Spinal neurofibromas occur sporadically and typically occur in association with neurofibromatosis 1. Patients afflicted with neurofibromatosis 1 usually present with involvement of several nerve roots. This report describes the case of a 14- year-old child with a large intraspinal, but extradural tumour with paraspinal extension, dumbbell neurofibroma of the cervical region extending from the C2 to C4 vertebrae. The lesions were readily detected by MR imaging and were successfully resected in a two-stage surgery. The time interval between the first and second surgery was one month. We provide a brief review of the literature regarding various surgical approaches, emphasising the utility of anterior and posterior approaches.
Introduction: Necrotising fasciitis (NF) is a rapidly progressive infection of the subcutaneous tissue and fascia which spreads rapidly. The scoring system of Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) developed by Wong et al has been proposed as a tool for distinguishing NF and other soft tissue infections (STI) in Singapore. We set out to establish whether the LRINEC score is applicable in our Malaysian setting. Materials and Methods: A cross sectional study of all patients admitted to our hospital diagnosed with NF or To Rule Out NF (TRO NF) between January 1st 2016 to 30th June 2016. The sensitivity, specificity, positive and negative predictive values were then calculated for LRINEC score of ≥ 6 and ≥ 8. Results: Fourty-four patients were identified with the diagnosis of NF or TRO NF in the study. Twenty-seven patients (61.4%) were deemed post-operatively as having NF and 17 patients (38.6%) not having NF. A sensitivity of 59.3% and specificity of 47.1% when a LRINEC score of ≥ 6 was taken with positive predictive value (PPV) of 64.0% and the negative predictive value (NPV) of 42.1%. When score ≥ 8 was taken, the sensitivity was 48.1% and specificity of 58.8% with PPV of 65% and NPV of 41.7%. Conclusion: The low sensitivity and low PPV achieved in this study as well as other studies makes the LRINEC score unsuitable to be used solely to distinguish NF with other soft tissue infections.
Being a rare clinical entity, discal cyst presents indistinguishably from other causes of lower back pain and radiculopathy. It is an extremely rare pathology with unclear pathogenesis, indeterminate natural history with no consensus on the ideal management of the condition. We report a rare case of discal cyst in a patient who presented to our centre with localised low back pain and subsequently left sided radicular pain. With the aid of MRI and with clear surgical indication we proceeded with endoscopic removal of the cyst and intraoperatively confirmed its origin from the adjacent disc. The patient had immediate relief of his symptoms and no postoperative complications. We recommend that endoscopic surgery can be an effective alternative to conventional open surgery for discal cyst of the lumbar spine.
This study was to evaluate the morphological features of degenerative spinal stenosis and adequacy of lateral canal stenosis decompression via unilateral and bilateral laminectomy. Measurements of facet joint angulation (FJA), mid facet point (MFP), mid facet point distance (MFPD), the narrowest point of the lateral spinal canal (NPLC) and the narrowest point of the lateral spinal canal distance (NPLCD) were performed. At L4L5 of the right and left side, the mean distance between the lateral border of the dura and MFP was 1.0 ± 0.2 cm and 1.0 ± 0.3cm respectively. The mean NPLC was seen at 0.7 ± 0.3 and 0.7 ± 0.3 cm cm from the dura. At L5S1 of the right and left side, the mean distance between the lateral border of the dura and MFP was 1.2± 0.2 and 1.3 ± 0.2 cm respectively. The mean NPLC was seen at 0.8 ± 0.4 and 0.9 ± 0.5 cm from the dura. Unilateral laminectomy may result in incomplete decompression.
Introduction: The vertical diameter of the foramen is dependent upon the vertical diameter of the corresponding intervertebral disc. A decrease in disc vertical diameter has direct anatomic consequences to the foraminal diameter and area available for the nerve root passing through it. This study is to establish the relationship amongst the intervertebral disc vertical diameter, lateral foramen diameters and nerve root compression in the lumbar vertebra. Materials and Methods: Measurements of the study parameters were performed using sagittal MRI images. The parameters studied were: intervertebral disc vertical diameter (DVD), foraminal vertical diameter (FVD), foraminal transverse diameter (FTD) and nerve root diameter (NRD) of both sides. The relationship between the measured parameters were then analyzed. Results: A total of 62 MRI images were available for this study. Statistical analysis showed moderate to strong correlation between DVD and FVD at all the lumbar levels except at left L23 and L5S1 and right L3L4 and L4L5. Correlation between DVD and FTD were not significant at all lumbar levels. Regression analysis showed that a decrease of 1mm of DVD was associated with 1.3, 1.7, 3.3, 3.3 and 1.3mm reduction of FVD at L1L2, L2L3, L3L4, L4L5 and L5S1 respectively. Conclusion: Reduction of DVD was associated with reduction of FVD. However, FVD was relatively wide for the nerve root even with complete loss of DVD. FTD was much narrower than the FVD making it more likely to cause nerve root compression at the exit foramina. These anatomical details should be given consideration in treating patients with lateral canal stenosis.
