Fluoroscopic Placement Research Articles

Spinal Hematoma Following Fluoroscopic Placement of a Spinal Drain for Thoracic Endovascular Aortic Repair: Advantages of Paramedian versus Midline Approach

Spinal Hematoma Following Fluoroscopic Placement of a Spinal Drain for Thoracic Endovascular Aortic Repair: Advantages of Paramedian versus Midline Approach

Accurate placement of thoracolumbar pedicle screws using a handheld iOS-based navigation device: a prospective intra-patient agreement study

BACKGROUNDAccurate pedicle screw placement is a challenge with reported misplacement rates of 10% and higher. A handheld navigation device (HND) may provide accuracy equal to CT-based navigation (CT-Nav) but without the cost and complexity. OBJECTIVETo study the accuracy of a handheld navigation device for pedicle screw placement. STUDY DESIGNThis prospective cross-sectional study with consistently applied reference standard enrolled 20 patients undergoing 92 pedicle screw placements. PATIENTSPatients who underwent pedicle screw placement between May 2022 and September 2022. OUTCOME MEASURESPedicle screw placement accuracy per Gertzbein–Robbins. METHODSOnce the screw pilot hole was established, the proposed trajectory of the HND was compared with that proposed by CT-Nav. Postoperatively, screw accuracy was graded according to Gertzbein–Robbins by a blinded radiologist based on CT scans. Accuracy was compared between the two systems and published control for fluoroscopy assisted and CT-Nav placement using Bayesian posterior distribution. RESULTSThe trajectory proposed by the HND and CT-Nav were in agreement in 98.9% (95% Exact CI; 94.09%–99.97%). The HND accuracy was 98.9% with 91 screws rated “A” and 1 rated “C”. Noninferiority to fluoroscopic placement was achieved because the one-sided normal-approximation 95% CI Lower Bound (LB) of 95.3% is greater than the Performance Goal (PG) of 83.4%. Posthoc analysis demonstrated that the probability of superiority of the HND relative to the historical accuracy rate of 91.5% for fluoroscopy assisted procedures is >0.999 and that the HND's accuracy rate is within 4.5% of CT-Nav of 95.5% is >0.999. No adverse events or intra-operative complications associated with HND were observed. There was 1 (1.1%) intra-operative repositioning and no reoperations for any reason. CONCLUSIONSThe accuracy rate of the HND was 98.9%, and the proposed trajectory matched with CT-Nav in 98.9% of the time. This is superior to the historical published accuracy rate for fluoroscopy-assisted procedures and equivalent to the historical published accuracy rate for CT-Nav. Clinical Trial Registration NumberDutch trial register NL74268.058.20.

Placement of Resonance Stent for Malignant or Benign Ureteral Obstruction.

The aim of this article is to illustrate a step-by-step guide to placement of Resonance® metallic ureteral stent (Cook Medical, Bloomington, IN) for management of malignant or benign ureteral obstruction. In this article, the steps of operating room setup, patient positioning, gaining access to the upper urinary tract, and endoscopic and fluoroscopic placement of a Resonance ureteral stent are described.

Fluoroscopic placement of nasojejunal feeding tubes in COVID-19 patients in the prone position.

BackgroundCoronavirus disease 2019 (COVID‐19) has caused an increase in patients requiring enteral feeding access while undergoing proning for severe acute respiratory distress syndrome (ARDS). We investigated the safety and feasibility of fluoroscopy‐guided nasojejunal (NJ) feeding tube placement in the prone position.MethodsThis is a retrospective cohort study of all patients who underwent fluoroscopic placement of NJ feeding tubes at a single institution between March 2020 and December 2020. Primary end points were success rate and number of attempts. Chi‐squared and Fischer exact tests were used to compare prone and supine groups.ResultsA total of 210 patients were included in the study: 53 patients received NJ feeding tubes while prone and 157 while supine. All but one patient in the prone group had ARDS secondary to COVID‐19, whereas 47 (30.3%) had COVID‐19 in the supine group. The rate of successful placement was 94.3% in the prone group and 100% in the supine group. Mean number of attempts was 1.1 (SD, ±0.4) in the prone and 1.0 (SD, ±0.1) in the supine group (P = .14). Prone patients had a longer median fluoroscopy time (69 s, interquartile range [IQR] = 92; vs 48 s, IQR = 43; P < .001) and received a higher radiation dose during the procedure (47 mGy, IQR = 50; vs 25 mGy, IQR = 33; P = .004). No procedural complications were reported.ConclusionFluoroscopy‐guided NJ feeding tube placement in prone patients is feasible and safe. Patient positioning should not delay obtaining postpyloric feeding access.

