Imaging

 

Sued If You Do, Sued If You Don’t

A 52-year-old woman presented to the ED with complaints of abdominal pain, vaginal bleeding, and left leg pain. The patient stated that the symptoms, which she had been experiencing over the past few days, were becoming progressively worse. She denied fevers, chills, nausea, vomiting, diarrhea, or constipation. Her surgical history was
remarkable for an appendectomy 30 years prior. The patient was not currently on any medications. Regarding social history, she denied alcohol or tobacco use. She also denied any allergies to medications.

On physical examination, all of the patient’s vital signs were normal. The head, eyes, ears, nose, and throat, and lung and heart examinations were also normal; however, on abdominal examination, she exhibited tenderness throughout the lower abdomen, but without guarding or rebound. There was no costovertebral angle tenderness of the back. The pelvic examination was remarkable for a small amount of blood from the cervical os and a slightly enlarged uterus. The adnexa were normal and without tenderness.

The emergency physician (EP) ordered a complete blood count, basic metabolic profile, and urinalysis. An intravenous (IV) catheter was placed, and the patient was administered an IV analgesic and antiemetic. A normal saline drip of 125 cc per hour was also ordered. In view of the abdominal pain and tenderness, the EP ordered a computed tomography (CT) scan of the abdomen and pelvis with IV contrast. Within a few minutes of receiving the IV contrast, the patient experienced a sharp increase in blood pressure, followed by an abrupt change in mental status. A stat noncontrast head CT scan revealed a subarachnoid hemorrhage (SAH), and a CT angiogram (CTA) of the head revealed a ruptured cerebral aneurysm. Although the patient was taken immediately to the operating room by neurosurgery services, she had permanent left-sided weakness; as a result, she was no longer able to perform her previous type of work.

The patient sued both the EP and the hospital, claiming that the CT scan was unnecessary and had it not been performed, she would not have experienced the stroke. The defense asserted that the CT scan with contrast was appropriate given the patient’s symptoms and physical findings, and that the contrast dye used was not the cause of the stroke. The jury awarded the plaintiff $3.6 million.

Discussion

This case is unique in that the EP was sued for ordering a CT scan. In the overwhelming majority of malpractice cases, EPs are sued for not obtaining a certain test—frequently a CT scan. It does not appear the jury in this case was correct in their judgment as there was no conceivable way the EP could have anticipated this type of unusual reaction, especially in a patient with no history of medication allergies.

This jury ruling places EPs in an untenable situation: If they order a test and anything bad happens, they will be sued. If they do not order a test and something bad happens, they will be sued. In legal theory, there must be proximal cause between what the physician did (ie, order the CT scan) and the bad outcome, or negligence (ie, SAH). For this case, the two events seem true-true and unrelated. The contrast dye clearly did not cause the cerebral aneurysm, which was a preexisting condition.

Emergency physicians are very familiar with the contraindications for obtaining studies with IV contrast dye. The most important concern is for some type of adverse reaction to the iodinated contrast media (ICM). While such reactions are typically lumped under “allergy,” this term is actually incorrect. Rather, two types of reactions can occur following exposure to ICM: idiosyncratic (more common) and nonidiosyncratic.¹ A more accurate description of the idiosyncratic reaction is anaphylactoid. This type of reaction occurs within a few minutes of exposure, and no previous sensitization is necessary. Symptoms are classified as mild, moderate, or severe (Table).

Nonidiosyncratic reactions are due to direct toxic or osmolar effects. Symptoms include bradycardia, hypotension, vasovagal reactions, sensation of warmth, metallic taste in the mouth, and nausea and vomiting.¹

Ironically, the majority of adverse reactions to ICM involve hypotension, not hypertension. This includes cardiovascular reactions to ICM, which typically involve bradycardia, peripheral vasodilation, and hypotension.¹ The incidence and severity of an adverse reaction to ICM also depends on whether ionic or nonionic ICM was used. (Unfortunately, the type of ICM administered to the patient in this case was not disclosed.)

The incidence and severity of adverse reactions to ICM are less with nonionic compared to ionic ICM. More than 90% of adverse reactions to nonionic ICM are anaphlyactoid.² In general, adverse reactions occur in 4% to 12% of patients receiving ionic ICM compared to 1% to 3% of those receiving nonionic ICM.² In a study of more than 300,000 contrast administrations, Katayama et al,³ found the overall risk for severe adverse reaction to be 0.2% for ionic ICM compared to 0.04% for nonionic ICM.

 

The bottom line in this case is that the patient’s event was a very rare and completely unforeseen result temporally related to the contrast CT scan ordered to evaluate the etiology of this patient’s abdominal pain.

  

 

Falls

A 67-year-old woman with a chief complaint of lightheadedness and dizziness was transferred from a dialysis center to the ED by emergency medical services (EMS). She stated that her symptoms came on suddenly right after she had completed her scheduled dialysis.

As the patient was being rolled on a stretcher from the ambulance to the ED entrance, the stretcher collapsed and tipped over, causing the patient to fall and strike her head on the pavement. The patient suffered a severe intraparenchymal brain hemorrhage, requiring intubation, ventilation, and admission to the intensive care unit. On the second day of admission, the patient’s family signed “do not resuscitate” orders and, in accordance with their wishes, life support was withdrawn and the patient died.

The family sued the ambulance company, stating the patient’s death was a direct result of negligent training and supervision of EMS personnel. The plaintiff further claimed the incident was caused by the failure to properly secure a locking mechanism on the stretcher, which caused it to tip. The ambulance company disputed the liability, asserting that what occurred was a tragic accident, not negligence. The jury found in favor of the plaintiff and awarded $1.5 million.

Discussion

While this is not a true ED case since the patient’s fall occurred just outside the ED, it does emphasize the importance of falls and the challenges of fall prevention within the hospital—including the ED. The incidence of falls within hospitals ranges from 1.3 to 9 falls per 1,000 occupied bed days (OBD).¹ This incidence, however, is not evenly distributed across hospital departments. Not surprisingly, the highest rates are reported in areas such as geriatric, neurology, and rehabilitation units.¹ The highest rates, 17 to 67 per 1,000 OBDs, appear to occur in geropsychiatric units,^2,3 and a significant number of such patient falls are serious, with some type of injury resulting from the fall in 30% to 51% of cases.¹ The percentage of falls resulting in a fracture ranges from 1% to 3%.¹

As previously noted, the ED is not immune to patient falls. A review of one academic medical center ED with 75,000 annual visits found an incidence of 1.3 falls per month, 31% of which resulted in patient injury.⁴

Some relatively simple steps can be taken to reduce the incidence of falls. For example, identifying patients at high risk of falling (eg, patients who are elderly, confused, dizzy) and ensuring other care-team workers are aware of the risk, can be very helpful.^4,5 In addition, brightly colored signs on the stretcher or colored wrist bands indicating the patient is at high-risk for falls helps to engage the entire healthcare team in fall-prevention measures.⁴ Sitters with high-risk patients can also help minimize fall risk.

Although side rails on hospital beds are intended to increase patient safety, their use is not without controversy. Most hospitals require staff to have side rails up for obvious reasons. Some hospitals, however, are concerned that the use of side rails can cause a fall from a higher position and increase the risk of injury when a patient attempts to get out of bed. Additional important steps include ensuring that all wet surfaces are quickly identified and cleaned, and making sure everyone is aware of the importance of fall-prevention measures.

 The employment of the abovementioned fall-prevention measures is especially important in relation to the aging US population. As the number of elderly patients in the United States continues to grow, the risk of patient falls is expected to increase. Therefore, hospitals should be proactive in implementing preventive measures to reduce the risk of patient falls and injury.  

 

Sued If You Do, Sued If You Don’t

A 52-year-old woman presented to the ED with complaints of abdominal pain, vaginal bleeding, and left leg pain. The patient stated that the symptoms, which she had been experiencing over the past few days, were becoming progressively worse. She denied fevers, chills, nausea, vomiting, diarrhea, or constipation. Her surgical history was
remarkable for an appendectomy 30 years prior. The patient was not currently on any medications. Regarding social history, she denied alcohol or tobacco use. She also denied any allergies to medications.

On physical examination, all of the patient’s vital signs were normal. The head, eyes, ears, nose, and throat, and lung and heart examinations were also normal; however, on abdominal examination, she exhibited tenderness throughout the lower abdomen, but without guarding or rebound. There was no costovertebral angle tenderness of the back. The pelvic examination was remarkable for a small amount of blood from the cervical os and a slightly enlarged uterus. The adnexa were normal and without tenderness.

The emergency physician (EP) ordered a complete blood count, basic metabolic profile, and urinalysis. An intravenous (IV) catheter was placed, and the patient was administered an IV analgesic and antiemetic. A normal saline drip of 125 cc per hour was also ordered. In view of the abdominal pain and tenderness, the EP ordered a computed tomography (CT) scan of the abdomen and pelvis with IV contrast. Within a few minutes of receiving the IV contrast, the patient experienced a sharp increase in blood pressure, followed by an abrupt change in mental status. A stat noncontrast head CT scan revealed a subarachnoid hemorrhage (SAH), and a CT angiogram (CTA) of the head revealed a ruptured cerebral aneurysm. Although the patient was taken immediately to the operating room by neurosurgery services, she had permanent left-sided weakness; as a result, she was no longer able to perform her previous type of work.

The patient sued both the EP and the hospital, claiming that the CT scan was unnecessary and had it not been performed, she would not have experienced the stroke. The defense asserted that the CT scan with contrast was appropriate given the patient’s symptoms and physical findings, and that the contrast dye used was not the cause of the stroke. The jury awarded the plaintiff $3.6 million.

Discussion

This case is unique in that the EP was sued for ordering a CT scan. In the overwhelming majority of malpractice cases, EPs are sued for not obtaining a certain test—frequently a CT scan. It does not appear the jury in this case was correct in their judgment as there was no conceivable way the EP could have anticipated this type of unusual reaction, especially in a patient with no history of medication allergies.

This jury ruling places EPs in an untenable situation: If they order a test and anything bad happens, they will be sued. If they do not order a test and something bad happens, they will be sued. In legal theory, there must be proximal cause between what the physician did (ie, order the CT scan) and the bad outcome, or negligence (ie, SAH). For this case, the two events seem true-true and unrelated. The contrast dye clearly did not cause the cerebral aneurysm, which was a preexisting condition.

Emergency physicians are very familiar with the contraindications for obtaining studies with IV contrast dye. The most important concern is for some type of adverse reaction to the iodinated contrast media (ICM). While such reactions are typically lumped under “allergy,” this term is actually incorrect. Rather, two types of reactions can occur following exposure to ICM: idiosyncratic (more common) and nonidiosyncratic.¹ A more accurate description of the idiosyncratic reaction is anaphylactoid. This type of reaction occurs within a few minutes of exposure, and no previous sensitization is necessary. Symptoms are classified as mild, moderate, or severe (Table).

Nonidiosyncratic reactions are due to direct toxic or osmolar effects. Symptoms include bradycardia, hypotension, vasovagal reactions, sensation of warmth, metallic taste in the mouth, and nausea and vomiting.¹

Ironically, the majority of adverse reactions to ICM involve hypotension, not hypertension. This includes cardiovascular reactions to ICM, which typically involve bradycardia, peripheral vasodilation, and hypotension.¹ The incidence and severity of an adverse reaction to ICM also depends on whether ionic or nonionic ICM was used. (Unfortunately, the type of ICM administered to the patient in this case was not disclosed.)

The incidence and severity of adverse reactions to ICM are less with nonionic compared to ionic ICM. More than 90% of adverse reactions to nonionic ICM are anaphlyactoid.² In general, adverse reactions occur in 4% to 12% of patients receiving ionic ICM compared to 1% to 3% of those receiving nonionic ICM.² In a study of more than 300,000 contrast administrations, Katayama et al,³ found the overall risk for severe adverse reaction to be 0.2% for ionic ICM compared to 0.04% for nonionic ICM.

 

The bottom line in this case is that the patient’s event was a very rare and completely unforeseen result temporally related to the contrast CT scan ordered to evaluate the etiology of this patient’s abdominal pain.

  

 

Falls

A 67-year-old woman with a chief complaint of lightheadedness and dizziness was transferred from a dialysis center to the ED by emergency medical services (EMS). She stated that her symptoms came on suddenly right after she had completed her scheduled dialysis.

As the patient was being rolled on a stretcher from the ambulance to the ED entrance, the stretcher collapsed and tipped over, causing the patient to fall and strike her head on the pavement. The patient suffered a severe intraparenchymal brain hemorrhage, requiring intubation, ventilation, and admission to the intensive care unit. On the second day of admission, the patient’s family signed “do not resuscitate” orders and, in accordance with their wishes, life support was withdrawn and the patient died.

The family sued the ambulance company, stating the patient’s death was a direct result of negligent training and supervision of EMS personnel. The plaintiff further claimed the incident was caused by the failure to properly secure a locking mechanism on the stretcher, which caused it to tip. The ambulance company disputed the liability, asserting that what occurred was a tragic accident, not negligence. The jury found in favor of the plaintiff and awarded $1.5 million.

Discussion

While this is not a true ED case since the patient’s fall occurred just outside the ED, it does emphasize the importance of falls and the challenges of fall prevention within the hospital—including the ED. The incidence of falls within hospitals ranges from 1.3 to 9 falls per 1,000 occupied bed days (OBD).¹ This incidence, however, is not evenly distributed across hospital departments. Not surprisingly, the highest rates are reported in areas such as geriatric, neurology, and rehabilitation units.¹ The highest rates, 17 to 67 per 1,000 OBDs, appear to occur in geropsychiatric units,^2,3 and a significant number of such patient falls are serious, with some type of injury resulting from the fall in 30% to 51% of cases.¹ The percentage of falls resulting in a fracture ranges from 1% to 3%.¹

As previously noted, the ED is not immune to patient falls. A review of one academic medical center ED with 75,000 annual visits found an incidence of 1.3 falls per month, 31% of which resulted in patient injury.⁴

Some relatively simple steps can be taken to reduce the incidence of falls. For example, identifying patients at high risk of falling (eg, patients who are elderly, confused, dizzy) and ensuring other care-team workers are aware of the risk, can be very helpful.^4,5 In addition, brightly colored signs on the stretcher or colored wrist bands indicating the patient is at high-risk for falls helps to engage the entire healthcare team in fall-prevention measures.⁴ Sitters with high-risk patients can also help minimize fall risk.

Although side rails on hospital beds are intended to increase patient safety, their use is not without controversy. Most hospitals require staff to have side rails up for obvious reasons. Some hospitals, however, are concerned that the use of side rails can cause a fall from a higher position and increase the risk of injury when a patient attempts to get out of bed. Additional important steps include ensuring that all wet surfaces are quickly identified and cleaned, and making sure everyone is aware of the importance of fall-prevention measures.

 The employment of the abovementioned fall-prevention measures is especially important in relation to the aging US population. As the number of elderly patients in the United States continues to grow, the risk of patient falls is expected to increase. Therefore, hospitals should be proactive in implementing preventive measures to reduce the risk of patient falls and injury.  

 

Sued If You Do, Sued If You Don’t

A 52-year-old woman presented to the ED with complaints of abdominal pain, vaginal bleeding, and left leg pain. The patient stated that the symptoms, which she had been experiencing over the past few days, were becoming progressively worse. She denied fevers, chills, nausea, vomiting, diarrhea, or constipation. Her surgical history was
remarkable for an appendectomy 30 years prior. The patient was not currently on any medications. Regarding social history, she denied alcohol or tobacco use. She also denied any allergies to medications.

