Degenerative Lumbar Stenosis Surgery: Predictive Factors of Clinical Outcome-Experience with 1001 Patients.

BACKGROUND: Degenerative lumbar spinal stenosis (DLSS) carries a high risk of morbidity and represents a financial burden to society. A late diagnosis can lead to severe disability. Although lumbar decompressive surgery has been widely used worldwide, the proper preoperative factors to define the ideal candidates for decompression are missing. METHODS: A total of 1001 patients who had undergone decompressive surgery from 2012 to 2019 for DLSS were screened for the presence of 9 clinical and radiological parameters. For all cases, the differences between the baseline and postoperative Oswestry disability index were calculated and the results categorized as 5 different classes (ranging from very poor outcomes to excellent outcomes) according to the specific scores. Generalized ordinal logistic regression was then used to analyze the significance of the 9 parameters (coded as dummy variables) in predicting the outcome as measured by Oswestry disability index improvement after surgery. RESULTS: Of the 9 parameters, 8 were found to be significant predictors. The radiological grade of compression was the strongest, followed by polyneuropathy, obesity, symptom duration, gait autonomy, radicular deficits, American Society of Anesthesiologists score, and level of surgery. In contrast, previous back surgery was not predictive of the outcome. CONCLUSIONS: Our findings have indicated that the ideal candidate for surgery will have the following preoperative characteristics: Schizas grade D, no signs of peripheral polyneuropathy, body mass index <30 kg/m2, symptom duration of <2 years, gait autonomy <100 m, no radicular deficits, 1 level of stenosis, and an American Society of Anesthesiologists score of 1, 2, or 3.

Extracorporeal Shock Wave Therapy Is Effective in the Treatment of Bone Marrow Edema of the Medial Compartment of the Knee: A Comparative Study.

OBJECTIVE: To test the hypothesis that shock wave therapy can produce a statistically significant improvement in symptoms and imaging features of the knee bone marrow edema syndrome (BMES) within 6 months of treatment. SUBJECTS AND METHODS: Eighty-six consecutive patients suffering from BMES of the medial compartment of the knee were prescribed a course of high-energy extracorporeal shock wave therapy (ESWT) and clinically followed up at 3 and 6 months and finally from 14 to approximately 18 months after treatment. Thirty-one patients were unable to undergo ESWT but returned for the 6-month and final follow-up; these were referred to as the conservative (control) group, while the other 55 patients constituted the ESWT group. The Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Visual Analog Scale (VAS) score of each patient were calculated at every follow-up. The BME area was assessed using magnetic resonance imaging before treatment and at the 6-month follow-up. RESULTS: Statistically significant improvements were observed in clinical scores and in the BME area for both the ESWT and the control group (p < 0.05). The improvements in the ESWT group were statistically better in all parameters compared with the control group: the ESWT group had a reduction in the BME area of 86% versus 41% in the control group, the VAS pain score improved by 88% in the ESWT group versus 42% in the control group, and the WOMAC score improved by 65% in the ESWT group versus 22% in the control group. Clinical scores were significantly better for patients with medial tibial lesions in the ESWT group. CONCLUSION: In this study, ESWT reduced pain and the BME area in the knee, with significant clinical improvement noticed 3 months after treatment.

A bizarre complication of shoulder arthroscopy.

A case is presented of an unusual complication of shoulder arthroscopy, which was caused by incorrect location of the posterior portal, inducing neurapraxia of both the axillary and radial nerves, with significant clinical and functional sequelae. A subsequent open surgical neurolysis was required to restore normal nerve function. This type of lesion has not been reported previously. Level of evidence V.

Effectiveness of extracorporeal shock wave therapy in bone marrow edema syndrome of the hip.

There is no gold standard for treatment of bone marrow edema syndrome of the hip (BMESH). Usually, treatment is conservative, owing to the favorable and self limiting prognosis. In musculoskeletal disorders, the effectiveness of extracorporeal shock wave therapy (ESWT) has been widely recognized and recent research supports its use in the treatment of the first stages of avascular osteonecrosis of the proximal femur and in other conditions where bone marrow edema is present. On this basis, we performed a prospective study to evaluate the effectiveness of ESWT in normalizing the symptoms and imaging features of BMESH. Twenty consecutive symptomatic patients underwent two treatments of high-energy ESWT and were followed-up at 2, 3 and 6 months, with a final clinical follow-up at mean 15.52 ± 1.91 months. Patients underwent magnetic resonance imaging of the hip and were evaluated according to the Harris hip score. The mean improvement in HHS over the course of the study was of 58.5 ± 14.9 points (p < 0.0001), and the mean edema area reduced from 981.9 ± 453.2 mm(2) pre-treatment to 107.8 ± 248.1 mm(2) at 6 months. ESWT seems to be a powerful, non-pharmacological tool that produces rapid pain relief and functional improvement and aids the normalization of the vascular and metabolic impairments which characterize BMESH.

Extracorporeal shock wave therapy in musculoskeletal disorders: a review.

Regenerative therapy is one of the most challenging and intriguing branches of modern medicine. Basic research has demonstrated the effectiveness of extracorporeal shockwaves (ESWT) in stimulating biological activities that involve intra-cell and cell-matrix interactions. These interactions are at the basis of the current clinical applications, and open the horizons to new applications in tissue regeneration. It is also feasible that shock waves could be used to treat various orthopaedic pathologies, removing the need for surgery. However, suitable translational studies need to be performed before ESWT can become a valid alternative to surgery.

L-arginine, asymmetric dimethylarginine, and symmetric dimethylarginine in plasma and synovial fluid of patients with knee osteoarthritis.

BACKGROUND: The aim of this study was to investigate the involvement of the nitric oxide (NO) pathway in osteoarthritis (OA). MATERIAL AND METHODS: The study groups consisted of 32 patients with knee OA and 31 healthy controls. In peripheral venous blood samples (from the OA patients and the controls) and in synovial fluid samples (from the OA patients), the concentrations of L-arginine (ARN), asymmetric dimethylarginine (ADMA), and symmetric dimethylarginine (SDMA) were evaluated. In plasma samples, thiobarbituric acid reactive substances (TBARS) were also measured. RESULTS: Plasma ARN concentrations were lower in the OA patients than in controls (53.55 ± 16.37 vs. 70.20 ± 25.68 µmol/l) (P<0.05), while plasma ADMA concentrations were similar. Accordingly, the ARN/ADMA ratio was lower in the OA patients than in the control group (80.85 ± 29.58 vs. 110.51 ± 30.48, P<0.05). Plasma SDMA and TBARS concentrations were higher in the OA patients than in controls (0.69 ± 0.15 vs. 0.60 ± 0.10 µmol/l, P<0.05 and 1.21 ± 0.29 vs. 0.55 ± 0.12, respectively) (P<0.001). In the OA patients, ADMA concentrations were significantly higher in the synovial fluid than in plasma (0.75 ± 0.09 vs. 0.69 ± 0.14 µmol/l, P<0.05), as were ARN concentrations (76.96 ± 16.73 vs. 53.55 ± 16.73 µmol/l) (P<0.00001). Conclusions These results indicate a poor availability of NO in the synovial fluid of the OA patients, which may contribute to the progression of OA. The decreased ARN/ADMA ratio and the increased SDMA and TBARS in the plasma of the OA patients suggest an impairment of endothelial function in these subjects.