An expanding role for interventional radiology: Medicare trends in fluoroscopic, endoscopic, and surgical enteric tube placement and maintenance from 2010 to 2018

BackgroundThe purpose of this study is to provide an update on trends in physician volume and payments for enteric tube placement and maintenance procedures by method, provider specialty, and practice setting amongst Medicare beneficiaries from 2010 to 2018. Materials and methodsClaims from the Medicare Part B Physician/Supplier Procedure Summary Master File (PSPSMF) for the years 2010 to 2018 were extracted using current procedural terminology (CPT) codes for gastrostomy and jejunostomy placement, as well as conversion of gastrostomy to gastrojejunostomy, fluoroscopy guided and non-image guided replacement. Total volumes and provider reimbursement were analyzed by provider specialty and practice setting. ResultsVolume of de novo placement of all enteric tubes decreased from 157,123 to 106,549 (−32.2%). While endoscopic placement decreased from 133,658 to 81,171 (−39.3%), the volume of fluoroscopic placement increased from 17,999 to 21,277 (18.2%). Fluoroscopic placement was largely performed by interventional radiology (IR) (91.7% in 2018). Surgical placement decreased from 5466 to 4101 (−25.0%). Volume of fluoroscopic replacement increased from 24,799 to 38,470 (55.1%), while non-image guided replacements decreased from 61,377 to 55,116 (−10.2%). Share of both fluoroscopic and non-image guided replacements by advanced practice providers (APPs) more than doubled over this time period. ConclusionDe novo placement of enteric tubes decreased from 2010 to 2018, likely related to increased awareness of the complications and limited benefits in scenarios such as end of life care. In contrast to the diminishing volume for gastroenterologists, there was increased participation by IR in both placement and maintenance procedures under fluoroscopic guidance. Summary statementDecreasing placement of enteric tubes suggests shifting attitudes and recommendations around end-of-life care. Increase in role by IR/APPs highlights the need for comprehensive care in these patients.

Outcomes following percutaneous endoscopic gastrostomy versus fluoroscopic procedures in the Medicare population

BackgroundIn the United States, few high-quality manuscripts have directly compared the complication profiles of percutaneous endoscopic versus fluoroscopic gastrostomy. Thus, it is our goal to compare these 2 common procedures to better understand their efficacy and complication profiles. Materials and MethodsA retrospective analysis of patient records from Medicare parts A/B from 2007 to 2012 was used to identify percutaneous fluoroscopic gastrostomy and percutaneous endoscopic gastrostomy procedures. Patient demographics were stratified by age, sex, comorbidities, and complications. ResultsA total of 258,641 patients were found to have either percutaneous fluoroscopic gastrostomy (26,477, 10.2%) or percutaneous endoscopic gastrostomy (232,164, 89.8%). Percutaneous fluoroscopic gastrostomy experienced greater rates for all complications queried. Multivariate analysis revealed that the percutaneous fluoroscopic gastrostomy cohort had statistically significant increased odds for short-term complications, such as ileus (odds ratio 1.4, 95% confidence interval 1.22–1.54), mechanical (odds ratio 2.4, 95% confidence interval 2.28–2.58), wound infection (odds ratio 1.4, 95% confidence interval 1.24–1.52), persistent fistula after tube removal (odds ratio 1.9, 95% confidence interval 1.78–2.12), and other complications (odds ratio 2.2, 95% confidence interval 2.03–2.37), and long-term complications, including abdominal wall pain (odds ratio 1.4, 95% confidence interval 1.33–1.44), wound infection (odds ratio 1.1, 95% confidence interval 1.01–1.15), and persistent fistula after tube removal (odds ratio 1.8, 95% confidence interval 1.72–1.87). ConclusionGastrostomy tubes are more frequently being placed via percutaneous endoscopic and fluoroscopic methods. This study suggests that those undergoing fluoroscopic placement have higher odds of developing short- and long-term postoperative complications.