On physical examination, all of the patient’s vital signs were normal. The head, eyes, ears, nose, and throat, and lung and heart examinations were also normal; however, on abdominal examination, she exhibited tenderness throughout the lower abdomen, but without guarding or rebound. There was no costovertebral angle tenderness of the back. The pelvic examination was remarkable for a small amount of blood from the cervical os and a slightly enlarged uterus. The adnexa were normal and without tenderness.

The emergency physician (EP) ordered a complete blood count, basic metabolic profile, and urinalysis. An intravenous (IV) catheter was placed, and the patient was administered an IV analgesic and antiemetic. A normal saline drip of 125 cc per hour was also ordered. In view of the abdominal pain and tenderness, the EP ordered a computed tomography (CT) scan of the abdomen and pelvis with IV contrast. Within a few minutes of receiving the IV contrast, the patient experienced a sharp increase in blood pressure, followed by an abrupt change in mental status. A stat noncontrast head CT scan revealed a subarachnoid hemorrhage (SAH), and a CT angiogram (CTA) of the head revealed a ruptured cerebral aneurysm. Although the patient was taken immediately to the operating room by neurosurgery services, she had permanent left-sided weakness; as a result, she was no longer able to perform her previous type of work.

The patient sued both the EP and the hospital, claiming that the CT scan was unnecessary and had it not been performed, she would not have experienced the stroke. The defense asserted that the CT scan with contrast was appropriate given the patient’s symptoms and physical findings, and that the contrast dye used was not the cause of the stroke. The jury awarded the plaintiff $3.6 million.

Discussion

This case is unique in that the EP was sued for ordering a CT scan. In the overwhelming majority of malpractice cases, EPs are sued for not obtaining a certain test—frequently a CT scan. It does not appear the jury in this case was correct in their judgment as there was no conceivable way the EP could have anticipated this type of unusual reaction, especially in a patient with no history of medication allergies.

This jury ruling places EPs in an untenable situation: If they order a test and anything bad happens, they will be sued. If they do not order a test and something bad happens, they will be sued. In legal theory, there must be proximal cause between what the physician did (ie, order the CT scan) and the bad outcome, or negligence (ie, SAH). For this case, the two events seem true-true and unrelated. The contrast dye clearly did not cause the cerebral aneurysm, which was a preexisting condition.

Emergency physicians are very familiar with the contraindications for obtaining studies with IV contrast dye. The most important concern is for some type of adverse reaction to the iodinated contrast media (ICM). While such reactions are typically lumped under “allergy,” this term is actually incorrect. Rather, two types of reactions can occur following exposure to ICM: idiosyncratic (more common) and nonidiosyncratic.¹ A more accurate description of the idiosyncratic reaction is anaphylactoid. This type of reaction occurs within a few minutes of exposure, and no previous sensitization is necessary. Symptoms are classified as mild, moderate, or severe (Table).

Nonidiosyncratic reactions are due to direct toxic or osmolar effects. Symptoms include bradycardia, hypotension, vasovagal reactions, sensation of warmth, metallic taste in the mouth, and nausea and vomiting.¹

Ironically, the majority of adverse reactions to ICM involve hypotension, not hypertension. This includes cardiovascular reactions to ICM, which typically involve bradycardia, peripheral vasodilation, and hypotension.¹ The incidence and severity of an adverse reaction to ICM also depends on whether ionic or nonionic ICM was used. (Unfortunately, the type of ICM administered to the patient in this case was not disclosed.)

The incidence and severity of adverse reactions to ICM are less with nonionic compared to ionic ICM. More than 90% of adverse reactions to nonionic ICM are anaphlyactoid.² In general, adverse reactions occur in 4% to 12% of patients receiving ionic ICM compared to 1% to 3% of those receiving nonionic ICM.² In a study of more than 300,000 contrast administrations, Katayama et al,³ found the overall risk for severe adverse reaction to be 0.2% for ionic ICM compared to 0.04% for nonionic ICM.

 

The bottom line in this case is that the patient’s event was a very rare and completely unforeseen result temporally related to the contrast CT scan ordered to evaluate the etiology of this patient’s abdominal pain.

  

 

Falls

A 67-year-old woman with a chief complaint of lightheadedness and dizziness was transferred from a dialysis center to the ED by emergency medical services (EMS). She stated that her symptoms came on suddenly right after she had completed her scheduled dialysis.

As the patient was being rolled on a stretcher from the ambulance to the ED entrance, the stretcher collapsed and tipped over, causing the patient to fall and strike her head on the pavement. The patient suffered a severe intraparenchymal brain hemorrhage, requiring intubation, ventilation, and admission to the intensive care unit. On the second day of admission, the patient’s family signed “do not resuscitate” orders and, in accordance with their wishes, life support was withdrawn and the patient died.

The family sued the ambulance company, stating the patient’s death was a direct result of negligent training and supervision of EMS personnel. The plaintiff further claimed the incident was caused by the failure to properly secure a locking mechanism on the stretcher, which caused it to tip. The ambulance company disputed the liability, asserting that what occurred was a tragic accident, not negligence. The jury found in favor of the plaintiff and awarded $1.5 million.

Discussion

While this is not a true ED case since the patient’s fall occurred just outside the ED, it does emphasize the importance of falls and the challenges of fall prevention within the hospital—including the ED. The incidence of falls within hospitals ranges from 1.3 to 9 falls per 1,000 occupied bed days (OBD).¹ This incidence, however, is not evenly distributed across hospital departments. Not surprisingly, the highest rates are reported in areas such as geriatric, neurology, and rehabilitation units.¹ The highest rates, 17 to 67 per 1,000 OBDs, appear to occur in geropsychiatric units,^2,3 and a significant number of such patient falls are serious, with some type of injury resulting from the fall in 30% to 51% of cases.¹ The percentage of falls resulting in a fracture ranges from 1% to 3%.¹

As previously noted, the ED is not immune to patient falls. A review of one academic medical center ED with 75,000 annual visits found an incidence of 1.3 falls per month, 31% of which resulted in patient injury.⁴

Some relatively simple steps can be taken to reduce the incidence of falls. For example, identifying patients at high risk of falling (eg, patients who are elderly, confused, dizzy) and ensuring other care-team workers are aware of the risk, can be very helpful.^4,5 In addition, brightly colored signs on the stretcher or colored wrist bands indicating the patient is at high-risk for falls helps to engage the entire healthcare team in fall-prevention measures.⁴ Sitters with high-risk patients can also help minimize fall risk.

Although side rails on hospital beds are intended to increase patient safety, their use is not without controversy. Most hospitals require staff to have side rails up for obvious reasons. Some hospitals, however, are concerned that the use of side rails can cause a fall from a higher position and increase the risk of injury when a patient attempts to get out of bed. Additional important steps include ensuring that all wet surfaces are quickly identified and cleaned, and making sure everyone is aware of the importance of fall-prevention measures.

 The employment of the abovementioned fall-prevention measures is especially important in relation to the aging US population. As the number of elderly patients in the United States continues to grow, the risk of patient falls is expected to increase. Therefore, hospitals should be proactive in implementing preventive measures to reduce the risk of patient falls and injury.  

Gorham-Stout disease (GSD) is a rare condition characterized by spontaneous idiopathic resorption of bone with lymphovascular proliferation and an absence of malignant features. It was originally described by Jackson¹ in an 1838 report of a 36-year-old man whose “arm bone, between the shoulder and elbow” had completely vanished after 2 fractures. The disease was defined and its pathology characterized by Gorham and Stout² in 1955 in a series of 24 patients. Despite about 200 reported cases in the literature,³ its etiology remains unclear. Any bone in the skeleton may be affected by GSD, although there is a predilection for the skull, humerus, clavicle, ribs, pelvis, and femur.^4-6 It commonly manifests within the first 3 decades of life, but case reports range from as early as 2 months of age to the eighth decade.^5,7

Gorham-Stout disease is a diagnosis of exclusion that requires careful consideration of the clinical context, radiographic findings, and histopathology. Typical histopathologic findings include benign lymphatic or vascular proliferation, involution of adipose tissue within the bone marrow, and thinning of bony trabeculae.⁶ Fibrous tissue may replace vascular tissue after the initial vasoproliferative, osteolytic phase.⁶ Some authors describe the disease as having 2 phases, the first with massive osteolysis followed by relative dormancy and the second without progression or re-ossification.^8,9 Treatment remains controversial and is guided by management of the disease’s complications. Options range from careful observation and supportive management to aggressive surgical resection and reconstruction, with positive outcomes reported using many different modalities.¹⁰ Most treatment successes, however, hinge on halting bony resorption using medical and radiation therapy. Surgery is usually reserved as a salvage option for patients who have failed medical modalities and have residual symptoms or functional limitations.⁶

This case report describes the successful surgical management of a patient with pelvic GSD who had progressive pain and functional limitation despite exhaustive medical and radiation therapy. The patient provided written informed consent for print and electronic publication of this case report.

Case Report

A healthy 27-year-old man sought medical attention after a fall while mowing his lawn that resulted in difficulty ambulating. Radiographic studies showed discontinuous lytic lesions in the right periacetabular region and the right sacroiliac (SI) joint. Biopsy at an outside institution revealed an infiltration of thin-walled branching vascular channels involving intertrabecular marrow spaces and periosteal connective tissue. The vessels were devoid of a muscular coat and lined by flattened epithelium; these features were seen as consistent with GSD.

The patient was managed medically at the outside institution for approximately 2 years, with regimens consisting of zoledronate, denosumab, sorafenib, vincristine, sirolimus, and bevacizumab. Because there is no standard chemotherapy protocol for GSD, this broad regimen was likely an attempt by treating physicians to control disease progression before considering radiation or surgery. Zoledronate, a bisphosphonate, and denosumab, a monoclonal antibody against the receptor activator of nuclear factor κβ ligand (RANKL), both inhibit bone resorption, making them logical choices in treating an osteolytic disease. Sorafenib, vincristine, sirolimus, and bevacizumab may be of clinical benefit in GSD via inhibition of vascular proliferation, which is a key histologic feature in GSD. Sorafenib inhibits the vascular endothelial growth factor (VEGF) receptor, vincristine and sirolimus inhibit VEGF production, and bevacizumab is a monoclonal antibody targeting VEGF.

The patient’s disease continued to involve more of his right hemipelvis despite this extensive regimen of chemotherapy, and he experienced significant functional decline about 2 years after initial presentation, when he was no longer able to ambulate unassisted. Radiation therapy to the pelvis was attempted at the outside institution (6/15 MV photons, 5040 cGy, 28 fractions) without improvement. Three years after his initial injury, he presented to our clinic.

Now age 30 years, the patient ambulated only with crutches and endorsed minimal improvement in his pain over 3 years of treatment. Physical examination of the patient revealed that he was a tall, thin man in visible discomfort. Sensation was intact to light touch in the bilateral L1 to S1 nerve distributions. There was marked weakness of the right lower extremity, and his examination was limited by pain. He could not perform a straight leg raise on the right side. Right quadriceps strength was 4/5, and right hamstrings strength was 3/5. There was no weakness in the left leg. Reflexes were normal and symmetric bilaterally at the patellar and gastrocnemius soleus tendons. Distal circulatory status in both extremities was normal, and there were no deformities of the skin.

Figure 1 shows the patient’s computed tomography (CT) scan. Figures 1A and 1B reveal fragmentation of the posterior ilia and sacrum along both SI joints. Dislocation of the pubic symphysis is shown in Figures 1C and 1D, and discontinuous involvement of the ischium and posterior wall of the acetabulum is visible in Figure 1E.

 

Serum studies, including C-reactive protein, erythrocyte sedimentation rate, and a complete blood count, were within normal limits. A CT-guided core needle biopsy and aspiration of the right SI joint revealed no infection; pathology was nondiagnostic. Anesthetic injection of the hip joint resulted in no relief. As this man was severely functionally limited and had exhausted all medical and radiation treatment options, a collaborative decision was made to proceed with surgical management. Surgical options included spinopelvic fusion unilaterally or bilaterally, hip arthroplasty, or sacropelvic resection with or without reconstruction. The patient opted for intralesional surgery and spinopelvic fusion in place of more radical options.

Thirty-seven months after his initial presentation, he underwent posterior spinal fusion L5 to S1, SI fusion, and anterior locking plate fixation of the pubic symphysis, as seen in Figure 2. Pathology from surgical specimens, seen at original magnification ×20 and ×100 in Figures 3A and 3B, respectively, showed prominent vascular proliferation in the right ilium, with reactive bone changes in the left ilium and right sacrum. A lytic lesion showed fibrous tissue with an embedded fragment of necrotic bone.

 

Six weeks after surgery, the patient had substantial improvement in his pain and was partially weight-bearing. He was able to ambulate with crutches and returned to work. The patient’s overall clinical status continued to improve throughout the postoperative course. He developed low back pain 7 months after surgery and was found to have a sacrococcygeal abscess and coccygeal fracture anterior to the sacrum. He underwent irrigation and débridement of the abscess and distal coccygectomy and was treated with 6 weeks of intravenous cefazolin and long-term suppression with levofloxacin and rifampin for methicillin-sensitive Staphylococcus aureus hardware infection and osteomyelitis. The patient’s clinical course subsequently improved. At latest follow-up 16 months after the index operation, pain was reported as manageable and mostly an annoyance. He was prescribed up to 40 mg of oxycodone daily for pain. The patient returned to work, ambulates with a cane (no other assistive devices), and reports being able to get around without any difficulty.

Discussion

Gorham-Stout disease is an exceedingly rare condition resulting in spontaneous osteolysis. Approximately 200 cases have been reported with no apparent gender, race, or familial predilection or systemic symptoms differentiating it from other etiologies of idiopathic osteolysis.⁶ These patients often seek medical attention after sustaining a pathologic fracture,⁶ when a broad differential diagnosis narrows to GSD only after biopsy excludes other possibilities and demonstrates characteristic angiomatosis without malignant features.^2,4,6,8,10 Gorham-Stout disease appears more frequently at particular sites within the skeleton, and pelvic involvement is common—more than 20% of cases in 1 review.^5,10 Limitations in the patient’s ability to ambulate invariably result from osteolysis of the pelvis, which is concerning considering the young age at which GSD typically presents. A variety of treatment modalities have been described for pelvic GSD, but surgery has been undertaken in relatively few cases.⁵

The diagnosis is one of exclusion after considering the clinical context and radiologic and pathologic findings. In this case, a pathologic fracture was discovered with osteolytic lesions throughout the hemipelvis. Biopsy excluded malignancy and demonstrated the key hemangiomatous vascular proliferation with thin-walled vessels that is classic for GSD. While our patient initially appeared to have 2 sites of disease, the surgical specimen revealed a primary site of vascular proliferation in the right ilium from which 2 apparent foci had spread, consistent with the typical monocentric presentation of GSD.¹¹ A broad differential diagnosis must be considered at initial presentation, including osteomyelitis, metastatic disease, multiple myeloma, and primary bone sarcoma. Upon identifying a primary osteolytic process, several considerations besides GSD remain, such as Hajdu-Cheney syndrome, Winchester syndrome, multicentric osteolysis with nephropathy, familial osteolysis, Farber disease, and neurogenic osteolysis; most of these etiologies involve familial predispositions and/or systemic symptoms.

Treatment options for GSD include supportive care, medical therapy, radiation, and surgery. For pelvic GSD, numerous reports have demonstrated good outcomes with supportive management, since osteolysis often spontaneously arrests.^8,9,12 Others have had success with medical treatments in attempts to halt bone resorption.^6,13-15 Bisphosphonates are the cornerstone of medical therapy in GSD, as they appear to halt further osteoclastic bone breakdown. The levels of VEGF have been shown to be elevated in GSD,¹³ likely consistent with the vascular proliferation evident on pathology, and therapies such as bevacizumab and interferon α-2b have been used to target osteolysis via this pathway with good outcome.^13,14,16 External beam-radiation therapy has been shown to prevent local progression of osteolysis in up to 80% of cases.⁴ However, even with arrest of bone resorption, damage to affected bone may have progressed to the point of significant functional limitation. This may be especially true in the pelvis.