Introduction: This study is to evaluate the reliability, sensitivity and specificity of nerve root sedimentation sign (NRS) in our populations. The NRS is a radiological sign to diagnose lumbar spinal stenosis (LSS). It is claimed to be reliable with high sensitivity and specificity. Materials and Methods: A total of 82 MRI images from 43 patients in Group A (LSS) and 39 patients in Group B (non LSS) were analysed and compared for the presence of the NRS sign. Two assessors were used to evaluate intra and inter-assessor reliability of this sign based on 56 (33 patients, Group A and 23 patients, Group B). The findings were statistically analysed using SPSS software. Results: There was a significant association between spinal claudication and leg numbness with LSS (p<0.001 and Kappa=0.857, p<0.001). The inter-assessor reliability was also good (Kappa of 0.786, p<0.001). Conclusion: The NRS sign has high sensitivity and specificity for diagnosing LSS. The sign also has good intra and inter-assessor reliability.
Scapulo-thoracic dissociation is an infrequent injury resulting from high energy trauma which is often associated with severe neurological and vascular injuries which may be unrecognised at the time of presentation. A 24 year-old female presented with bilateral rib fractures, pneumothorax, liver and kidney injuries following a road traffic accident. She also sustained fractures of her right scapula, odontoid, right transverse processes of the thoracic and lumbar vertebrae and a closed fracture of her right femur. Her right upper limb was later noted to be flail and pulseless, due to complete right brachial plexus injury, scapula-thoracic dissociation and subclavian artery avulsion. We managed the upper limb injuries non-operatively, and focused on resuscitation of the patient. Early exploration of the complete brachial plexus injury was not undertaken in spite of the possible associated poor functional outcome as there was no life-threatening indication.
We report a 21-year old female patient who presented with an 18-month history of a swelling in the distal phalanx of her right little finger. Although the history, clinical features and MRI were suggestive of a benign tumour or a tuberculous lesion, the histo-pathological examination of the swelling was reported as a conventional osteosarcoma. Osteosarcoma of the hand is very rare. This article highlights the possibility of a seemingly benign lesion seen in a routine clinic could well turn out to be malignant, and the need to maintain a high index of suspicion.
Splinter or foreign body removal from the hand and foot is a common occurrence. Usually only the deep seated, broken or missed splinters are referred to the surgeon for removal. Unless the object is radio-opaque, plain radiograph will not give any useful information, hence removal can sometimes be very difficult and traumatic. We are reporting a case where a radiolucent splinter was removed with the aid of ultrasonography. This modality can help to localize a splinter at the pre and intra-operative period, minimizing amount of exploration and time of operation.
Aim: This study was designed to evaluate the use of ultrasound in diagnosis of infection and tumour of long bones. Methodology: Patients referred from the orthopaedic unit with doubt regarding long bone clinical and/or radiological signs which could be tumour or infection were enrolled in this study. Analysis of ultrasound characteristics included presence of pericortical fluid over normal cortex well away from the primary lesion, wavy contour sign (fluid tracking in and out muscle planes), subperiosteal fluid and soft tissue mass displacing adjacent muscle planes. Results: Fourteen out of 15 patients with confirmed osteomyelitis were diagnosed by ultrasound examination. Ultrasound as a diagnostic tool has a sensitivity of 93% and specificity of 100%. The most accurate indicator was pericortical fluid noted up to several centimetres from the long bone abnormality seen on plain x-rays. Conclusion: Ultrasound is a safe, fast, cost-effective imaging modality that can play an important role in diagnosis of osteomyelitis as it then serves as a tool for ultrasound guided aspiration.