Ultrasound-guided cooled radiofrequency ablation of the genicular nerves: a technique paper.

Aim: Cooled radiofrequency ablation (CRFA) has demonstrated efficacy in the management of knee pain caused by osteoarthritis. A typical procedure involves fluoroscopic placement of internally cooled radiofrequency probes to ensure the probes are located near target genicular nerves. Patients & methods: A new technique was developed to perform CRFA using ultrasound (US) guidance. Patient outcomes were reported using a telephone survey. Results: Ablation procedures were successfully performed using US guidance. A total of 51 patients were retrospectively identified for telephone screening. A total of 22 patients completed the telephone questionnaire. There were no safety concerns identified and the majority of patients reported satisfactory outcomes. Conclusion: Patient outcomes demonstrate that US-guided CRFA procedures provide pain relief and functional improvement. Further studies are needed to compare the efficacy of US-guided CRFA to fluoroscopy-guided CRFA procedures.

Abstract No. 593 Endoscopic, fluoroscopy-guided, and surgically placed enteric feeding tubes: Medicare trends from 2010 to 2017

To study the trends in physician volume and payments of enteric feeding tube placement procedures by placement method among Medicare beneficiaries from 2010-2017. Claims from the Medicare Part B Physician/Supplier Procedure Summary Master File (PSPSMF) for the years 2010 to 2017 were extracted using the CPT codes for gastrostomy and jejunostomy tube placement. Total volumes and payment amounts (professional component) were analyzed. Volume for gastrostomy and jejunostomy tube placement from 2010-2017 decreased from 153,081 to 111,122 (27.4%). Total payments also decreased from $29,141,488 to $17,797,136 (38.9%). The relative share of fluoroscopy-guided placement increased over that time period (from 11.8-19.4%) with a corresponding decreased in endoscopic placement (87.3%-78.8%). Laparoscopic placements remained a small minority (0.9%-1.8%). The average payment (professional component) for fluoroscopic placement decreased from $186 to $167 while the average payment for endoscopic placement decreased from $189 to $154 over that time period. Volume and total payments for enteric feeding tube placement has decreased from 2010-2017, suggesting more restricted use for certain patient populations or indications such as end of life care. While the majority of placements were still performed endoscopically, the share of fluoroscopy-guided placements increased over this time period.

Catheter-based Minimally Invasive Evacuation of Extensive Spinal Epidural Abscess: A Technical Report.

Surgical treatment of extensive spinal epidural abscess (SEA) usually involves multilevel exposure of the dural sac with subsequent risk for iatrogenic instability. A minimally invasive technique using an epidural catheter inserted through a limited approach for distant irrigation and drainage of the abscess represents an interesting alternative. Most described techniques involve blind placement of the catheters, with the potential risk of damage to the spinal cord and incomplete abscess drainage. We present and analyze a new technique used in two cases of SEA. Those were successfully treated using a minimally invasive approach supplemented with fluoroscopically-guided catheter drainage. We suggest that fluoroscopic placement of the catheter is a safe and effective method that offers a more focused and potentially safer way to proceed to this technique.

Combined laparoscopic-fluoroscopic technique for primary gastrojejunostomy button tube placement

BackgroundGastrojejunostomy (GJ) tubes are frequently used to provide pediatric enteral nutritional support for pediatric patients. Various placement methods have been described, each with attendant advantages and disadvantages. Description of the operative techniqueWe present a technique for primary laparoscopic/fluoroscopic GJ button tube placement designed to avoid delay in placement of the jejunal limb, and difficulties associated with endoscopic-assisted and primary fluoroscopic placement. ResultsThere were 52 gastrojejunostomy button tubes placed via this technique in patients ranging from 3.8 to 90.3 kg in weight. Three postoperative complications were identified; one bowel perforation on postoperative day two, and two tube dislodgements within 30 days. ConclusionThe described technique was uniformly effective and was associated with a low complication rate (5.8%).