 

We present a case of a patient who continued to deteriorate after maximal medical and radiation therapy. Many reported cases of pelvic GSD have had good outcomes with some combination of conservative management, medical therapy, and radiation. However, in our patient, the pelvis and lumbosacral spine were unstable as a result of significant bone loss and fracture, and his clinical deterioration was dramatic. We considered reasonable surgical approaches, including local intralesional débridement and massive en bloc resection with structural allograft. We chose the less radical procedure given the patient’s age, minimal surgical history, and personal preference. Although structural pelvic allograft has been successful in a few cases, there remains a high risk of complications, such as fracture, resorption, or infection.¹⁷ We considered the addition of hip arthroplasty with either scenario, but we elected not to perform this component given his young age and lack of symptomatic improvement with diagnostic anesthetic hip injection. The key to this patient’s surgical reconstruction, aside from eliminating gross disease, was the stabilization of the spinopelvic junction and pelvic ring. His functional improvement as early as 6 weeks after surgery demonstrates that surgery can have an important role for patients with pelvic GSD who fail medical and radiation therapy.

Gorham-Stout disease (GSD) is a rare condition characterized by spontaneous idiopathic resorption of bone with lymphovascular proliferation and an absence of malignant features. It was originally described by Jackson¹ in an 1838 report of a 36-year-old man whose “arm bone, between the shoulder and elbow” had completely vanished after 2 fractures. The disease was defined and its pathology characterized by Gorham and Stout² in 1955 in a series of 24 patients. Despite about 200 reported cases in the literature,³ its etiology remains unclear. Any bone in the skeleton may be affected by GSD, although there is a predilection for the skull, humerus, clavicle, ribs, pelvis, and femur.^4-6 It commonly manifests within the first 3 decades of life, but case reports range from as early as 2 months of age to the eighth decade.^5,7

Gorham-Stout disease is a diagnosis of exclusion that requires careful consideration of the clinical context, radiographic findings, and histopathology. Typical histopathologic findings include benign lymphatic or vascular proliferation, involution of adipose tissue within the bone marrow, and thinning of bony trabeculae.⁶ Fibrous tissue may replace vascular tissue after the initial vasoproliferative, osteolytic phase.⁶ Some authors describe the disease as having 2 phases, the first with massive osteolysis followed by relative dormancy and the second without progression or re-ossification.^8,9 Treatment remains controversial and is guided by management of the disease’s complications. Options range from careful observation and supportive management to aggressive surgical resection and reconstruction, with positive outcomes reported using many different modalities.¹⁰ Most treatment successes, however, hinge on halting bony resorption using medical and radiation therapy. Surgery is usually reserved as a salvage option for patients who have failed medical modalities and have residual symptoms or functional limitations.⁶

This case report describes the successful surgical management of a patient with pelvic GSD who had progressive pain and functional limitation despite exhaustive medical and radiation therapy. The patient provided written informed consent for print and electronic publication of this case report.

Case Report

A healthy 27-year-old man sought medical attention after a fall while mowing his lawn that resulted in difficulty ambulating. Radiographic studies showed discontinuous lytic lesions in the right periacetabular region and the right sacroiliac (SI) joint. Biopsy at an outside institution revealed an infiltration of thin-walled branching vascular channels involving intertrabecular marrow spaces and periosteal connective tissue. The vessels were devoid of a muscular coat and lined by flattened epithelium; these features were seen as consistent with GSD.

The patient was managed medically at the outside institution for approximately 2 years, with regimens consisting of zoledronate, denosumab, sorafenib, vincristine, sirolimus, and bevacizumab. Because there is no standard chemotherapy protocol for GSD, this broad regimen was likely an attempt by treating physicians to control disease progression before considering radiation or surgery. Zoledronate, a bisphosphonate, and denosumab, a monoclonal antibody against the receptor activator of nuclear factor κβ ligand (RANKL), both inhibit bone resorption, making them logical choices in treating an osteolytic disease. Sorafenib, vincristine, sirolimus, and bevacizumab may be of clinical benefit in GSD via inhibition of vascular proliferation, which is a key histologic feature in GSD. Sorafenib inhibits the vascular endothelial growth factor (VEGF) receptor, vincristine and sirolimus inhibit VEGF production, and bevacizumab is a monoclonal antibody targeting VEGF.

The patient’s disease continued to involve more of his right hemipelvis despite this extensive regimen of chemotherapy, and he experienced significant functional decline about 2 years after initial presentation, when he was no longer able to ambulate unassisted. Radiation therapy to the pelvis was attempted at the outside institution (6/15 MV photons, 5040 cGy, 28 fractions) without improvement. Three years after his initial injury, he presented to our clinic.

Now age 30 years, the patient ambulated only with crutches and endorsed minimal improvement in his pain over 3 years of treatment. Physical examination of the patient revealed that he was a tall, thin man in visible discomfort. Sensation was intact to light touch in the bilateral L1 to S1 nerve distributions. There was marked weakness of the right lower extremity, and his examination was limited by pain. He could not perform a straight leg raise on the right side. Right quadriceps strength was 4/5, and right hamstrings strength was 3/5. There was no weakness in the left leg. Reflexes were normal and symmetric bilaterally at the patellar and gastrocnemius soleus tendons. Distal circulatory status in both extremities was normal, and there were no deformities of the skin.

Figure 1 shows the patient’s computed tomography (CT) scan. Figures 1A and 1B reveal fragmentation of the posterior ilia and sacrum along both SI joints. Dislocation of the pubic symphysis is shown in Figures 1C and 1D, and discontinuous involvement of the ischium and posterior wall of the acetabulum is visible in Figure 1E.

 

Serum studies, including C-reactive protein, erythrocyte sedimentation rate, and a complete blood count, were within normal limits. A CT-guided core needle biopsy and aspiration of the right SI joint revealed no infection; pathology was nondiagnostic. Anesthetic injection of the hip joint resulted in no relief. As this man was severely functionally limited and had exhausted all medical and radiation treatment options, a collaborative decision was made to proceed with surgical management. Surgical options included spinopelvic fusion unilaterally or bilaterally, hip arthroplasty, or sacropelvic resection with or without reconstruction. The patient opted for intralesional surgery and spinopelvic fusion in place of more radical options.

Thirty-seven months after his initial presentation, he underwent posterior spinal fusion L5 to S1, SI fusion, and anterior locking plate fixation of the pubic symphysis, as seen in Figure 2. Pathology from surgical specimens, seen at original magnification ×20 and ×100 in Figures 3A and 3B, respectively, showed prominent vascular proliferation in the right ilium, with reactive bone changes in the left ilium and right sacrum. A lytic lesion showed fibrous tissue with an embedded fragment of necrotic bone.

 

Six weeks after surgery, the patient had substantial improvement in his pain and was partially weight-bearing. He was able to ambulate with crutches and returned to work. The patient’s overall clinical status continued to improve throughout the postoperative course. He developed low back pain 7 months after surgery and was found to have a sacrococcygeal abscess and coccygeal fracture anterior to the sacrum. He underwent irrigation and débridement of the abscess and distal coccygectomy and was treated with 6 weeks of intravenous cefazolin and long-term suppression with levofloxacin and rifampin for methicillin-sensitive Staphylococcus aureus hardware infection and osteomyelitis. The patient’s clinical course subsequently improved. At latest follow-up 16 months after the index operation, pain was reported as manageable and mostly an annoyance. He was prescribed up to 40 mg of oxycodone daily for pain. The patient returned to work, ambulates with a cane (no other assistive devices), and reports being able to get around without any difficulty.

Discussion

Gorham-Stout disease is an exceedingly rare condition resulting in spontaneous osteolysis. Approximately 200 cases have been reported with no apparent gender, race, or familial predilection or systemic symptoms differentiating it from other etiologies of idiopathic osteolysis.⁶ These patients often seek medical attention after sustaining a pathologic fracture,⁶ when a broad differential diagnosis narrows to GSD only after biopsy excludes other possibilities and demonstrates characteristic angiomatosis without malignant features.^2,4,6,8,10 Gorham-Stout disease appears more frequently at particular sites within the skeleton, and pelvic involvement is common—more than 20% of cases in 1 review.^5,10 Limitations in the patient’s ability to ambulate invariably result from osteolysis of the pelvis, which is concerning considering the young age at which GSD typically presents. A variety of treatment modalities have been described for pelvic GSD, but surgery has been undertaken in relatively few cases.⁵

The diagnosis is one of exclusion after considering the clinical context and radiologic and pathologic findings. In this case, a pathologic fracture was discovered with osteolytic lesions throughout the hemipelvis. Biopsy excluded malignancy and demonstrated the key hemangiomatous vascular proliferation with thin-walled vessels that is classic for GSD. While our patient initially appeared to have 2 sites of disease, the surgical specimen revealed a primary site of vascular proliferation in the right ilium from which 2 apparent foci had spread, consistent with the typical monocentric presentation of GSD.¹¹ A broad differential diagnosis must be considered at initial presentation, including osteomyelitis, metastatic disease, multiple myeloma, and primary bone sarcoma. Upon identifying a primary osteolytic process, several considerations besides GSD remain, such as Hajdu-Cheney syndrome, Winchester syndrome, multicentric osteolysis with nephropathy, familial osteolysis, Farber disease, and neurogenic osteolysis; most of these etiologies involve familial predispositions and/or systemic symptoms.

Treatment options for GSD include supportive care, medical therapy, radiation, and surgery. For pelvic GSD, numerous reports have demonstrated good outcomes with supportive management, since osteolysis often spontaneously arrests.^8,9,12 Others have had success with medical treatments in attempts to halt bone resorption.^6,13-15 Bisphosphonates are the cornerstone of medical therapy in GSD, as they appear to halt further osteoclastic bone breakdown. The levels of VEGF have been shown to be elevated in GSD,¹³ likely consistent with the vascular proliferation evident on pathology, and therapies such as bevacizumab and interferon α-2b have been used to target osteolysis via this pathway with good outcome.^13,14,16 External beam-radiation therapy has been shown to prevent local progression of osteolysis in up to 80% of cases.⁴ However, even with arrest of bone resorption, damage to affected bone may have progressed to the point of significant functional limitation. This may be especially true in the pelvis.

 

We present a case of a patient who continued to deteriorate after maximal medical and radiation therapy. Many reported cases of pelvic GSD have had good outcomes with some combination of conservative management, medical therapy, and radiation. However, in our patient, the pelvis and lumbosacral spine were unstable as a result of significant bone loss and fracture, and his clinical deterioration was dramatic. We considered reasonable surgical approaches, including local intralesional débridement and massive en bloc resection with structural allograft. We chose the less radical procedure given the patient’s age, minimal surgical history, and personal preference. Although structural pelvic allograft has been successful in a few cases, there remains a high risk of complications, such as fracture, resorption, or infection.¹⁷ We considered the addition of hip arthroplasty with either scenario, but we elected not to perform this component given his young age and lack of symptomatic improvement with diagnostic anesthetic hip injection. The key to this patient’s surgical reconstruction, aside from eliminating gross disease, was the stabilization of the spinopelvic junction and pelvic ring. His functional improvement as early as 6 weeks after surgery demonstrates that surgery can have an important role for patients with pelvic GSD who fail medical and radiation therapy.

Gorham-Stout disease (GSD) is a rare condition characterized by spontaneous idiopathic resorption of bone with lymphovascular proliferation and an absence of malignant features. It was originally described by Jackson¹ in an 1838 report of a 36-year-old man whose “arm bone, between the shoulder and elbow” had completely vanished after 2 fractures. The disease was defined and its pathology characterized by Gorham and Stout² in 1955 in a series of 24 patients. Despite about 200 reported cases in the literature,³ its etiology remains unclear. Any bone in the skeleton may be affected by GSD, although there is a predilection for the skull, humerus, clavicle, ribs, pelvis, and femur.^4-6 It commonly manifests within the first 3 decades of life, but case reports range from as early as 2 months of age to the eighth decade.^5,7

Gorham-Stout disease is a diagnosis of exclusion that requires careful consideration of the clinical context, radiographic findings, and histopathology. Typical histopathologic findings include benign lymphatic or vascular proliferation, involution of adipose tissue within the bone marrow, and thinning of bony trabeculae.⁶ Fibrous tissue may replace vascular tissue after the initial vasoproliferative, osteolytic phase.⁶ Some authors describe the disease as having 2 phases, the first with massive osteolysis followed by relative dormancy and the second without progression or re-ossification.^8,9 Treatment remains controversial and is guided by management of the disease’s complications. Options range from careful observation and supportive management to aggressive surgical resection and reconstruction, with positive outcomes reported using many different modalities.¹⁰ Most treatment successes, however, hinge on halting bony resorption using medical and radiation therapy. Surgery is usually reserved as a salvage option for patients who have failed medical modalities and have residual symptoms or functional limitations.⁶

This case report describes the successful surgical management of a patient with pelvic GSD who had progressive pain and functional limitation despite exhaustive medical and radiation therapy. The patient provided written informed consent for print and electronic publication of this case report.

Case Report

A healthy 27-year-old man sought medical attention after a fall while mowing his lawn that resulted in difficulty ambulating. Radiographic studies showed discontinuous lytic lesions in the right periacetabular region and the right sacroiliac (SI) joint. Biopsy at an outside institution revealed an infiltration of thin-walled branching vascular channels involving intertrabecular marrow spaces and periosteal connective tissue. The vessels were devoid of a muscular coat and lined by flattened epithelium; these features were seen as consistent with GSD.

The patient was managed medically at the outside institution for approximately 2 years, with regimens consisting of zoledronate, denosumab, sorafenib, vincristine, sirolimus, and bevacizumab. Because there is no standard chemotherapy protocol for GSD, this broad regimen was likely an attempt by treating physicians to control disease progression before considering radiation or surgery. Zoledronate, a bisphosphonate, and denosumab, a monoclonal antibody against the receptor activator of nuclear factor κβ ligand (RANKL), both inhibit bone resorption, making them logical choices in treating an osteolytic disease. Sorafenib, vincristine, sirolimus, and bevacizumab may be of clinical benefit in GSD via inhibition of vascular proliferation, which is a key histologic feature in GSD. Sorafenib inhibits the vascular endothelial growth factor (VEGF) receptor, vincristine and sirolimus inhibit VEGF production, and bevacizumab is a monoclonal antibody targeting VEGF.

The patient’s disease continued to involve more of his right hemipelvis despite this extensive regimen of chemotherapy, and he experienced significant functional decline about 2 years after initial presentation, when he was no longer able to ambulate unassisted. Radiation therapy to the pelvis was attempted at the outside institution (6/15 MV photons, 5040 cGy, 28 fractions) without improvement. Three years after his initial injury, he presented to our clinic.

Now age 30 years, the patient ambulated only with crutches and endorsed minimal improvement in his pain over 3 years of treatment. Physical examination of the patient revealed that he was a tall, thin man in visible discomfort. Sensation was intact to light touch in the bilateral L1 to S1 nerve distributions. There was marked weakness of the right lower extremity, and his examination was limited by pain. He could not perform a straight leg raise on the right side. Right quadriceps strength was 4/5, and right hamstrings strength was 3/5. There was no weakness in the left leg. Reflexes were normal and symmetric bilaterally at the patellar and gastrocnemius soleus tendons. Distal circulatory status in both extremities was normal, and there were no deformities of the skin.

Figure 1 shows the patient’s computed tomography (CT) scan. Figures 1A and 1B reveal fragmentation of the posterior ilia and sacrum along both SI joints. Dislocation of the pubic symphysis is shown in Figures 1C and 1D, and discontinuous involvement of the ischium and posterior wall of the acetabulum is visible in Figure 1E.

