doppler during robotic MSCD for the purpose of arterial localization and verification of preservation. Methods: Robotic MSCD was performed in 10 cases of chronic orchialgia after failed conservative treatment and after an effective anesthetic cord block in the office. The procedure consists of a few distinct steps: division of the cremasteric muscle, isolation of the vas deferens and division of the central adipose tissue. ICG was injected twice in each procedure: to identify the testicular artery during central dissection and to confirm preservation of the artery at conclusion. Micro-Doppler was used adjunctly to confirm findings. Results: In all 10 patients, ICG angiography identified the location and course of the testicular artery, including in cases of aberrant and reoperative anatomy. Doppler assessment confirmed this. Conclusion: ICG angiography during robotic MSCD is a novel technique to clarify spermatic cord arterial anatomy and is especially useful in the setting of prior surgery and developmental abnormality. This technique is a valuable adjunct to this procedure for novice surgeons, as well as producing visual documentation of arterial preservation, without adding significant time or complication. Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. No funding was received for this article. No competing financial interests exist. Runtime of video: 7 mins and 53 secs

Odontoid Type II fractures in elderly: what are the real management goals and how to best achieve them? A multicenter European study on functional outcome.

Odontoid fractures constitute the most common cervical fractures in elderly. External immobilization is the treatment of choice for Type I and III; there is still no wide consensus about the best management of Type II fractures. Observational multicenter study was conducted on a prospectively built database on elderly patients (> 75years) with Type II odontoid fracture managed conservatively during the last 10years. All patients underwent CT scan on admission and at 3months; if indicated, selected patient had CT scan at 6 and 12months. All patients were clinically evaluated by Neck Disability Index (NDI), Charlson Comorbidity Index (CCI), and American Society of Anaesthesiologists classification (ASA) on admission; NDI was assessed also at 6weeks, 3, 6, 12, and 24months; furthermore, a quality of life (QoL) assessment with the SF-12 form was performed at 3 and 12months. Among the 260 patients enrolled, 177 (68%) were women and 83 (32%) men, with a median age of 83years. Patients were followed up for a minimum of 24months: 247 (95%) showed an excellent functional outcome within 6weeks, among them 117 (45%) showed a good bony healing, whereas 130 (50%) healed in pseudo-arthrosis. The residual 5% were still variably symptomatic at 12weeks; however, only 5 out of 13 (2% of the total cohort) required delayed surgery. This study showed that a conservative approach to odontoid Type II fracture in elderly is an effective and valid option, resulting in an excellent functional outcome (regardless of bony fusion) in the majority of cases. Failure of conservative treatment can be safely addressed with surgical fixation at a later stage.