Charactor of Modality and Resident Level in Pedicle Screw Accuracy and Neurosurgical Education

Objective: Evolving pressure on surgical education necessitates safe and efficient learning of techniques. We evaluated the effect of training year using anatomic, percutaneous fluoroscopy guided and computer navigated techniques on the accuracy of pedicle screw placement to attempt to determine if different modalities may be better suited for different levels of training. Methods: All instrumented thoracic and lumbar cases performed at Detroit Medical Center by the Neurosurgery Service between August 2012 and June 2013 were included.Cases had hardware verified by post-operative CT. Hardware placement was graded according to Mirza SK et al., grade 0 (within pedicle), grade 1 (&lt; 2 mm breach), grade 2 (&gt; 2 mm breach) , and grade 3 (extrapedicular). Pedicle screws were reviewed independently by a resident and attending surgeon. Rates of pedicle breach, EBL, length of case, pedicle size and pedicle starting point were all reviewed. Pedicles were analyzed on PACS system in axial views, using sagittal views to identify the correct level. Results: A total of 306 pedicle screws were evaluated in 36 patients. The overall rate of accurate pedicle screw placement among residents defined as Grade 0 or 1 placement was 86.8%.Fluoroscopically placed screws had significantly less breaches than anatomic screws 11% vs 20% (p = 0.03). Fluoroscopic cases had significantly less medial breeches (20%) than anatomic (50%) (p &lt; 0.05) and computer assisted cases (73%) (p &lt; 0.05). EBL values for fluoroscopic, anatomic and Body Tom cases were 425 cc, 720 cc, and 816 cc respectively. Resident level was found to be inversely proportional to breech rate (R squared 0.45). We did not see any clear difference in breach rate for resident level in different modalities. Conclusion: Supervised neurosurgical residents can place pedicle screws within published rates of acceptable breach. Interestingly our study revealed an inverse relationship between resident experience and pedicle screw accuracy. Fluoroscopic placement of pedicle screws compared to computer assisted and anatomic techniques results in lower medial breach rate and may be better suited for junior level residents.

Fluoroscopic Gastroduodenal Stent Placement in 55 Patients with Endoscopic Stent Placement Failure.

To evaluate the technical feasibility and clinical effectiveness of fluoroscopic self-expandable metal stent (SEMS) placement in malignant gastroduodenal obstructions after failed endoscopic SEMS placement. Between September 2010 and July 2017, 874 patients underwent endoscopic SEMS placement for dysphagia caused by malignant gastroduodenal obstructions. Endoscopic SEMS placement failed in 55 of 874 patients (6.3%). These patients were referred for fluoroscopic SEMS placement. In case of failed fluoroscopic SEMS placement, combined endoscopic and fluoroscopic SEMS placement was attempted at the same setting. Fluoroscopic SEMS placement was technically successful in 40 of 55 patients (72.7%). Combined endoscopic and fluoroscopic SEMS placement was technically successful in 6 of 15 patients with fluoroscopic SEMS placement failure. Failures in the nine patients were due to complete obstruction (n = 5) and acute angulation at the stricture site (n = 4). The overall technical success rate was 83.6% (46/55). Clinical success was achieved in 95.6% of patients (44/46). Complications occurred in 7 of 46 patients (15.2%), including tumor overgrowth (n = 3), SEMS migration (n = 3), and bleeding (n = 1). The median SEMS patency and patient survival periods were 515 (95% confidence interval (CI), 266.6-761.5) and 83 (95% CI 60.6-105.4) days, respectively. Fluoroscopic SEMS placement is technically feasible and clinically effective in cases of endoscopic SEMS placement failure. A combined endoscopic and fluoroscopic approach increases the technical success rate after failure of the endoscopic or fluoroscopic approach. Level IV.

Immediate, short-, and long-term changes in tracheal stent diameter, length, and positioning after placement in dogs with tracheal collapse syndrome.