 

Serum studies, including C-reactive protein, erythrocyte sedimentation rate, and a complete blood count, were within normal limits. A CT-guided core needle biopsy and aspiration of the right SI joint revealed no infection; pathology was nondiagnostic. Anesthetic injection of the hip joint resulted in no relief. As this man was severely functionally limited and had exhausted all medical and radiation treatment options, a collaborative decision was made to proceed with surgical management. Surgical options included spinopelvic fusion unilaterally or bilaterally, hip arthroplasty, or sacropelvic resection with or without reconstruction. The patient opted for intralesional surgery and spinopelvic fusion in place of more radical options.

Thirty-seven months after his initial presentation, he underwent posterior spinal fusion L5 to S1, SI fusion, and anterior locking plate fixation of the pubic symphysis, as seen in Figure 2. Pathology from surgical specimens, seen at original magnification ×20 and ×100 in Figures 3A and 3B, respectively, showed prominent vascular proliferation in the right ilium, with reactive bone changes in the left ilium and right sacrum. A lytic lesion showed fibrous tissue with an embedded fragment of necrotic bone.

 

Six weeks after surgery, the patient had substantial improvement in his pain and was partially weight-bearing. He was able to ambulate with crutches and returned to work. The patient’s overall clinical status continued to improve throughout the postoperative course. He developed low back pain 7 months after surgery and was found to have a sacrococcygeal abscess and coccygeal fracture anterior to the sacrum. He underwent irrigation and débridement of the abscess and distal coccygectomy and was treated with 6 weeks of intravenous cefazolin and long-term suppression with levofloxacin and rifampin for methicillin-sensitive Staphylococcus aureus hardware infection and osteomyelitis. The patient’s clinical course subsequently improved. At latest follow-up 16 months after the index operation, pain was reported as manageable and mostly an annoyance. He was prescribed up to 40 mg of oxycodone daily for pain. The patient returned to work, ambulates with a cane (no other assistive devices), and reports being able to get around without any difficulty.

Discussion

Gorham-Stout disease is an exceedingly rare condition resulting in spontaneous osteolysis. Approximately 200 cases have been reported with no apparent gender, race, or familial predilection or systemic symptoms differentiating it from other etiologies of idiopathic osteolysis.⁶ These patients often seek medical attention after sustaining a pathologic fracture,⁶ when a broad differential diagnosis narrows to GSD only after biopsy excludes other possibilities and demonstrates characteristic angiomatosis without malignant features.^2,4,6,8,10 Gorham-Stout disease appears more frequently at particular sites within the skeleton, and pelvic involvement is common—more than 20% of cases in 1 review.^5,10 Limitations in the patient’s ability to ambulate invariably result from osteolysis of the pelvis, which is concerning considering the young age at which GSD typically presents. A variety of treatment modalities have been described for pelvic GSD, but surgery has been undertaken in relatively few cases.⁵

The diagnosis is one of exclusion after considering the clinical context and radiologic and pathologic findings. In this case, a pathologic fracture was discovered with osteolytic lesions throughout the hemipelvis. Biopsy excluded malignancy and demonstrated the key hemangiomatous vascular proliferation with thin-walled vessels that is classic for GSD. While our patient initially appeared to have 2 sites of disease, the surgical specimen revealed a primary site of vascular proliferation in the right ilium from which 2 apparent foci had spread, consistent with the typical monocentric presentation of GSD.¹¹ A broad differential diagnosis must be considered at initial presentation, including osteomyelitis, metastatic disease, multiple myeloma, and primary bone sarcoma. Upon identifying a primary osteolytic process, several considerations besides GSD remain, such as Hajdu-Cheney syndrome, Winchester syndrome, multicentric osteolysis with nephropathy, familial osteolysis, Farber disease, and neurogenic osteolysis; most of these etiologies involve familial predispositions and/or systemic symptoms.

Treatment options for GSD include supportive care, medical therapy, radiation, and surgery. For pelvic GSD, numerous reports have demonstrated good outcomes with supportive management, since osteolysis often spontaneously arrests.^8,9,12 Others have had success with medical treatments in attempts to halt bone resorption.^6,13-15 Bisphosphonates are the cornerstone of medical therapy in GSD, as they appear to halt further osteoclastic bone breakdown. The levels of VEGF have been shown to be elevated in GSD,¹³ likely consistent with the vascular proliferation evident on pathology, and therapies such as bevacizumab and interferon α-2b have been used to target osteolysis via this pathway with good outcome.^13,14,16 External beam-radiation therapy has been shown to prevent local progression of osteolysis in up to 80% of cases.⁴ However, even with arrest of bone resorption, damage to affected bone may have progressed to the point of significant functional limitation. This may be especially true in the pelvis.

 

We present a case of a patient who continued to deteriorate after maximal medical and radiation therapy. Many reported cases of pelvic GSD have had good outcomes with some combination of conservative management, medical therapy, and radiation. However, in our patient, the pelvis and lumbosacral spine were unstable as a result of significant bone loss and fracture, and his clinical deterioration was dramatic. We considered reasonable surgical approaches, including local intralesional débridement and massive en bloc resection with structural allograft. We chose the less radical procedure given the patient’s age, minimal surgical history, and personal preference. Although structural pelvic allograft has been successful in a few cases, there remains a high risk of complications, such as fracture, resorption, or infection.¹⁷ We considered the addition of hip arthroplasty with either scenario, but we elected not to perform this component given his young age and lack of symptomatic improvement with diagnostic anesthetic hip injection. The key to this patient’s surgical reconstruction, aside from eliminating gross disease, was the stabilization of the spinopelvic junction and pelvic ring. His functional improvement as early as 6 weeks after surgery demonstrates that surgery can have an important role for patients with pelvic GSD who fail medical and radiation therapy.

Rising health care costs have led many health insurers to limit benefits, which may be a problem for children in need of specialty care. Uninsured children have poorer access to specialty care than insured children. Children with public health coverage have better access to specialty care than uninsured children but inferior access compared with privately insured children.^1,2 It is well documented that children with government insurance have limited access to orthopedic care for fractures, ligamentous knee injuries, and other injuries.^1,3-5 Adolescent idiopathic scoliosis (AIS) differs from many other conditions managed by pediatric orthopedists, as it may be progressive, with management becoming increasingly more complex as the curve magnitude increases.⁶ The ability to access care earlier in the disease process may allow for earlier nonoperative interventions, such as bracing. For patients who require spinal fusion, earlier diagnosis and referral to a specialist could potentially result in shorter fusions and preserve distal motion segments. The ability to access the health care system in a timely fashion would therefore be of utmost importance for patients with scoliosis.

The literature on AIS is lacking in studies focused on care access based on insurance coverage and the potential impact that this may have on curve progression.^7-9 We conducted a study to determine whether there is a difference between patients with and without private insurance who present to a busy urban pediatric orthopedic practice for management of scoliosis that eventually resulted in surgical treatment.

Materials and Methods

After obtaining institutional review board approval for this study, we retrospectively reviewed the medical records of patients (age, 10-18 years) who underwent posterior spinal fusion (PSF) for newly diagnosed AIS between 2008 and 2012. We excluded patients treated with growing spine instrumentation (growing rods), patients younger than 10 years or older than 18 years at presentation, and patients without adequate radiographs or clinical data, including insurance status. To focus on newly diagnosed scoliosis, we also excluded patients who had been seen for second opinions or whose scoliosis had been managed elsewhere in the past. Patients with syndromic, neuromuscular, or congenital scoliosis were also excluded.

Medical records were checked to ascertain time from initial evaluation to decision for surgery, time from recommendation for surgery until actual procedure, and insurance status. Distance traveled was figured from patients’ home addresses. Cobb angles were calculated from initial preoperative and final preoperative posteroanterior (PA) radiographs. Curves as seen on PA, lateral, and maximal effort, supine bending thoracic and lumbar radiographs from the initial preoperative visit were classified using the system of Lenke and colleagues.¹⁰ Hospital records were queried to determine number of levels fused at surgery, number of implants placed, and length of stay. Patients were evaluated without prior screening of insurance status and without prior consultation with referring physicians. Surgical procedures were scheduled on a first-come, first-served basis without preference for insurance status.

Results

We identified 135 consecutive patients with newly diagnosed AIS treated with PSF by our group between January 2008 and December 2012 (Table 1). Sixty-one percent had private insurance; 39% had Medicaid. There was no difference in age or ASA (American Society of Anesthesiologists) score between groups. Mean (SD) Cobb angle at initial presentation was 47.5° (14.3°) (range, 18.0°-86.0°) for the private insurance group and 57.2° (15.7°) (range, 23.0°-95.0°) for the Medicaid group (P < .0001). At time of surgery, mean (SD) Cobb angles were 54.6° (11.7°) and 60.6° (13.9°) for the private insurance and Medicaid groups, respectively (P = .008). There was no difference in curve types (Lenke and colleagues¹⁰ classification) between groups (Table 2, P = .83). Medicaid patients traveled a shorter mean (SD) distance for care, 56.3 (57.0) miles, versus 73.7 (66.7) miles (P = .05). There was no statistical difference (P = .14) in mean (SD) surgical wait time from surgery recommendation to actual surgery, 103.1 (62.4) days and 128.8 (137.5) days for the private insurance and Medicaid groups, respectively. The difference between patient groups in mean (SD) number of levels fused did not reach statistical significance (P = .16), 10.3 (2.2) levels for the Medicaid group and 9.7 (2.3) levels for the private insurance group. Mean (SD) estimated blood loss was higher for Medicaid patients, 445.7 (415.9) mL versus 335.1 (271.5) mL (P = .06), though there was no difference in use of posterior column osteotomies between groups. There was no difference (P = .11) in mean (SD) length of hospital stay between Medicaid patients, 2.6 (0.8) days, and private insurance patients, 2.4 (0.5) days.

 

 

Discussion

According to an extensive body of literature, patients with government insurance have limited access to specialty care.^1,11,12 Medicaid-insured children in need of orthopedic care are no exception. Sabharwal and colleagues¹³ examined a database of pediatric fracture cases and found that 52% of the privately insured patients and 22% of the publicly insured patients received orthopedic care (P = .013).¹³ When Pierce and colleagues¹⁴ called 42 orthopedic practices regarding a fictitious 14-year-old patient with an anterior cruciate ligament tear, 38 offered an appointment within 2 weeks to a privately insured patient, and 6 offered such an appointment to a publicly insured patient. Skaggs and colleagues⁴ surveyed 230 orthopedic practices nationally and found that Medicaid-insured children had limited access to orthopedic care; 41 practices (18%) would not see a child with Medicaid under any circumstances. Using a fictitious case of a 10-year-old boy with a forearm fracture, Iobst and colleagues³ tried making an appointment at 100 orthopedic offices. Eight gave an appointment within 1 week to a Medicaid-insured patient, and 36 gave an appointment to a privately insured patient.³

There are few data regarding insurance status and scoliosis care in children. Spinal deformity differs from simple fractures and ligamentous injuries, as timely care may result in a less invasive treatment (bracing) if the curvature is caught early. Goldstein and colleagues⁹ recently evaluated 642 patients who presented for scoliosis evaluation over a 10-year period. There was no difference in curve magnitudes between patients with and without Medicaid insurance. Thirty-two percent of these patients were evaluated for a second opinion, and the authors chose not to subdivide patients on the basis of curve severity and treatment needed, noting only no difference between groups. There was no discussion of the potential difference between patients with and without private insurance with respect to surgically versus nonsurgically treated curves. We wanted to focus specifically on patients who required surgical intervention, as our experience has been that many patients with government insurance present with either very mild scoliosis (10°) or very large curves that were not identified because of lack of primary care access or inadequate school screening. Although summing these 2 groups would result in a similar average, they would represent a different cohort than patients with curves along a bell curve. Furthermore, it is the group of patients who would require surgical intervention that is so critical to identify early in order to intervene.

Our data suggest a difference in presenting curves between patients with and without private insurance. The approximately 10° difference between patient groups in this study could potentially represent the difference between bracing and surgery. Furthermore, Miyanji and colleagues⁶ evaluated the relationship between Cobb angle and health care consumption and correlated larger curve magnitudes with more levels fused, longer surgeries, and higher rates of transfusion. Specifically, every 10° increase in curve magnitude resulted in 7.8 more minutes of operative time, 0.3 extra levels fused, and 1.5 times increased risk for requiring a blood transfusion.

Cho and Egorova¹⁵ recently evaluated insurance status with respect to surgical outcomes using a national inpatient database and found that 42.4% of surgeries for AIS in children with Medicaid had fusions involving 9 or more levels, whereas only 33.6% of privately insured patients had fusions of 9 or more levels. There was no difference in osteotomy or reoperation for pseudarthrosis between groups, but there was a slightly higher rate of infectious (1.1% vs 0.6%) and hemorrhagic (2.5% vs 1.7%) complications in the Medicaid group. Hospital stay was longer in patients with Medicaid, though complications were not different between groups.

The mean difference in the magnitude of the curves treated in our study was not more than 10° between patients with and without Medicaid, perhaps explaining the lack of a statistically significant difference in number of levels fused between groups. Although the groups were similar with respect to the percentage requiring posterior column spinal osteotomies, we noted a difference in estimated blood loss between groups, likely explained by the fact that a junior surgeon was added just before initiation of the study period, potentially skewing the estimated blood loss as this surgeon gained experience. Payer status has been correlated to length of hospital stay in children with scoliosis. Vitale and colleagues⁸ reviewed the effect of payer status on surgical outcomes in 3606 scoliosis patients from a statewide database in California and concluded that, compared with patients having all other payment sources, Medicaid patients had higher odds for complications and longer hospital stay. Our hospital has adopted a highly coordinated care pathway that allows for discharge on postoperative day 2, likely explaining the lack of any difference in postoperative stay.¹⁶

 

The disparity in curve magnitudes among patients with and without private insurance is striking and probably multifactorial. Very likely, the combination of schools with limited screening programs within urban or rural school systems,¹⁷ restricted access to pediatricians,^18,19 and longer waits to see orthopedic specialists²⁰ all contribute to this disparity. It should be noted that school screening is mandatory in our state. This discrepancy may be related to a previously established tendency in minority populations toward waiting longer to seek care and refusing surgical recommendations, though we were unable to query socioeconomic factors such as race and household income.^21,22 It is clearly important to increase access to care for underinsured patients with scoliosis. A comprehensive approach, including providing better education in the schools, establishing communication with referring primary care providers, and increasing access through more physicians or physician extenders, is likely needed. Orthopedists should perhaps treat scoliosis evaluation with the same sense of urgency given to minor fractures, and primary care providers should try to ensure that appropriate referrals for scoliosis are made. Also curious was the shorter travel distance for Medicaid patients versus private insurance patients in this study. We hypothesize this is related to our urban location and its large Medicaid population.

Our study had several limitations. Our electronic medical records (EMR) system does not store data related to the time a patient calls for an initial appointment, limiting our ability to determine how long patients waited for their initial consultation. Furthermore, the decision to undergo surgery is multifactorial and cannot be simplified into time from initial recommendation to surgery, as some patients delay surgery because of school or other obligations. These data should be reasonably consistent over time, as patients seen in the early spring in both groups may delay surgery until the summer, and those diagnosed in June may prefer earlier surgery.

Summary

Children with AIS are at risk for curve progression. Therefore, delays in providing timely care may result in worsening scoliosis. Compared with private insurance patients, Medicaid patients presented with larger curve magnitudes. Further study is needed to better delineate ways to improve care access for patients with scoliosis in communities with larger Medicaid populations.