Introduction: We assessed the role of the Pirani score in determining the number of casts and its ability to suggest requirement for tenotomy in the management of clubfoot by the Ponseti method. Materials and Methods: Prospective analysis of 66 (110 feet) cases of idiopathic clubfoot up to one year of age was done. Exclusion criteria included children more than one year of age at the start of treatment, non-idiopathic cases and previously treated or operated cases. Results: The initial Pirani score was (5.5±0.7) for the tenotomy group and the initial Pirani score was (3.3±1.6) for the non-tenotomy group. There was a significant difference between the initial Pirani score for the tenotomy and the non-tenotomy group with t= -7.9, df= 64 p<0.0001. The tenotomy group had a significantly higher number of casts (four to seven) compared to non-tenotomy group (two to five) t=-10.4, df=64, p<0.0001. Spearman's rank correlation coefficient was significant and confirmed positive correlation between the initial Pirani score and the number of casts required to correct the deformity (r = 0.931, p<0.0001). Conclusion: Initial high Pirani score suggests the need for greater number of casts to achieve correction and probable need for tenotomy. The number of casts required in achieving complete correction increases with increase in the initial Pirani score. The initial high hindfoot score (2.5-3) signifies the probable need of a minor surgical intervention of percutaneous tendoachilles tenotomy. Based on the initial Pirani score, parents can be informed about the probable duration of treatment and the need for tenotomy.
Glomus tumours (GT), neoplasms of the glomus body comprise 4.5% of upper limb tumours. Seventy-five per cent of these occur in the hand, and most are subungual (50%). We performed a literature review and retrospective search of histopathologically confirmed GT seen from 1995 to 2009. Fifteen patients were identified, with an average age of 49.6 years. Eight were in the hand, 2 in the upper limb, 2 lower limb and 3 in the ear. Eighty-six per cent presented with pain and 50% underwent radiological investigation. Most diagnoses followed biopsy findings. Surgical excision resulted in a recurrence rate of 13%. The average time to diagnosis was 3.3 years. The average duration of symptoms was 7 to 11 years with an average of 2 to 3 consultations prediagnosis. MRI remains the most useful imaging modality (82 to 90% sensitivity). Excision biopsy is the most common treatment. Greater awareness is needed for quicker diagnosis.
A 32 year-old Malay lady presented with a swelling over the dorsal surface of her right thumb for 6 months. The swelling was non-tender, smooth surfaced, mobile and nonfluctuating with no bony involvement. The provisional diagnosis was ganglion cyst. Excisional biopsy did not show features of ganglion cyst as it appeared to be wellencapsulated, multi-lobulated and yellowish in colour. Histopathological examination showed that it was a schwannoma. Schwannomas are relatively rare benign tumours which are frequently misdiagnosed. In this case, it was misdiagnosed both as a ganglion and a lipoma.
Introduction: Microsurgery is a subspecialised field which requires high technical skill. Laboratory training offers good opportunity for novice surgeons to learn and repetitively practise their skills prior to hands-on clinical practice. Commonly, the training programme consists of models in a stepwise increase in fidelity: from latex sheet to anaesthetised rat. We introduce microgrids model as a daily warm up procedure in a 5-day basic microsurgery course. The purpose of this study is to evaluate the correlation between microgrids colouring under magnification with microsuturing proficiency among novice surgeons. Materials and Methods: Participants were required to fill in microgrids under magnification everyday during their 5-day training as a starter test. The number of completely filled in microgrids in 20 seconds was recorded. A simulated cut on latex sheet was sutured and the time taken to apply five sutures was recorded. The sutures were evaluated with modified Global Rating Scale (GRS). Data was analysed with SPSS. Results: There was a statistically significant correlation between the number of microgrids coloured and the time taken to apply five sutures (p<0.01). An increase in number of microgrids coloured was significantly associated with the increase in quality of the suturing technique (p< 0.01). During the 5-day basic microsurgery skills training for novice surgeons, microsuturing skill improvement correlated with microgrid colouring. Conclusion: Microgrids colouring reflected microsuturing proficiency. It is an inexpensive, readily available, and simple model of 'warm up' for hand dexterity. The microgrids model can function as a starter test for initial training and a quick screening measure to assess microsurgical skill.
Introduction: Large wounds in the leg require combination of local flaps or free flap for wound coverage. Gastrocnemius musculocutaneous flap (GMCF) allows a large wound to be covered by a single local flap. However, the conventional GMCF is often associated with donor site morbidity where the exposed soleus raphe causes poor uptake of the skin graft. Islanding the skin on the muscles allows the donor site to be closed primarily, thus avoiding the donor site morbidity. Materials and Methods: Medical records of twelve patients who underwent islanded GMCF surgery from 2004 till 2018 were reviewed retrospectively. Results: The mean age was 31 years old. Eight cases were with open fracture of the tibia, two degloving injury exposing the patella, one open fracture of patella and necrotising soft tissue infection. The wound size ranged from 12cm2 to 120cm2. All flaps survived. Three patients required skin grafting at the donor site while in the rest the donor sites were able to be closed primarily. Four patients developed deep infection, one healed after vacuum dressing, one after bone transport and one after split thickness skin graft. One patient ended up with below knee amputation after developing chronic osteomyelitis of the tibia. Conclusion: Islanded gastrocnemius musculocutaneous flap is an effective simple alternative for coverage of large soft tissue defects from the knee to half of the leg distally with minimal donor site morbidity. Aggressive debridement of unhealthy tissue is necessary to prevent infection following wound coverage with this flap.