BackgroundIntraluminal tracheal stenting is a minimally invasive procedure shown to have variable degrees of success in managing clinical signs associated with tracheal collapse syndrome (CTCS) in dogs.ObjectivesIdentify immediate post‐stent changes in tracheal diameter, determine the extent of stent migration, and stent shortening after stent placement in the immediate‐, short‐, and long‐term periods, and evaluate inter‐observer reliability of radiographic measurements.AnimalsFifty client‐owned dogs.MethodsRetrospective study in which medical records were reviewed in dogs with CTCS treated with an intraluminal tracheal stent. Data collected included signalment, location, and type of collapse, stent diameter and length, and post‐stent placement radiographic follow‐up times. Radiographs were used to obtain pre‐stent tracheal measurements and post‐stent placement measurements.ResultsImmediate mean percentage change was 5.14%, 5.49%, and 21.64% for cervical, thoracic inlet, and intra‐thoracic tracheal diameters, respectively. Ultimate mean follow‐up time was 446 days, with mean percentage change of 2.55%, 15.09%, and 8.65% for cervical, thoracic inlet, and intra‐thoracic tracheal diameters, respectively. Initial mean stent length was 26.72% higher than nominal length and ultimate long‐term tracheal mean stent shortening was only 9.90%. No significant stent migration was identified in the immediate, short‐, or long‐term periods. Good inter‐observer agreement of radiographic measurements was found among observers of variable experience level.Conclusions and Clinical ImportanceUse of an intraluminal tracheal stent for CTCS is associated with minimal stent shortening with no clinically relevant stent migration after fluoroscopic placement. Precise stent sizing and placement techniques likely play important roles in avoiding these reported complications.

Successful External Cardioversion via Fluoroscopic Electrode Positioning in Patients with Enlarged Trans-Thoracic Diameter

Case seriesPatient: Female, 71 • Male, 48 • Male, 74Final Diagnosis: Failed cardioversionSymptoms: Dizziness • dyspnea • fatigue • palpitationsMedication: Ace Inhibitors • Beta Blockers • Calcium Channel Blockers • Dronedarone • Novel Oral Anticoagulants • WarfarinClinical Procedure: Fluoroscopic cardioversion • radiofrequency catheter ablationSpecialty: CardiologyObjective:Unusual setting of medical careBackground:Atrial fibrillation is the most common cardiac arrhythmia. It increases the risk of stroke by at least five-fold and is associated with higher risk for mortality and morbidity. Therefore, prompt diagnosis and treatment is crucial. In addition to anti-coagulation therapy, electrical and pharmacological cardioversion to restore sinus rhythm remains the standard of care. The most common and effective method for electrical cardioversion is achieved with placement of electrodes in the anteroposterior position.Case Report:We present three cases of patients with initial unsuccessful cardioversion attempts for persistent atrial fibrillation. These patients had elevated body mass indices and large trans-thoracic diameters. Their initial external cardioversion via the conventional method was not successful for restoration of sinus rhythm. This failure may have been attributed to their body habitus. To ensure that the current would traverse through the atrial tissue, the electrode pads were applied using fluoroscopic guidance for adequate myocardial depolarization.Conclusions:Optimal fluoroscopic placement of the electrode pads during external cardioversion procedure increases the odds of successful restoration of sinus rhythm when compared to the conventional method.

Urea-based recirculation validation of the symmetrical palindrome catheter.

High blood flow and low recirculation rates are central for adequate haemodialysis. A new symmetrical tip has been invented promising efficient haemodialysis even if the ports are reversed. To evaluate access recirculation of the 'palindrome' catheter and to report initial experiences in a clinical setting. After implantation of the new catheter in 20 patients (male: 14; female: 6; mean age 72 ± 12.2), access recirculation was evaluated using the urea-based recirculation test. After 30 minutes of haemodialysis, ultrafiltration was stopped and arterial and venous samples were taken. Afterwards, the blood flow rate was reduced to 120 ml/min. Another systemic arterial blood sample was taken 10 seconds after the blood pump was switched off. All 20 interventions were performed successfully without complications. The average recirculation rate was 8.1% with a median of 2.5% ranging from 0 to 85.8%. Recirculation rates under 5% were measured in 13 patients and more than 10% recirculation were found in two patients. The median of days between catheter implantation and recirculation assessment was the day following implantation. The new symmetrical catheter presented low recirculation rates in a clinical setting. Since there is just a single tip, fluoroscopic placement in the right atrium is facilitated.