Rising health care costs have led many health insurers to limit benefits, which may be a problem for children in need of specialty care. Uninsured children have poorer access to specialty care than insured children. Children with public health coverage have better access to specialty care than uninsured children but inferior access compared with privately insured children.^1,2 It is well documented that children with government insurance have limited access to orthopedic care for fractures, ligamentous knee injuries, and other injuries.^1,3-5 Adolescent idiopathic scoliosis (AIS) differs from many other conditions managed by pediatric orthopedists, as it may be progressive, with management becoming increasingly more complex as the curve magnitude increases.⁶ The ability to access care earlier in the disease process may allow for earlier nonoperative interventions, such as bracing. For patients who require spinal fusion, earlier diagnosis and referral to a specialist could potentially result in shorter fusions and preserve distal motion segments. The ability to access the health care system in a timely fashion would therefore be of utmost importance for patients with scoliosis.

The literature on AIS is lacking in studies focused on care access based on insurance coverage and the potential impact that this may have on curve progression.^7-9 We conducted a study to determine whether there is a difference between patients with and without private insurance who present to a busy urban pediatric orthopedic practice for management of scoliosis that eventually resulted in surgical treatment.

Materials and Methods

After obtaining institutional review board approval for this study, we retrospectively reviewed the medical records of patients (age, 10-18 years) who underwent posterior spinal fusion (PSF) for newly diagnosed AIS between 2008 and 2012. We excluded patients treated with growing spine instrumentation (growing rods), patients younger than 10 years or older than 18 years at presentation, and patients without adequate radiographs or clinical data, including insurance status. To focus on newly diagnosed scoliosis, we also excluded patients who had been seen for second opinions or whose scoliosis had been managed elsewhere in the past. Patients with syndromic, neuromuscular, or congenital scoliosis were also excluded.

Medical records were checked to ascertain time from initial evaluation to decision for surgery, time from recommendation for surgery until actual procedure, and insurance status. Distance traveled was figured from patients’ home addresses. Cobb angles were calculated from initial preoperative and final preoperative posteroanterior (PA) radiographs. Curves as seen on PA, lateral, and maximal effort, supine bending thoracic and lumbar radiographs from the initial preoperative visit were classified using the system of Lenke and colleagues.¹⁰ Hospital records were queried to determine number of levels fused at surgery, number of implants placed, and length of stay. Patients were evaluated without prior screening of insurance status and without prior consultation with referring physicians. Surgical procedures were scheduled on a first-come, first-served basis without preference for insurance status.

Results

We identified 135 consecutive patients with newly diagnosed AIS treated with PSF by our group between January 2008 and December 2012 (Table 1). Sixty-one percent had private insurance; 39% had Medicaid. There was no difference in age or ASA (American Society of Anesthesiologists) score between groups. Mean (SD) Cobb angle at initial presentation was 47.5° (14.3°) (range, 18.0°-86.0°) for the private insurance group and 57.2° (15.7°) (range, 23.0°-95.0°) for the Medicaid group (P < .0001). At time of surgery, mean (SD) Cobb angles were 54.6° (11.7°) and 60.6° (13.9°) for the private insurance and Medicaid groups, respectively (P = .008). There was no difference in curve types (Lenke and colleagues¹⁰ classification) between groups (Table 2, P = .83). Medicaid patients traveled a shorter mean (SD) distance for care, 56.3 (57.0) miles, versus 73.7 (66.7) miles (P = .05). There was no statistical difference (P = .14) in mean (SD) surgical wait time from surgery recommendation to actual surgery, 103.1 (62.4) days and 128.8 (137.5) days for the private insurance and Medicaid groups, respectively. The difference between patient groups in mean (SD) number of levels fused did not reach statistical significance (P = .16), 10.3 (2.2) levels for the Medicaid group and 9.7 (2.3) levels for the private insurance group. Mean (SD) estimated blood loss was higher for Medicaid patients, 445.7 (415.9) mL versus 335.1 (271.5) mL (P = .06), though there was no difference in use of posterior column osteotomies between groups. There was no difference (P = .11) in mean (SD) length of hospital stay between Medicaid patients, 2.6 (0.8) days, and private insurance patients, 2.4 (0.5) days.

 

 

Discussion

According to an extensive body of literature, patients with government insurance have limited access to specialty care.^1,11,12 Medicaid-insured children in need of orthopedic care are no exception. Sabharwal and colleagues¹³ examined a database of pediatric fracture cases and found that 52% of the privately insured patients and 22% of the publicly insured patients received orthopedic care (P = .013).¹³ When Pierce and colleagues¹⁴ called 42 orthopedic practices regarding a fictitious 14-year-old patient with an anterior cruciate ligament tear, 38 offered an appointment within 2 weeks to a privately insured patient, and 6 offered such an appointment to a publicly insured patient. Skaggs and colleagues⁴ surveyed 230 orthopedic practices nationally and found that Medicaid-insured children had limited access to orthopedic care; 41 practices (18%) would not see a child with Medicaid under any circumstances. Using a fictitious case of a 10-year-old boy with a forearm fracture, Iobst and colleagues³ tried making an appointment at 100 orthopedic offices. Eight gave an appointment within 1 week to a Medicaid-insured patient, and 36 gave an appointment to a privately insured patient.³

There are few data regarding insurance status and scoliosis care in children. Spinal deformity differs from simple fractures and ligamentous injuries, as timely care may result in a less invasive treatment (bracing) if the curvature is caught early. Goldstein and colleagues⁹ recently evaluated 642 patients who presented for scoliosis evaluation over a 10-year period. There was no difference in curve magnitudes between patients with and without Medicaid insurance. Thirty-two percent of these patients were evaluated for a second opinion, and the authors chose not to subdivide patients on the basis of curve severity and treatment needed, noting only no difference between groups. There was no discussion of the potential difference between patients with and without private insurance with respect to surgically versus nonsurgically treated curves. We wanted to focus specifically on patients who required surgical intervention, as our experience has been that many patients with government insurance present with either very mild scoliosis (10°) or very large curves that were not identified because of lack of primary care access or inadequate school screening. Although summing these 2 groups would result in a similar average, they would represent a different cohort than patients with curves along a bell curve. Furthermore, it is the group of patients who would require surgical intervention that is so critical to identify early in order to intervene.

Our data suggest a difference in presenting curves between patients with and without private insurance. The approximately 10° difference between patient groups in this study could potentially represent the difference between bracing and surgery. Furthermore, Miyanji and colleagues⁶ evaluated the relationship between Cobb angle and health care consumption and correlated larger curve magnitudes with more levels fused, longer surgeries, and higher rates of transfusion. Specifically, every 10° increase in curve magnitude resulted in 7.8 more minutes of operative time, 0.3 extra levels fused, and 1.5 times increased risk for requiring a blood transfusion.

Cho and Egorova¹⁵ recently evaluated insurance status with respect to surgical outcomes using a national inpatient database and found that 42.4% of surgeries for AIS in children with Medicaid had fusions involving 9 or more levels, whereas only 33.6% of privately insured patients had fusions of 9 or more levels. There was no difference in osteotomy or reoperation for pseudarthrosis between groups, but there was a slightly higher rate of infectious (1.1% vs 0.6%) and hemorrhagic (2.5% vs 1.7%) complications in the Medicaid group. Hospital stay was longer in patients with Medicaid, though complications were not different between groups.

The mean difference in the magnitude of the curves treated in our study was not more than 10° between patients with and without Medicaid, perhaps explaining the lack of a statistically significant difference in number of levels fused between groups. Although the groups were similar with respect to the percentage requiring posterior column spinal osteotomies, we noted a difference in estimated blood loss between groups, likely explained by the fact that a junior surgeon was added just before initiation of the study period, potentially skewing the estimated blood loss as this surgeon gained experience. Payer status has been correlated to length of hospital stay in children with scoliosis. Vitale and colleagues⁸ reviewed the effect of payer status on surgical outcomes in 3606 scoliosis patients from a statewide database in California and concluded that, compared with patients having all other payment sources, Medicaid patients had higher odds for complications and longer hospital stay. Our hospital has adopted a highly coordinated care pathway that allows for discharge on postoperative day 2, likely explaining the lack of any difference in postoperative stay.¹⁶

 

The disparity in curve magnitudes among patients with and without private insurance is striking and probably multifactorial. Very likely, the combination of schools with limited screening programs within urban or rural school systems,¹⁷ restricted access to pediatricians,^18,19 and longer waits to see orthopedic specialists²⁰ all contribute to this disparity. It should be noted that school screening is mandatory in our state. This discrepancy may be related to a previously established tendency in minority populations toward waiting longer to seek care and refusing surgical recommendations, though we were unable to query socioeconomic factors such as race and household income.^21,22 It is clearly important to increase access to care for underinsured patients with scoliosis. A comprehensive approach, including providing better education in the schools, establishing communication with referring primary care providers, and increasing access through more physicians or physician extenders, is likely needed. Orthopedists should perhaps treat scoliosis evaluation with the same sense of urgency given to minor fractures, and primary care providers should try to ensure that appropriate referrals for scoliosis are made. Also curious was the shorter travel distance for Medicaid patients versus private insurance patients in this study. We hypothesize this is related to our urban location and its large Medicaid population.

Our study had several limitations. Our electronic medical records (EMR) system does not store data related to the time a patient calls for an initial appointment, limiting our ability to determine how long patients waited for their initial consultation. Furthermore, the decision to undergo surgery is multifactorial and cannot be simplified into time from initial recommendation to surgery, as some patients delay surgery because of school or other obligations. These data should be reasonably consistent over time, as patients seen in the early spring in both groups may delay surgery until the summer, and those diagnosed in June may prefer earlier surgery.

Summary

Children with AIS are at risk for curve progression. Therefore, delays in providing timely care may result in worsening scoliosis. Compared with private insurance patients, Medicaid patients presented with larger curve magnitudes. Further study is needed to better delineate ways to improve care access for patients with scoliosis in communities with larger Medicaid populations.

Rising health care costs have led many health insurers to limit benefits, which may be a problem for children in need of specialty care. Uninsured children have poorer access to specialty care than insured children. Children with public health coverage have better access to specialty care than uninsured children but inferior access compared with privately insured children.^1,2 It is well documented that children with government insurance have limited access to orthopedic care for fractures, ligamentous knee injuries, and other injuries.^1,3-5 Adolescent idiopathic scoliosis (AIS) differs from many other conditions managed by pediatric orthopedists, as it may be progressive, with management becoming increasingly more complex as the curve magnitude increases.⁶ The ability to access care earlier in the disease process may allow for earlier nonoperative interventions, such as bracing. For patients who require spinal fusion, earlier diagnosis and referral to a specialist could potentially result in shorter fusions and preserve distal motion segments. The ability to access the health care system in a timely fashion would therefore be of utmost importance for patients with scoliosis.

The literature on AIS is lacking in studies focused on care access based on insurance coverage and the potential impact that this may have on curve progression.^7-9 We conducted a study to determine whether there is a difference between patients with and without private insurance who present to a busy urban pediatric orthopedic practice for management of scoliosis that eventually resulted in surgical treatment.

Materials and Methods

After obtaining institutional review board approval for this study, we retrospectively reviewed the medical records of patients (age, 10-18 years) who underwent posterior spinal fusion (PSF) for newly diagnosed AIS between 2008 and 2012. We excluded patients treated with growing spine instrumentation (growing rods), patients younger than 10 years or older than 18 years at presentation, and patients without adequate radiographs or clinical data, including insurance status. To focus on newly diagnosed scoliosis, we also excluded patients who had been seen for second opinions or whose scoliosis had been managed elsewhere in the past. Patients with syndromic, neuromuscular, or congenital scoliosis were also excluded.

Medical records were checked to ascertain time from initial evaluation to decision for surgery, time from recommendation for surgery until actual procedure, and insurance status. Distance traveled was figured from patients’ home addresses. Cobb angles were calculated from initial preoperative and final preoperative posteroanterior (PA) radiographs. Curves as seen on PA, lateral, and maximal effort, supine bending thoracic and lumbar radiographs from the initial preoperative visit were classified using the system of Lenke and colleagues.¹⁰ Hospital records were queried to determine number of levels fused at surgery, number of implants placed, and length of stay. Patients were evaluated without prior screening of insurance status and without prior consultation with referring physicians. Surgical procedures were scheduled on a first-come, first-served basis without preference for insurance status.

Results

We identified 135 consecutive patients with newly diagnosed AIS treated with PSF by our group between January 2008 and December 2012 (Table 1). Sixty-one percent had private insurance; 39% had Medicaid. There was no difference in age or ASA (American Society of Anesthesiologists) score between groups. Mean (SD) Cobb angle at initial presentation was 47.5° (14.3°) (range, 18.0°-86.0°) for the private insurance group and 57.2° (15.7°) (range, 23.0°-95.0°) for the Medicaid group (P < .0001). At time of surgery, mean (SD) Cobb angles were 54.6° (11.7°) and 60.6° (13.9°) for the private insurance and Medicaid groups, respectively (P = .008). There was no difference in curve types (Lenke and colleagues¹⁰ classification) between groups (Table 2, P = .83). Medicaid patients traveled a shorter mean (SD) distance for care, 56.3 (57.0) miles, versus 73.7 (66.7) miles (P = .05). There was no statistical difference (P = .14) in mean (SD) surgical wait time from surgery recommendation to actual surgery, 103.1 (62.4) days and 128.8 (137.5) days for the private insurance and Medicaid groups, respectively. The difference between patient groups in mean (SD) number of levels fused did not reach statistical significance (P = .16), 10.3 (2.2) levels for the Medicaid group and 9.7 (2.3) levels for the private insurance group. Mean (SD) estimated blood loss was higher for Medicaid patients, 445.7 (415.9) mL versus 335.1 (271.5) mL (P = .06), though there was no difference in use of posterior column osteotomies between groups. There was no difference (P = .11) in mean (SD) length of hospital stay between Medicaid patients, 2.6 (0.8) days, and private insurance patients, 2.4 (0.5) days.

 

 

Discussion

According to an extensive body of literature, patients with government insurance have limited access to specialty care.^1,11,12 Medicaid-insured children in need of orthopedic care are no exception. Sabharwal and colleagues¹³ examined a database of pediatric fracture cases and found that 52% of the privately insured patients and 22% of the publicly insured patients received orthopedic care (P = .013).¹³ When Pierce and colleagues¹⁴ called 42 orthopedic practices regarding a fictitious 14-year-old patient with an anterior cruciate ligament tear, 38 offered an appointment within 2 weeks to a privately insured patient, and 6 offered such an appointment to a publicly insured patient. Skaggs and colleagues⁴ surveyed 230 orthopedic practices nationally and found that Medicaid-insured children had limited access to orthopedic care; 41 practices (18%) would not see a child with Medicaid under any circumstances. Using a fictitious case of a 10-year-old boy with a forearm fracture, Iobst and colleagues³ tried making an appointment at 100 orthopedic offices. Eight gave an appointment within 1 week to a Medicaid-insured patient, and 36 gave an appointment to a privately insured patient.³

There are few data regarding insurance status and scoliosis care in children. Spinal deformity differs from simple fractures and ligamentous injuries, as timely care may result in a less invasive treatment (bracing) if the curvature is caught early. Goldstein and colleagues⁹ recently evaluated 642 patients who presented for scoliosis evaluation over a 10-year period. There was no difference in curve magnitudes between patients with and without Medicaid insurance. Thirty-two percent of these patients were evaluated for a second opinion, and the authors chose not to subdivide patients on the basis of curve severity and treatment needed, noting only no difference between groups. There was no discussion of the potential difference between patients with and without private insurance with respect to surgically versus nonsurgically treated curves. We wanted to focus specifically on patients who required surgical intervention, as our experience has been that many patients with government insurance present with either very mild scoliosis (10°) or very large curves that were not identified because of lack of primary care access or inadequate school screening. Although summing these 2 groups would result in a similar average, they would represent a different cohort than patients with curves along a bell curve. Furthermore, it is the group of patients who would require surgical intervention that is so critical to identify early in order to intervene.