Cannulated screw fixation is a widely accepted surgical method for management of fractures of the neck of femur especially in patients with poor premorbid conditions, minimally displaced fractures and those from a younger age group. A five year retrospective study was carried out in 53 consecutive patients between 2006 to 2010 to determine the pattern of injuries, management, outcomes and the associated predictive factors.All the patients underwent cannulated screw fixation, with 37 (69.8%) having had surgery within 24 hours and the remaining 16 (30.2%) 24 hours after the initial injury. All patients were followed up to union of fractures and complications thereafter if any. Good outcome was observed in 43 (81.1%) patients leaving only 10 (18.9%) patients with a poor outcome, of whom nine developed avascular necrosis (90%) and one non-union (10%). We found no significant relationship between the incidence of avascular necrosis and age of patient, fracture displacement, numbers of cannulated screws used, fracture reduction acceptability and anatomical location of the fracture. The time interval from injury to surgery and the presence of posterior comminution did seem to influence the rate of avascular necrosis but due to the small number of patients, was not statistically significant.We conclude that cannulated screw fixation is a viable option of treatment for fractures of the neck of femur.
We report a case of a 21 years old female who presented with a history of anterior knee pain for previous 3 months. Pain was localized to the anteromedial aspect of the left knee and aggravated by flexion. Clinical examination revealed a 2x2cm painful lump on the anteromedial aspect of the left medial condyle with no effusion. Magnetic resonance imaging revealed an anterosuperior tear of the medial collateral ligament. The patient subsequently underwent left knee arthroscopic examination. Two yellowish pedunculated masses arising from the anteromedial portion of the synovium were discovered and completely excised. Histopathological examination of the excision biopsy revealed pigmented villonodular synovitis (PVNS) with marked central necrosis. One year post excision, she is well with no signs or symptoms of recurrence. This case highlights an uncommon cause of anterior knee pain. Localized PVNS typically presents with mechanical symptoms, however, pain could arise from pedicle torsion and necrosis.
Despite its claimed therapeutic effects, the action of sea cucumber (known as gamat in the Malay language) on human osteoblast cells is still unknown. We performed in vitro studies utilising extract of Stichopus sp1 (gamat) to elucidate its effects on cell viability and functional activity. We found an inverse relationship between gamat concentration and its effect on osteoblast cell viability (p<0.001). Only gamat concentration at 1mg/ml significantly promoted cell viability at day 3 of incubation. There was a trend towards increased osteoblast cell function in the presence of gamat at 5mg/ml and 10mg/ml but this observation was not consistent at different incubation periods.
Good knowledge and practice regarding diabetic foot care will reduce the risk of diabetic foot complications and ultimately amputation. This study is conducted to assess patients' knowledge and compliance of diabetic foot care. A cross sectional study performed on patients who were admitted to HSNZ from the 1st September 2013 to 30th April 2014 for diabetic foot infections. They were interviewed with a questionnaire of 15 'yes' or 'no' questions on foot care knowledge and practice. Score of 1 was given for each 'yes' answer. The level of knowledge and practice, whether good or poor, was determined based on the median score of each category. The result was tested using a chi-square test in SPSS version 17. A total of 157 patients were included in this study with a mean age of 56.33 years (31-77). There were 72 male (45.9%) and 85 female (54.1%) patients with the majority of them being Malays (154 patients, 98.1%). Majority of the patients (58%) had poor foot care knowledge while 97 patients (61.8%) had poor diabetic foot care practice as compared to the median score. Based on the chi square test of relatedness, there was no significant association between knowledge and practice with any of the variables. In conclusion, the majority of patients admitted for diabetic foot infections had poor knowledge and practice of diabetic foot care. Education regarding foot care strategies should be emphasized and empowered within the diabetic population.
Study site: Hospital Sultanah Nur Zahirah, Kuala Terengganu,Terengganu, Malaysia