Comparison of Inferior Vena Cava Filters Placed at the Bedside via Intravenous Ultrasound Guidance Versus Fluoroscopic Guidance

Bedside placement of an intravenous ultrasound (IVUS)-guided inferior vena cava filter (IVCF) is safe, but with higher procedural complications when compared with fluoroscopic placement. Long-term indwelling complications are similar when comparing the two approaches.

Fluoroscopic-guided stent placement in failed tentative endoscopic approaches to malignant gastroduodenal obstructions.

Background Fluoroscopic or endoscopic placement of metallic stents is used as a safe, non-surgical, palliative treatment option for malignant gastroduodenal obstructions. However, endoscopic stent placement is not always feasible, due to the tight or tortuous stricture of the obstructed area and insufficient visualization of the stomach due to remnant food material. Purpose To assess the technical feasibility and clinical outcomes of fluoroscopic-guided stent placement in malignant gastroduodenal obstructions following the technical failure of endoscopic stent placement. Material and Methods In all, 19 patients (14 men, 5 women; age range, 36-85 years) were referred due to technical failures of tentative endoscopic stent placement. Indications were failure to pass the guide wire through the obstruction (n = 13), failure to reach the stricture lesion due to short endoscope (n = 5), and acute angulation of the stricture lesion (n = 1). Data were retrospectively collected regarding the technical and clinical success of the fluoroscopy, the dysphagia score before and after stent placement, and major complications and their management. Results Fluoroscopic stent placement was technically successful in 15/19 patients (79%). Failures were due to complete obstruction (n = 3) and acute angulation of the stricture lesion (n = 1). Clinical success was achieved in all 15 patients with successful stent placement. The dysphagia score significantly improved after stent placement ( P < 0.001). Complications occurred in 4/15 patients (27%), including tumor overgrowth (n = 2), stent collapse (n = 1), and jaundice (n = 1). Conclusion Fluoroscopic stent placement in malignant gastroduodenal obstructions following a technical failure of endoscopic stent placement is technically feasible and has an acceptable clinical outcome.

Comparison of Inferior Vena Cava Filters Placed at the Bedside via Intravenous Ultrasound Guidance Versus Fluoroscopic Guidance

IVCFs are usually placed under fluoroscopic guidance in dedicated angiography suites. Bedside placement of inferior vena cava filters (IVCF) is possible in patients not suitable for transportation, but data regarding their use are limited. The objective of this study is to compare utilization, procedural outcomes, complications, and long-term patient outcomes associated with bedside placement of IVCFs using intravascular ultrasound (IVUS) and fluoroscopic placement of IVCF. All patients receiving IVCF between January 2009 and December 2011 at a tertiary care institution were retrospectively identified. Data regarding patient characteristics, IVCF indications, complications, and outcomes were collected, and comparisons were made between patients receiving fluoroscopic-guided and IVUS-guided bedside IVCF. There were 117 bedside and 571 fluoroscopic-guided IVCF placed during this period. Patients receiving bedside IVCF were younger (50.8 vs. 60.7years, P<0.001), less often had malignancy (22.2% vs. 42.6%, P<0.001), and received prophylactic filters more commonly (59.9% vs. 29.9%, P<0.001). Placement-related complications occurred in 4.3% and 0.6%, respectively (bedside IVCF: 4 malpositions, 1 severe tilt; fluoroscopic-guided IVCF: 1 malposition, 1 severe tilt, P=0.01). Indwelling IVCF-related complications occurred equally during median follow-up of 463 and 488days, respectively (deep vein thrombosis: 13.7% vs. 13.3%, P=0.92; pulmonary embolism: 5.1% vs. 4.0%, P=0.61; filter thrombosis: 3.4% vs. 3.9%, P=0.82). Time to indwelling complication was similar between groups (74 vs. 127 days, P=0.29). Bedside placement of IVUS-guided IVCF is safe, but with higher procedural complications when compared with fluoroscopic placement. Long-term indwelling complications are similar between IVCF placed via bedside IVUS guidance and fluoroscopic approach.