Our data suggest a difference in presenting curves between patients with and without private insurance. The approximately 10° difference between patient groups in this study could potentially represent the difference between bracing and surgery. Furthermore, Miyanji and colleagues⁶ evaluated the relationship between Cobb angle and health care consumption and correlated larger curve magnitudes with more levels fused, longer surgeries, and higher rates of transfusion. Specifically, every 10° increase in curve magnitude resulted in 7.8 more minutes of operative time, 0.3 extra levels fused, and 1.5 times increased risk for requiring a blood transfusion.

Cho and Egorova¹⁵ recently evaluated insurance status with respect to surgical outcomes using a national inpatient database and found that 42.4% of surgeries for AIS in children with Medicaid had fusions involving 9 or more levels, whereas only 33.6% of privately insured patients had fusions of 9 or more levels. There was no difference in osteotomy or reoperation for pseudarthrosis between groups, but there was a slightly higher rate of infectious (1.1% vs 0.6%) and hemorrhagic (2.5% vs 1.7%) complications in the Medicaid group. Hospital stay was longer in patients with Medicaid, though complications were not different between groups.

The mean difference in the magnitude of the curves treated in our study was not more than 10° between patients with and without Medicaid, perhaps explaining the lack of a statistically significant difference in number of levels fused between groups. Although the groups were similar with respect to the percentage requiring posterior column spinal osteotomies, we noted a difference in estimated blood loss between groups, likely explained by the fact that a junior surgeon was added just before initiation of the study period, potentially skewing the estimated blood loss as this surgeon gained experience. Payer status has been correlated to length of hospital stay in children with scoliosis. Vitale and colleagues⁸ reviewed the effect of payer status on surgical outcomes in 3606 scoliosis patients from a statewide database in California and concluded that, compared with patients having all other payment sources, Medicaid patients had higher odds for complications and longer hospital stay. Our hospital has adopted a highly coordinated care pathway that allows for discharge on postoperative day 2, likely explaining the lack of any difference in postoperative stay.¹⁶

 

The disparity in curve magnitudes among patients with and without private insurance is striking and probably multifactorial. Very likely, the combination of schools with limited screening programs within urban or rural school systems,¹⁷ restricted access to pediatricians,^18,19 and longer waits to see orthopedic specialists²⁰ all contribute to this disparity. It should be noted that school screening is mandatory in our state. This discrepancy may be related to a previously established tendency in minority populations toward waiting longer to seek care and refusing surgical recommendations, though we were unable to query socioeconomic factors such as race and household income.^21,22 It is clearly important to increase access to care for underinsured patients with scoliosis. A comprehensive approach, including providing better education in the schools, establishing communication with referring primary care providers, and increasing access through more physicians or physician extenders, is likely needed. Orthopedists should perhaps treat scoliosis evaluation with the same sense of urgency given to minor fractures, and primary care providers should try to ensure that appropriate referrals for scoliosis are made. Also curious was the shorter travel distance for Medicaid patients versus private insurance patients in this study. We hypothesize this is related to our urban location and its large Medicaid population.

Our study had several limitations. Our electronic medical records (EMR) system does not store data related to the time a patient calls for an initial appointment, limiting our ability to determine how long patients waited for their initial consultation. Furthermore, the decision to undergo surgery is multifactorial and cannot be simplified into time from initial recommendation to surgery, as some patients delay surgery because of school or other obligations. These data should be reasonably consistent over time, as patients seen in the early spring in both groups may delay surgery until the summer, and those diagnosed in June may prefer earlier surgery.

Summary

Children with AIS are at risk for curve progression. Therefore, delays in providing timely care may result in worsening scoliosis. Compared with private insurance patients, Medicaid patients presented with larger curve magnitudes. Further study is needed to better delineate ways to improve care access for patients with scoliosis in communities with larger Medicaid populations.

Carpal tunnel syndrome (CTS) is a disorder characterized by entrapment of the median nerve at the wrist, which may lead to symptoms of pain, paresthesia, and, ultimately, thenar muscle atrophy. Surgical intervention is indicated with persistent or progressive symptoms despite nonoperative management. Timely surgical decompression aims to halt progression of this disorder and prevent permanent peripheral nerve injury.

Carpal tunnel release (CTR) is the most common hand and wrist surgery in the United States, with about 400,000 operations performed annually.^1,2 Several methods of decompressing the carpal tunnel have been described.³ These include standard open CTR (OCTR), mini-open approaches, and various endoscopic techniques. OCTR was initially described by Sir James Learmonth in 1933,⁴ and it remains the gold-standard surgical treatment for patients with symptomatic CTS. Uniform excellent results with high patient satisfaction and low complication rates have been reported in several series.^5-9 Common to all techniques is complete proximal-to-distal division of the transverse carpal ligament (TCL). Magnetic resonance imaging studies have shown that TCL transection and the resulting diastasis between the radial and ulnar leaflets cause a significant increase in the volume of the carpal tunnel, leading to decreased pressure.^10,11

Endoscopic CTR (ECTR) techniques were developed in an effort to reduce complications, scar sensitivity, and pillar pain and facilitate more rapid return to work.^12-17 Outcome studies have demonstrated that both open and endoscopic releases yield patient-reported subjective improvements over preoperative symptoms.^18-22 A randomized, controlled trial by Trumble and colleagues²³ in 2002 found that ECTR led to improved patient outcomes in the early postoperative period (first 3 months), though differences in outcomes were reduced at final follow-up. More recently (2007), a Cochrane review of 33 trials concluded there was no strong evidence favoring use of alternative techniques over OCTR.³ Further, OCTR has been found to be technically less demanding and associated with decreased complications and costs.²⁴

Indications

The benefit of median nerve decompression at the wrist for CTS is clear.^6,7 Indications for surgery in patients with CTS include persistent symptoms despite nonoperative treatment, objective sensory disturbance or motor weakness, and thenar atrophy. Symptomatic response to corticosteroid injection is predictive of success after carpal tunnel surgery.²⁵ More than 87% of patients who gain symptomatic relief from corticosteroid injection have an excellent surgical outcome.

Technique

OCTR allows direct visualization of the TCL and the distal volar forearm fascia (DVFF) and evaluation for the presence of anomalous branching patterns of the median nerve. OCTR traditionally was performed through a 4- to 5-cm longitudinal incision extending from the wrist crease proximally to the Kaplan cardinal line distally. The mini-open technique is identical with the exception of incision length. We routinely use a 2.5- to 3-cm incision. Regardless of incision length, each OCTR should proceed through the same reproducible steps.

We perform OCTR under tourniquet control. Choice of anesthesia is surgeon and patient preference. We prefer local anesthesia with conscious sedation. After conscious sedation is administered, we infiltrate the carpal tunnel and surrounding subcutaneous tissue with 10 mL of a 50:50 mixture of 0.5% bupivacaine and 1% lidocaine without epinephrine.

A 2.5- to 3-cm longitudinal incision is made along the axis of the radial border of the ring finger from the Kaplan cardinal line²⁶ and extending about 3 cm proximally toward the wrist flexion crease ulnar to the palmaris longus if present (Figure 1).

After the skin is incised longitudinally, the subcutaneous fat is mobilized and cutaneous sensory branches identified and protected. The underlying superficial palmar fascia is incised in line with the skin incision. The underlying midportion of the TCL is now visualized.

Transverse Carpal Ligament Release

Occasionally, the investing fascia along the ulnar edge of the thenar musculature is mobilized radialward (if the thenar musculature is well developed) to visualize the proximal limb of the TCL. Injury to any anomalous motor branch of the median nerve is avoided by directly visualizing and then incising the TCL (Figure 2). The TCL is incised along its ulnar border just radial to the hook of hamate from distal to proximal in line with the radial border of the ring finger. Staying near the ulnar attachment of the TCL keeps the plane of ligament division farther away from the median nerve and its recurrent motor branches. Although the ulnar neurovascular bundle typically resides ulnar to the hook of hamate in the canal of Guyon, the surgeon must be aware that it can be located radial to the hook in some instances.^27,28 In the elderly, the ulnar artery may be tortuous and enter the field and require retraction. The TCL is incised distally until the sentinel fat pad, which marks the superficial palmar arterial arch, is visualized. This bed of adipose tissue marks the distal edge of the TCL.²⁹

 

Proximally, subcutaneous tissues above the proximal limb of the TCL and DVFF are mobilized to about 2 cm proximal to the wrist flexion crease to create a plane for the fine long nasal turbinate speculum. The nasal turbinate speculum is then inserted into this plane above the proximal limb of the TCL and DVFF (Figure 3). Once inserted to the level of the confluence of the TCL and the DVFF, the speculum is opened.

Topside visualization is now encountered with the ulnar neurovascular bundle protected by the ulnar blade of the speculum. A long-handle scalpel is used to incise the TCL and the DVFF under direct visualization from proximal to distal in line with the previously completed distal release (Figure 4). As the nasal turbinate speculum is stretching the TCL and putting it under tension, the TCL can be heard splitting as it is being incised. Once the TCL and the DVFF are divided, the speculum is slowly closed and removed. Wide diastasis of the radial and ulnar leaflets of the TCL and the DVFF is directly visualized. Complete decompression of the median nerve from the distal forearm fascia to the superficial palmar arch is confirmed.

Adhesions between the undersurface of the radial leaflet and the flexor tendons and median nerve are mobilized. The median nerve is assessed for “hourglass” morphology or atrophy. The flexor tendons can be swept radialward with a free elevator to inspect the floor of the carpal tunnel. Flexor tenosynovectomy is not routinely performed. The incision is closed with interrupted simple sutures using 4-0 nylon.

Study Results

This study was conducted at Hand Surgery PC, Newton-Wellesley Hospital, Tufts University School of Medicine. Over a 10-month interval, 101 consecutive mini-OCTRs (63 right hands, 38 left hands) were performed with this proximal release modification in 88 patients (51 females, 37 males) by Dr. Ruchelsman and Dr. Belsky (Table). CTRs performed in the setting of wrist and/or carpal trauma were excluded. Mean age was 62.8 years. Mean follow-up was 11.3 weeks (~3 months). For isolated cases of CTR, mean tourniquet time was 16 minutes. CTS symptoms were relieved in all patients with a high degree of satisfaction as measured with history and examination findings at follow-up visits. There were no major complications (eg, infection, neural or vascular damage, severe residual pain). Four patients reported minor residual numbness in the fingers at latest follow-up but nevertheless had major improvement over preoperative baseline. These 4 patients had preoperative electromyograms or nerve conduction studies documenting the extent of their disease. There was 1 case of minor wound complication. Three weeks after surgery, the patient had a 1-cm wound opening, which closed with local wound care. The patient did not develop any drainage, infection, bleeding, or neurologic symptoms.

Discussion

Open release of the TCL—the gold standard of surgical treatment for CTS—produces reliable symptom relief in the vast majority of patients.^25,30 Given that the most common complication of carpal tunnel surgery is incomplete release of the TCL,^31,32 this technique, which uses a nasal turbinate speculum to better visualize the median nerve, could potentially reduce the reoperation rate. The nasal turbinate speculum allows the surgeon to see the confluence of the TCL and the DVFF. In addition, as the complete release can be visualized, there is minimal chance of injury.

The 2007 Cochrane review³ found no strong evidence supporting replacing OCTR with endoscopic techniques. Previous investigators have questioned the utility of ECTR given that it is higher in cost and more resource-intensive than OCTR^1,33,34 and is associated with higher rates of certain complications.^5,22,35-37 A 2004 meta-analysis of 13 randomized, controlled trials found a higher rate of reversible nerve damage with an odds ratio of 3.1 for ECTR versus OCTR.³⁵ A more recent (2006) review of more than 80 studies found transient neurapraxias in 1.45% of ECTR cases and 0.25% of OCTR cases.⁵ The same study reported overall complication rates (reversible and major neurovascular structural injuries) of 0.74% for OCTR and 1.63% for ECTR (P < .005). Another limitation of ECTR is that endoscopic techniques require a higher degree of surgical skill, which makes teaching residents and fellows more challenging.

The novel nasal turbinate speculum technique presented here is easily reproducible and allows first-time surgeons to visualize all important structures. Given that this technique does not require an endoscope or an endoscope-viewing tower, it is likely more cost-effective and requires less time for turnover between cases. Patients obtain good relief of their CTS symptoms with this technique, and most return to their daily activities within weeks after operation.

Carpal tunnel syndrome (CTS) is a disorder characterized by entrapment of the median nerve at the wrist, which may lead to symptoms of pain, paresthesia, and, ultimately, thenar muscle atrophy. Surgical intervention is indicated with persistent or progressive symptoms despite nonoperative management. Timely surgical decompression aims to halt progression of this disorder and prevent permanent peripheral nerve injury.

Carpal tunnel release (CTR) is the most common hand and wrist surgery in the United States, with about 400,000 operations performed annually.^1,2 Several methods of decompressing the carpal tunnel have been described.³ These include standard open CTR (OCTR), mini-open approaches, and various endoscopic techniques. OCTR was initially described by Sir James Learmonth in 1933,⁴ and it remains the gold-standard surgical treatment for patients with symptomatic CTS. Uniform excellent results with high patient satisfaction and low complication rates have been reported in several series.^5-9 Common to all techniques is complete proximal-to-distal division of the transverse carpal ligament (TCL). Magnetic resonance imaging studies have shown that TCL transection and the resulting diastasis between the radial and ulnar leaflets cause a significant increase in the volume of the carpal tunnel, leading to decreased pressure.^10,11

Endoscopic CTR (ECTR) techniques were developed in an effort to reduce complications, scar sensitivity, and pillar pain and facilitate more rapid return to work.^12-17 Outcome studies have demonstrated that both open and endoscopic releases yield patient-reported subjective improvements over preoperative symptoms.^18-22 A randomized, controlled trial by Trumble and colleagues²³ in 2002 found that ECTR led to improved patient outcomes in the early postoperative period (first 3 months), though differences in outcomes were reduced at final follow-up. More recently (2007), a Cochrane review of 33 trials concluded there was no strong evidence favoring use of alternative techniques over OCTR.³ Further, OCTR has been found to be technically less demanding and associated with decreased complications and costs.²⁴

Indications

The benefit of median nerve decompression at the wrist for CTS is clear.^6,7 Indications for surgery in patients with CTS include persistent symptoms despite nonoperative treatment, objective sensory disturbance or motor weakness, and thenar atrophy. Symptomatic response to corticosteroid injection is predictive of success after carpal tunnel surgery.²⁵ More than 87% of patients who gain symptomatic relief from corticosteroid injection have an excellent surgical outcome.

Technique

OCTR allows direct visualization of the TCL and the distal volar forearm fascia (DVFF) and evaluation for the presence of anomalous branching patterns of the median nerve. OCTR traditionally was performed through a 4- to 5-cm longitudinal incision extending from the wrist crease proximally to the Kaplan cardinal line distally. The mini-open technique is identical with the exception of incision length. We routinely use a 2.5- to 3-cm incision. Regardless of incision length, each OCTR should proceed through the same reproducible steps.

We perform OCTR under tourniquet control. Choice of anesthesia is surgeon and patient preference. We prefer local anesthesia with conscious sedation. After conscious sedation is administered, we infiltrate the carpal tunnel and surrounding subcutaneous tissue with 10 mL of a 50:50 mixture of 0.5% bupivacaine and 1% lidocaine without epinephrine.

A 2.5- to 3-cm longitudinal incision is made along the axis of the radial border of the ring finger from the Kaplan cardinal line²⁶ and extending about 3 cm proximally toward the wrist flexion crease ulnar to the palmaris longus if present (Figure 1).

After the skin is incised longitudinally, the subcutaneous fat is mobilized and cutaneous sensory branches identified and protected. The underlying superficial palmar fascia is incised in line with the skin incision. The underlying midportion of the TCL is now visualized.

Transverse Carpal Ligament Release

Occasionally, the investing fascia along the ulnar edge of the thenar musculature is mobilized radialward (if the thenar musculature is well developed) to visualize the proximal limb of the TCL. Injury to any anomalous motor branch of the median nerve is avoided by directly visualizing and then incising the TCL (Figure 2). The TCL is incised along its ulnar border just radial to the hook of hamate from distal to proximal in line with the radial border of the ring finger. Staying near the ulnar attachment of the TCL keeps the plane of ligament division farther away from the median nerve and its recurrent motor branches. Although the ulnar neurovascular bundle typically resides ulnar to the hook of hamate in the canal of Guyon, the surgeon must be aware that it can be located radial to the hook in some instances.^27,28 In the elderly, the ulnar artery may be tortuous and enter the field and require retraction. The TCL is incised distally until the sentinel fat pad, which marks the superficial palmar arterial arch, is visualized. This bed of adipose tissue marks the distal edge of the TCL.²⁹

 

Proximally, subcutaneous tissues above the proximal limb of the TCL and DVFF are mobilized to about 2 cm proximal to the wrist flexion crease to create a plane for the fine long nasal turbinate speculum. The nasal turbinate speculum is then inserted into this plane above the proximal limb of the TCL and DVFF (Figure 3). Once inserted to the level of the confluence of the TCL and the DVFF, the speculum is opened.

Topside visualization is now encountered with the ulnar neurovascular bundle protected by the ulnar blade of the speculum. A long-handle scalpel is used to incise the TCL and the DVFF under direct visualization from proximal to distal in line with the previously completed distal release (Figure 4). As the nasal turbinate speculum is stretching the TCL and putting it under tension, the TCL can be heard splitting as it is being incised. Once the TCL and the DVFF are divided, the speculum is slowly closed and removed. Wide diastasis of the radial and ulnar leaflets of the TCL and the DVFF is directly visualized. Complete decompression of the median nerve from the distal forearm fascia to the superficial palmar arch is confirmed.

Adhesions between the undersurface of the radial leaflet and the flexor tendons and median nerve are mobilized. The median nerve is assessed for “hourglass” morphology or atrophy. The flexor tendons can be swept radialward with a free elevator to inspect the floor of the carpal tunnel. Flexor tenosynovectomy is not routinely performed. The incision is closed with interrupted simple sutures using 4-0 nylon.

Study Results

This study was conducted at Hand Surgery PC, Newton-Wellesley Hospital, Tufts University School of Medicine. Over a 10-month interval, 101 consecutive mini-OCTRs (63 right hands, 38 left hands) were performed with this proximal release modification in 88 patients (51 females, 37 males) by Dr. Ruchelsman and Dr. Belsky (Table). CTRs performed in the setting of wrist and/or carpal trauma were excluded. Mean age was 62.8 years. Mean follow-up was 11.3 weeks (~3 months). For isolated cases of CTR, mean tourniquet time was 16 minutes. CTS symptoms were relieved in all patients with a high degree of satisfaction as measured with history and examination findings at follow-up visits. There were no major complications (eg, infection, neural or vascular damage, severe residual pain). Four patients reported minor residual numbness in the fingers at latest follow-up but nevertheless had major improvement over preoperative baseline. These 4 patients had preoperative electromyograms or nerve conduction studies documenting the extent of their disease. There was 1 case of minor wound complication. Three weeks after surgery, the patient had a 1-cm wound opening, which closed with local wound care. The patient did not develop any drainage, infection, bleeding, or neurologic symptoms.

Discussion

Open release of the TCL—the gold standard of surgical treatment for CTS—produces reliable symptom relief in the vast majority of patients.^25,30 Given that the most common complication of carpal tunnel surgery is incomplete release of the TCL,^31,32 this technique, which uses a nasal turbinate speculum to better visualize the median nerve, could potentially reduce the reoperation rate. The nasal turbinate speculum allows the surgeon to see the confluence of the TCL and the DVFF. In addition, as the complete release can be visualized, there is minimal chance of injury.

The 2007 Cochrane review³ found no strong evidence supporting replacing OCTR with endoscopic techniques. Previous investigators have questioned the utility of ECTR given that it is higher in cost and more resource-intensive than OCTR^1,33,34 and is associated with higher rates of certain complications.^5,22,35-37 A 2004 meta-analysis of 13 randomized, controlled trials found a higher rate of reversible nerve damage with an odds ratio of 3.1 for ECTR versus OCTR.³⁵ A more recent (2006) review of more than 80 studies found transient neurapraxias in 1.45% of ECTR cases and 0.25% of OCTR cases.⁵ The same study reported overall complication rates (reversible and major neurovascular structural injuries) of 0.74% for OCTR and 1.63% for ECTR (P < .005). Another limitation of ECTR is that endoscopic techniques require a higher degree of surgical skill, which makes teaching residents and fellows more challenging.

The novel nasal turbinate speculum technique presented here is easily reproducible and allows first-time surgeons to visualize all important structures. Given that this technique does not require an endoscope or an endoscope-viewing tower, it is likely more cost-effective and requires less time for turnover between cases. Patients obtain good relief of their CTS symptoms with this technique, and most return to their daily activities within weeks after operation.

Carpal tunnel syndrome (CTS) is a disorder characterized by entrapment of the median nerve at the wrist, which may lead to symptoms of pain, paresthesia, and, ultimately, thenar muscle atrophy. Surgical intervention is indicated with persistent or progressive symptoms despite nonoperative management. Timely surgical decompression aims to halt progression of this disorder and prevent permanent peripheral nerve injury.

Carpal tunnel release (CTR) is the most common hand and wrist surgery in the United States, with about 400,000 operations performed annually.^1,2 Several methods of decompressing the carpal tunnel have been described.³ These include standard open CTR (OCTR), mini-open approaches, and various endoscopic techniques. OCTR was initially described by Sir James Learmonth in 1933,⁴ and it remains the gold-standard surgical treatment for patients with symptomatic CTS. Uniform excellent results with high patient satisfaction and low complication rates have been reported in several series.^5-9 Common to all techniques is complete proximal-to-distal division of the transverse carpal ligament (TCL). Magnetic resonance imaging studies have shown that TCL transection and the resulting diastasis between the radial and ulnar leaflets cause a significant increase in the volume of the carpal tunnel, leading to decreased pressure.^10,11

Endoscopic CTR (ECTR) techniques were developed in an effort to reduce complications, scar sensitivity, and pillar pain and facilitate more rapid return to work.^12-17 Outcome studies have demonstrated that both open and endoscopic releases yield patient-reported subjective improvements over preoperative symptoms.^18-22 A randomized, controlled trial by Trumble and colleagues²³ in 2002 found that ECTR led to improved patient outcomes in the early postoperative period (first 3 months), though differences in outcomes were reduced at final follow-up. More recently (2007), a Cochrane review of 33 trials concluded there was no strong evidence favoring use of alternative techniques over OCTR.³ Further, OCTR has been found to be technically less demanding and associated with decreased complications and costs.²⁴

Indications

The benefit of median nerve decompression at the wrist for CTS is clear.^6,7 Indications for surgery in patients with CTS include persistent symptoms despite nonoperative treatment, objective sensory disturbance or motor weakness, and thenar atrophy. Symptomatic response to corticosteroid injection is predictive of success after carpal tunnel surgery.²⁵ More than 87% of patients who gain symptomatic relief from corticosteroid injection have an excellent surgical outcome.

Technique

OCTR allows direct visualization of the TCL and the distal volar forearm fascia (DVFF) and evaluation for the presence of anomalous branching patterns of the median nerve. OCTR traditionally was performed through a 4- to 5-cm longitudinal incision extending from the wrist crease proximally to the Kaplan cardinal line distally. The mini-open technique is identical with the exception of incision length. We routinely use a 2.5- to 3-cm incision. Regardless of incision length, each OCTR should proceed through the same reproducible steps.

We perform OCTR under tourniquet control. Choice of anesthesia is surgeon and patient preference. We prefer local anesthesia with conscious sedation. After conscious sedation is administered, we infiltrate the carpal tunnel and surrounding subcutaneous tissue with 10 mL of a 50:50 mixture of 0.5% bupivacaine and 1% lidocaine without epinephrine.

A 2.5- to 3-cm longitudinal incision is made along the axis of the radial border of the ring finger from the Kaplan cardinal line²⁶ and extending about 3 cm proximally toward the wrist flexion crease ulnar to the palmaris longus if present (Figure 1).

After the skin is incised longitudinally, the subcutaneous fat is mobilized and cutaneous sensory branches identified and protected. The underlying superficial palmar fascia is incised in line with the skin incision. The underlying midportion of the TCL is now visualized.

Transverse Carpal Ligament Release

Occasionally, the investing fascia along the ulnar edge of the thenar musculature is mobilized radialward (if the thenar musculature is well developed) to visualize the proximal limb of the TCL. Injury to any anomalous motor branch of the median nerve is avoided by directly visualizing and then incising the TCL (Figure 2). The TCL is incised along its ulnar border just radial to the hook of hamate from distal to proximal in line with the radial border of the ring finger. Staying near the ulnar attachment of the TCL keeps the plane of ligament division farther away from the median nerve and its recurrent motor branches. Although the ulnar neurovascular bundle typically resides ulnar to the hook of hamate in the canal of Guyon, the surgeon must be aware that it can be located radial to the hook in some instances.^27,28 In the elderly, the ulnar artery may be tortuous and enter the field and require retraction. The TCL is incised distally until the sentinel fat pad, which marks the superficial palmar arterial arch, is visualized. This bed of adipose tissue marks the distal edge of the TCL.²⁹

 

Proximally, subcutaneous tissues above the proximal limb of the TCL and DVFF are mobilized to about 2 cm proximal to the wrist flexion crease to create a plane for the fine long nasal turbinate speculum. The nasal turbinate speculum is then inserted into this plane above the proximal limb of the TCL and DVFF (Figure 3). Once inserted to the level of the confluence of the TCL and the DVFF, the speculum is opened.

Topside visualization is now encountered with the ulnar neurovascular bundle protected by the ulnar blade of the speculum. A long-handle scalpel is used to incise the TCL and the DVFF under direct visualization from proximal to distal in line with the previously completed distal release (Figure 4). As the nasal turbinate speculum is stretching the TCL and putting it under tension, the TCL can be heard splitting as it is being incised. Once the TCL and the DVFF are divided, the speculum is slowly closed and removed. Wide diastasis of the radial and ulnar leaflets of the TCL and the DVFF is directly visualized. Complete decompression of the median nerve from the distal forearm fascia to the superficial palmar arch is confirmed.

Adhesions between the undersurface of the radial leaflet and the flexor tendons and median nerve are mobilized. The median nerve is assessed for “hourglass” morphology or atrophy. The flexor tendons can be swept radialward with a free elevator to inspect the floor of the carpal tunnel. Flexor tenosynovectomy is not routinely performed. The incision is closed with interrupted simple sutures using 4-0 nylon.

Study Results

This study was conducted at Hand Surgery PC, Newton-Wellesley Hospital, Tufts University School of Medicine. Over a 10-month interval, 101 consecutive mini-OCTRs (63 right hands, 38 left hands) were performed with this proximal release modification in 88 patients (51 females, 37 males) by Dr. Ruchelsman and Dr. Belsky (Table). CTRs performed in the setting of wrist and/or carpal trauma were excluded. Mean age was 62.8 years. Mean follow-up was 11.3 weeks (~3 months). For isolated cases of CTR, mean tourniquet time was 16 minutes. CTS symptoms were relieved in all patients with a high degree of satisfaction as measured with history and examination findings at follow-up visits. There were no major complications (eg, infection, neural or vascular damage, severe residual pain). Four patients reported minor residual numbness in the fingers at latest follow-up but nevertheless had major improvement over preoperative baseline. These 4 patients had preoperative electromyograms or nerve conduction studies documenting the extent of their disease. There was 1 case of minor wound complication. Three weeks after surgery, the patient had a 1-cm wound opening, which closed with local wound care. The patient did not develop any drainage, infection, bleeding, or neurologic symptoms.

Discussion

Open release of the TCL—the gold standard of surgical treatment for CTS—produces reliable symptom relief in the vast majority of patients.^25,30 Given that the most common complication of carpal tunnel surgery is incomplete release of the TCL,^31,32 this technique, which uses a nasal turbinate speculum to better visualize the median nerve, could potentially reduce the reoperation rate. The nasal turbinate speculum allows the surgeon to see the confluence of the TCL and the DVFF. In addition, as the complete release can be visualized, there is minimal chance of injury.

The 2007 Cochrane review³ found no strong evidence supporting replacing OCTR with endoscopic techniques. Previous investigators have questioned the utility of ECTR given that it is higher in cost and more resource-intensive than OCTR^1,33,34 and is associated with higher rates of certain complications.^5,22,35-37 A 2004 meta-analysis of 13 randomized, controlled trials found a higher rate of reversible nerve damage with an odds ratio of 3.1 for ECTR versus OCTR.³⁵ A more recent (2006) review of more than 80 studies found transient neurapraxias in 1.45% of ECTR cases and 0.25% of OCTR cases.⁵ The same study reported overall complication rates (reversible and major neurovascular structural injuries) of 0.74% for OCTR and 1.63% for ECTR (P < .005). Another limitation of ECTR is that endoscopic techniques require a higher degree of surgical skill, which makes teaching residents and fellows more challenging.

The novel nasal turbinate speculum technique presented here is easily reproducible and allows first-time surgeons to visualize all important structures. Given that this technique does not require an endoscope or an endoscope-viewing tower, it is likely more cost-effective and requires less time for turnover between cases. Patients obtain good relief of their CTS symptoms with this technique, and most return to their daily activities within weeks after operation.

SAN FRANCISCO – The newly discovered issue of reduced leaflet motion and possible thrombus on bioprosthetic aortic heart valves, called by one expert “an imaging observation of uncertain clinical significance,” nonetheless drew lots of attention at the Transcatheter Cardiovascular Therapeutics annual meeting. Reduced leaflet motion was the focus of the meeting’s opening session as well as a specially scheduled press conference.

Much of the attention dealt with clarifying the situation and calling for calm after patient concerns were aroused by a report on Oct. 5 that examination of detailed CT scans from small series of patients who had recently undergone aortic valve replacement showed reduced-motion or immobilized valve leaflets on some of the bioprosthetic valves. The pattern of the finding, made using four-dimensional CT imaging, indicated that reduced-motion leaflets did not occur, and possibly even resolved, when patients were on anticoagulant therapy, suggesting that leaflet immobilization involved thrombus. Also, reduced-motion leaflets appeared following both transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR), said Dr. Raj R. Makkar.

Mitchel L. Zoler/Frontline Medical News

Dr. Makkar summarized his CT findings in several talks during the meeting and also in a report published a few days before the meeting (N Engl J Med. 2015 Oct 5. doi: 10.1056/NEJMoa1509233).

“We started with what we thought was an imaging artifact and established that is it real. We also established with reasonable certainty that it is related to thrombus,” said Dr. Makkar, professor at the University of California, Los Angeles, and director of the Cardiovascular Interventional Center at Cedars-Sinai Medical Center in Los Angeles. The evidence also indicates that this is a class effect that occurs with all types of TAVR systems as well as surgically placed valves.