PP12.4 – 2816: Status dystonicus: Is it a gut feeling?

Objective Status dystonicus (SD) is a life-threatening movement disorder. We report nine severely disabled children with SD and gut motility problems managed by the paediatric neurology and gastroenterology teams at the Sheffield Children's Hospital U.K. Methods Retrospective case notes review of nine children admitted with SD at our tertiary paediatric centre looking at underlying neurological diagnoses, age of onset of dystonia, concomitant anti-dystonia medication, intrathecal baclofen pump with rate of daily infusion, anti-reflux medication, gastroenterological investigations, use of enteral feeding (oral, gastrostomy and jejunal feeds) and parental nutrition (PN). Results Nine children, mean age 8.43 years (range 5 months to 15.2 years) presented with SD. Pain, pallor, sweating and spasms were precipitated by enteral feeding. All had multiple, independently observed time points where stopping feeds resulted in resolution of symptoms and recommencement of enteral feeds even at 5 ml per hour lead to the return of dystonic spasms and pain. All showed no evidence of reflux disease on pH impedance studies and gastroscopy and did not show peptic oesophagitis on oesophageal biopsies. All nine had jejunal feeding tubes (jejunal extensions to the PEG) with confirmed tip position in the first loop of the jejunum or close to the duodenojejunal flexure by fluoroscopic placement. Barium studies and plain films ruled out intestinal obstruction or sub-acute obstruction. Five of nine patients with severe feed induced pain and dystonia were treated with PN (3 long term and 2 short term). There was objective evidence of substantial pain resolution in all five. Conclusion Children with SD can be at risk of enteral feed induced abdominal pain and small bowel (foregut) dysmotility with some needing PN. The severity of the neurological condition seems to correlate with the severity of gastrointestinal problems raising the need for an ethical frame work and greater understanding of neuro-gastroenterological relationship.

Biomechanical Comparisons of Pull Out Strengths After Pedicle Screw Augmentation with Hydroxyapatite, Calcium Phosphate, or Polymethylmethacrylate in the Cadaveric Spine

In vertebrae with low bone mineral densities pull out strength is often poor, thus various substances have been used to fill screw holes before screw placement for corrective spine surgery. We performed biomechanical cadaveric studies to compare nonaugmented pedicle screws versus hydroxyapatite, calcium phosphate, or polymethylmethacrylate augmented pedicle screws for screw tightening torques and pull out strengths in spine procedures requiring bone screw insertion. Seven human cadaveric T10-L1 spines with 28 vertebral bodies were examined by x-ray to exclude bony abnormalities. Dual-energy x-ray absorptiometry scans evaluated bone mineral densities. Twenty of 28 vertebrae underwent ipsilateral fluoroscopic placement of 6-mm holes augmented with hydroxyapatite, calcium phosphate, or polymethylmethacrylate, followed by transpedicular screw placements. Controls were pedicle screw placements in the contralateral hemivertebrae without augmentation. All groups were evaluated for axial pull out strength using a biomechanical loading frame. Mean pedicle screw axial pull out strength compared with controls increased by 12.5% in hydroxyapatite augmented hemivertebrae (P = 0.600) and by 14.9% in calcium phosphate augmented hemivertebrae (P = 0.234), but the increase was not significant for either method. Pull out strength of polymethylmethacrylate versus hydroxyapatite augmented pedicle screws was 60.8% higher (P = 0.028). Hydroxyapatite and calcium phosphate augmentation in osteoporotic vertebrae showed a trend toward increased pedicle screw pull out strength versus controls. Pedicle screw pull out force of polymethylmethacrylate in the insertion stage was higher than that of hydroxyapatite. However, hydroxyapatite is likely a better clinical alternative to polymethylmethacrylate, as hydroxyapatite augmentation, unlike polymethylmethacrylate augmentation, stimulates bone growth and can be revised.