What the evidence so far does not indicate is that patients with reduced-motion leaflets face any clinical consequence nor need for routine CT imaging of a newly-placed TAVR or SAVR valve. Also no need for routine anticoagulant therapy instead of standard treatment with dual antiplatelet therapy for several months following placement of a bioprosthetic aortic valve. “We should not make the leap that following TAVR, everyone should be on an anticoagulant” because anticoagulant treatment carries it own risks, said Dr. Makkar, who noted that roughly a quarter of TAVR patients receive anticoagulant treatment because of another indication, such as atrial fibrillation.

Mitchel L. Zoler/Frontline Medical News

“The study did not show a temporal or causal relationship between the imaging findings and stroke. That needs emphasis,” commented Dr. Susheel Kodali, codirector of the Heart Valve Center at the Center for Interventional Vascular Therapy at Columbia University in New York. The possible link between leaflet immobility and strokes or other neurologic events “warrants further study,” as the data that Dr. Makkar reported involved a total of only six strokes or transient ischemic attacks. Data from all the TAVR trials and registries reported so far showed “no late signal of stroke,” said Dr. Kodali, who added that SAVR had a 30-year record of net benefit for appropriate patients.

“Is valve-leaflet thickening an important controversy or much ado about nothing?” wondered Dr. Martin B. Leon, director of the Center for Interventional Vascular Therapy of Columbia University.

“Patients should not feel at risk, and there is no need to do anything differently” for the time being in routine practice, commented Dr. Jeffrey J. Popma, professor at Harvard Medical School and director of interventional cardiology at Beth Israel Deaconess Medical Center, both in Boston.

Dr. Makkar said that in the days following the publication of his report, he had “a lot of phone calls and time spent allaying anxiety in patients and reassuring them.”

One reason why these leaflet-motion abnormalities may have shown up on CT examinations recently is that “the cameras have gotten better,” said Dr. Jonathon A. Leipsic, codirector of advanced cardiac imaging at the Providence Health Care Heart Center at St. Paul’s Hospital in Vancouver. Dr. Leipsic also highlighted that with state-of-the-art CT images, immobilized leaflets are easy to identify.

Mitchel L. Zoler/Frontline Medical News

Despite that, Dr. Popma stressed that standardized imaging protocols are needed going forward to produce reliable incidence data.

The data that Dr. Makkar reported came from a review of four-dimensional CT imaging done on 187 replacement aortic valves, usually within 3 months of placement. Images for 55 aortic valves came from the device-approval trial for a new TAVR system, taken 30 days after patients underwent TAVR with any of three types of systems. The images showed reduced leaflet motion in 22 valves (40%).

 

CT images for another 132 valves came from a Cedar’s-Sinai registry and a second, independent registry maintained in Denmark. CT images showed that 17 (13%) of the replaced aortic valves showed a leaflet-motion abnormality, including two valves placed using SAVR. Half the registry patients had undergone CT imaging within 88 days of valve replacement. The only signal of a clinical outcome linked with reduced-motion leaflets was a small increase in the incidence of transient ischemic attacks, but Dr. Makkar cautioned that transient ischemic attacks “are hard to adjudicate.”

Dr. Makkar’s report was “a small but important study, one of the first reports of this phenomenon. You don’t want to lose sight of all the evidence of patient benefit” from aortic valve replacement, stressed Dr. Kodali at the meeting, sponsored by the Cardiovascular Research Foundation. “This needs to be investigated further, probably by a Food and Drug Administration–mandated trial with CT imaging.”

“Aortic valves are lifesaving devices. The last thing that should happen is patients not getting their aortic valves replaced” when their condition demands it, Dr. Makkar said.

The PORTICO IDE study and RESOLVE registry were funded by St. Jude. Dr. Makkar has received honoraria and research support from St. Jude, lecture fees from Edwards Lifesciences, research grants from Edwards and Medtronic, and has an equity interest in Entourage. Dr. Kodali has been a consultant to Edwards Lifesciences and Claret Medical and has an equity interest in Thubrikar Aortic Valve. Dr. Leon has been a consultant to Edwards. Dr. Popma has been a consultant to Abbott Laboratories, Boston Scientific, and St. Jude, and he has been a speaker for and received grants from Medtronic, Dr. Leipsic has been a consultant to Edwards and Heartflow and received grants from Edwards, Neovasc, and Tendyne.

[email protected]

On Twitter @mitchelzoler

SAN FRANCISCO – The newly discovered issue of reduced leaflet motion and possible thrombus on bioprosthetic aortic heart valves, called by one expert “an imaging observation of uncertain clinical significance,” nonetheless drew lots of attention at the Transcatheter Cardiovascular Therapeutics annual meeting. Reduced leaflet motion was the focus of the meeting’s opening session as well as a specially scheduled press conference.

Much of the attention dealt with clarifying the situation and calling for calm after patient concerns were aroused by a report on Oct. 5 that examination of detailed CT scans from small series of patients who had recently undergone aortic valve replacement showed reduced-motion or immobilized valve leaflets on some of the bioprosthetic valves. The pattern of the finding, made using four-dimensional CT imaging, indicated that reduced-motion leaflets did not occur, and possibly even resolved, when patients were on anticoagulant therapy, suggesting that leaflet immobilization involved thrombus. Also, reduced-motion leaflets appeared following both transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR), said Dr. Raj R. Makkar.

Mitchel L. Zoler/Frontline Medical News

Dr. Makkar summarized his CT findings in several talks during the meeting and also in a report published a few days before the meeting (N Engl J Med. 2015 Oct 5. doi: 10.1056/NEJMoa1509233).

“We started with what we thought was an imaging artifact and established that is it real. We also established with reasonable certainty that it is related to thrombus,” said Dr. Makkar, professor at the University of California, Los Angeles, and director of the Cardiovascular Interventional Center at Cedars-Sinai Medical Center in Los Angeles. The evidence also indicates that this is a class effect that occurs with all types of TAVR systems as well as surgically placed valves.

What the evidence so far does not indicate is that patients with reduced-motion leaflets face any clinical consequence nor need for routine CT imaging of a newly-placed TAVR or SAVR valve. Also no need for routine anticoagulant therapy instead of standard treatment with dual antiplatelet therapy for several months following placement of a bioprosthetic aortic valve. “We should not make the leap that following TAVR, everyone should be on an anticoagulant” because anticoagulant treatment carries it own risks, said Dr. Makkar, who noted that roughly a quarter of TAVR patients receive anticoagulant treatment because of another indication, such as atrial fibrillation.

Mitchel L. Zoler/Frontline Medical News

“The study did not show a temporal or causal relationship between the imaging findings and stroke. That needs emphasis,” commented Dr. Susheel Kodali, codirector of the Heart Valve Center at the Center for Interventional Vascular Therapy at Columbia University in New York. The possible link between leaflet immobility and strokes or other neurologic events “warrants further study,” as the data that Dr. Makkar reported involved a total of only six strokes or transient ischemic attacks. Data from all the TAVR trials and registries reported so far showed “no late signal of stroke,” said Dr. Kodali, who added that SAVR had a 30-year record of net benefit for appropriate patients.

“Is valve-leaflet thickening an important controversy or much ado about nothing?” wondered Dr. Martin B. Leon, director of the Center for Interventional Vascular Therapy of Columbia University.

“Patients should not feel at risk, and there is no need to do anything differently” for the time being in routine practice, commented Dr. Jeffrey J. Popma, professor at Harvard Medical School and director of interventional cardiology at Beth Israel Deaconess Medical Center, both in Boston.

Dr. Makkar said that in the days following the publication of his report, he had “a lot of phone calls and time spent allaying anxiety in patients and reassuring them.”

One reason why these leaflet-motion abnormalities may have shown up on CT examinations recently is that “the cameras have gotten better,” said Dr. Jonathon A. Leipsic, codirector of advanced cardiac imaging at the Providence Health Care Heart Center at St. Paul’s Hospital in Vancouver. Dr. Leipsic also highlighted that with state-of-the-art CT images, immobilized leaflets are easy to identify.

Mitchel L. Zoler/Frontline Medical News

Despite that, Dr. Popma stressed that standardized imaging protocols are needed going forward to produce reliable incidence data.

The data that Dr. Makkar reported came from a review of four-dimensional CT imaging done on 187 replacement aortic valves, usually within 3 months of placement. Images for 55 aortic valves came from the device-approval trial for a new TAVR system, taken 30 days after patients underwent TAVR with any of three types of systems. The images showed reduced leaflet motion in 22 valves (40%).

 

CT images for another 132 valves came from a Cedar’s-Sinai registry and a second, independent registry maintained in Denmark. CT images showed that 17 (13%) of the replaced aortic valves showed a leaflet-motion abnormality, including two valves placed using SAVR. Half the registry patients had undergone CT imaging within 88 days of valve replacement. The only signal of a clinical outcome linked with reduced-motion leaflets was a small increase in the incidence of transient ischemic attacks, but Dr. Makkar cautioned that transient ischemic attacks “are hard to adjudicate.”

Dr. Makkar’s report was “a small but important study, one of the first reports of this phenomenon. You don’t want to lose sight of all the evidence of patient benefit” from aortic valve replacement, stressed Dr. Kodali at the meeting, sponsored by the Cardiovascular Research Foundation. “This needs to be investigated further, probably by a Food and Drug Administration–mandated trial with CT imaging.”

“Aortic valves are lifesaving devices. The last thing that should happen is patients not getting their aortic valves replaced” when their condition demands it, Dr. Makkar said.

The PORTICO IDE study and RESOLVE registry were funded by St. Jude. Dr. Makkar has received honoraria and research support from St. Jude, lecture fees from Edwards Lifesciences, research grants from Edwards and Medtronic, and has an equity interest in Entourage. Dr. Kodali has been a consultant to Edwards Lifesciences and Claret Medical and has an equity interest in Thubrikar Aortic Valve. Dr. Leon has been a consultant to Edwards. Dr. Popma has been a consultant to Abbott Laboratories, Boston Scientific, and St. Jude, and he has been a speaker for and received grants from Medtronic, Dr. Leipsic has been a consultant to Edwards and Heartflow and received grants from Edwards, Neovasc, and Tendyne.

[email protected]

On Twitter @mitchelzoler

SAN FRANCISCO – The newly discovered issue of reduced leaflet motion and possible thrombus on bioprosthetic aortic heart valves, called by one expert “an imaging observation of uncertain clinical significance,” nonetheless drew lots of attention at the Transcatheter Cardiovascular Therapeutics annual meeting. Reduced leaflet motion was the focus of the meeting’s opening session as well as a specially scheduled press conference.

Much of the attention dealt with clarifying the situation and calling for calm after patient concerns were aroused by a report on Oct. 5 that examination of detailed CT scans from small series of patients who had recently undergone aortic valve replacement showed reduced-motion or immobilized valve leaflets on some of the bioprosthetic valves. The pattern of the finding, made using four-dimensional CT imaging, indicated that reduced-motion leaflets did not occur, and possibly even resolved, when patients were on anticoagulant therapy, suggesting that leaflet immobilization involved thrombus. Also, reduced-motion leaflets appeared following both transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR), said Dr. Raj R. Makkar.

Mitchel L. Zoler/Frontline Medical News

Dr. Makkar summarized his CT findings in several talks during the meeting and also in a report published a few days before the meeting (N Engl J Med. 2015 Oct 5. doi: 10.1056/NEJMoa1509233).

“We started with what we thought was an imaging artifact and established that is it real. We also established with reasonable certainty that it is related to thrombus,” said Dr. Makkar, professor at the University of California, Los Angeles, and director of the Cardiovascular Interventional Center at Cedars-Sinai Medical Center in Los Angeles. The evidence also indicates that this is a class effect that occurs with all types of TAVR systems as well as surgically placed valves.

What the evidence so far does not indicate is that patients with reduced-motion leaflets face any clinical consequence nor need for routine CT imaging of a newly-placed TAVR or SAVR valve. Also no need for routine anticoagulant therapy instead of standard treatment with dual antiplatelet therapy for several months following placement of a bioprosthetic aortic valve. “We should not make the leap that following TAVR, everyone should be on an anticoagulant” because anticoagulant treatment carries it own risks, said Dr. Makkar, who noted that roughly a quarter of TAVR patients receive anticoagulant treatment because of another indication, such as atrial fibrillation.

Mitchel L. Zoler/Frontline Medical News

“The study did not show a temporal or causal relationship between the imaging findings and stroke. That needs emphasis,” commented Dr. Susheel Kodali, codirector of the Heart Valve Center at the Center for Interventional Vascular Therapy at Columbia University in New York. The possible link between leaflet immobility and strokes or other neurologic events “warrants further study,” as the data that Dr. Makkar reported involved a total of only six strokes or transient ischemic attacks. Data from all the TAVR trials and registries reported so far showed “no late signal of stroke,” said Dr. Kodali, who added that SAVR had a 30-year record of net benefit for appropriate patients.

“Is valve-leaflet thickening an important controversy or much ado about nothing?” wondered Dr. Martin B. Leon, director of the Center for Interventional Vascular Therapy of Columbia University.

“Patients should not feel at risk, and there is no need to do anything differently” for the time being in routine practice, commented Dr. Jeffrey J. Popma, professor at Harvard Medical School and director of interventional cardiology at Beth Israel Deaconess Medical Center, both in Boston.

Dr. Makkar said that in the days following the publication of his report, he had “a lot of phone calls and time spent allaying anxiety in patients and reassuring them.”

One reason why these leaflet-motion abnormalities may have shown up on CT examinations recently is that “the cameras have gotten better,” said Dr. Jonathon A. Leipsic, codirector of advanced cardiac imaging at the Providence Health Care Heart Center at St. Paul’s Hospital in Vancouver. Dr. Leipsic also highlighted that with state-of-the-art CT images, immobilized leaflets are easy to identify.

Mitchel L. Zoler/Frontline Medical News

Despite that, Dr. Popma stressed that standardized imaging protocols are needed going forward to produce reliable incidence data.

The data that Dr. Makkar reported came from a review of four-dimensional CT imaging done on 187 replacement aortic valves, usually within 3 months of placement. Images for 55 aortic valves came from the device-approval trial for a new TAVR system, taken 30 days after patients underwent TAVR with any of three types of systems. The images showed reduced leaflet motion in 22 valves (40%).

 

CT images for another 132 valves came from a Cedar’s-Sinai registry and a second, independent registry maintained in Denmark. CT images showed that 17 (13%) of the replaced aortic valves showed a leaflet-motion abnormality, including two valves placed using SAVR. Half the registry patients had undergone CT imaging within 88 days of valve replacement. The only signal of a clinical outcome linked with reduced-motion leaflets was a small increase in the incidence of transient ischemic attacks, but Dr. Makkar cautioned that transient ischemic attacks “are hard to adjudicate.”

Dr. Makkar’s report was “a small but important study, one of the first reports of this phenomenon. You don’t want to lose sight of all the evidence of patient benefit” from aortic valve replacement, stressed Dr. Kodali at the meeting, sponsored by the Cardiovascular Research Foundation. “This needs to be investigated further, probably by a Food and Drug Administration–mandated trial with CT imaging.”

“Aortic valves are lifesaving devices. The last thing that should happen is patients not getting their aortic valves replaced” when their condition demands it, Dr. Makkar said.

The PORTICO IDE study and RESOLVE registry were funded by St. Jude. Dr. Makkar has received honoraria and research support from St. Jude, lecture fees from Edwards Lifesciences, research grants from Edwards and Medtronic, and has an equity interest in Entourage. Dr. Kodali has been a consultant to Edwards Lifesciences and Claret Medical and has an equity interest in Thubrikar Aortic Valve. Dr. Leon has been a consultant to Edwards. Dr. Popma has been a consultant to Abbott Laboratories, Boston Scientific, and St. Jude, and he has been a speaker for and received grants from Medtronic, Dr. Leipsic has been a consultant to Edwards and Heartflow and received grants from Edwards, Neovasc, and Tendyne.

[email protected]

On Twitter @mitchelzoler