Optimal duration of conservative treatment for lumbar disc herniation depending on the type of herniation.

Six hundred and six clinical records of patients who were admitted to the Department of Orthopaedic Surgery, Suwa Red Cross Hospital, Nagano, Japan, due to lumbar disc herniation (LDH) between 1991 and 2002 were reviewed to determine the ideal conservative treatment period in relation to different types of LDH: contained and non-contained. Since 1997, we have prolonged in-hospital conservative treatment over a few weeks, which resulted in a decrease in the number of surgeries for non-contained LDH, especially of surgeries performed within 1 month. The number of surgeries for contained LDH did not decrease. The preoperative period of non-contained LDH was significantly shorter than that of contained LDH. These results indicate that for patients who have non-contained LDH, intensive conservative treatment may avoid a surgical procedure. For those patients who have contained LDH, conservative treatment should not be prolonged. We believe that the optimal duration of intensive conservative therapy should be less than 1 month.

Changes in total alkaline phosphatase level after hip fracture: comparison between femoral neck and trochanter fractures.

BACKGROUND: Biochemical bone metabolic markers are affected by fractures, and total alkaline phosphatase (ALP) is considered one of the bone formation markers. Only a few reports have dealt with changes in bone formation markers during the healing process of bone fragility hip fractures. Despite the difference in the amount of callus formation and bone fusion rate, no significant differences in longitudinal change of total ALP between femoral neck and trochanter fracture have been reported. METHODS: A total of 69 osteoporotic patients with femoral neck or trochanter fracture whose serum concentrations of total ALP were examined at least four times at six periodic examination points (1, 2, 3, 4, 6, and 8 weeks after surgery) and whose state of bone union was obtained within 24 weeks after surgery were selected for this retrospective study. The characteristic longitudinal change of total ALP during the healing process was shown, and the possibility of total ALP as a predictive factor for the state of osteosynthesis of hip fractures is discussed. RESULTS: Changes in the total ALP level according to the healing process were similar for femoral neck and trochanter fractures. The concentration of total ALP rose to a maximum at 3 weeks after surgery and then gradually decreased for both fractures. However, the range of change was significantly greater for trochanter fractures than for femoral neck fractures. For trochanter fractures, total ALP decreased from 3 to 6 weeks after surgery in all but one patient. CONCLUSIONS: Increases in the concentration of total ALP after surgery and the subsequent decreases may reflect the normal healing process. A significant difference in the changes of total ALP after surgery between femoral trochanter and neck fractures was shown. Periodic measurement of total ALP might be useful for obtaining information on the osteosynthesis state.

Carpal tunnel syndrome and development of trigger digit.

Although the coexistence of carpal tunnel syndrome and trigger digit in the same hand is well documented, the interactive relationship between them is unclear. This study was conducted to examine the factors that may impact on the development of trigger digit in the hand with idiopathic carpal tunnel syndrome. One hundred and eighty-one patients were enrolled. Their gender, age, dominant side, severity of carpal tunnel syndrome, history or presence of trigger digit, and treatment type were recorded. The patients were evaluated for the presence of trigger digit at 1, 3, 6 and 12 months after surgery or the initial evaluation. Two hundred and sixty-five hands in 152 patients were included in the final assessment. Logistic regression analysis revealed that surgery was a significant risk factor for the onset of trigger digit and may accelerate development of trigger digit when carpal tunnel syndrome was mild to moderate, but not when it was severe. In severe disease, other unknown factors, such as hypertrophy of the flexor tenosynovium, may mask the effect of surgery.

Snapping wrist after surgery for carpal tunnel syndrome and trigger digit: a case report.

We present a case of snapping dislocation of the flexor digitorum superficialis tendon to the small finger over the hook of the hamate that was noted after carpal tunnel release and trigger digit release.

Progressive symptomatic kyphotic deformity after decompressive surgery for lumbar destructive spondyloarthropathy.

Destructive spondyloarthropathy (DSA) is a serious complication of haemodialysis for end stage renal failure. We present a case of a patient who complained of back pain and cruralgia due to L2-3 disc degeneration with instability, and was treated with posterior decompression and bone grafting. Soon after surgery, the kyphotic deformity progressed and the symptoms deteriorated. A correction of the deformity and posterior fusion was required six years after initial surgery. Pathological findings showed characteristic findings of DSA. Our findings indicate that in some cases with unstable DSA, spinal decompression as well as spinal fixation may be necessary.

Median nerve damage during two-portal endoscopic carpal tunnel release.

OBJECTIVE: To evaluate the adverse effects of Chow's two-portal endoscopic carpal tunnel release (ECTR) performed by an experienced surgeon on median nerve function in patients with idiopathic carpal tunnel syndrome, as compared to open carpal tunnel release (OCTR). METHODS: Eighty-seven hands subjected to ECTR and 65 hands subjected to OCTR were reviewed. Both groups of patients were similar with regard to age, gender, and severity of the disease. Both groups were compared for the number of hands showing worsening of motor distal latency, sensory conduction velocity, and sensory disturbance after surgery. RESULTS: Thirteen hands of 12 patients showed worsening of median nerve function after ECTR, while only one hand showed worsening after OCTR. This difference was statistically significant (p=0.0041). CONCLUSIONS: Median nerve damage, although transient or not serious, may occur even if the procedure is done correctly.

Ulnar nerve palsy at the elbow after surgical treatment for fractures of the olecranon.

Despite close proximity of the fracture site to the nerve, ulnar nerve palsy after surgery for fracture of the olecranon is uncommon. We examined 18 cases of fracture of the olecranon treated surgically retrospectively to see if there were any characteristics common to 4 cases of ulnar nerve palsy. Three cases of palsy with a comminuted fracture had fair or poor reduction as revealed by both the lateral and anteroposterior radiographs taken at the time of surgery. The other case, with little displacement of the fragment, had osteoarthritic changes at the medial side of the elbow. The mechanism of development of ulnar nerve palsy is considered to be multifactorial. However, it should be noted that evaluation of reduction of the fracture, not only on a lateral radiograph but also on an anteroposterior radiograph at the time of surgery, is important to prevent the ulnar nerve from being jeopardized.

Abducens nerve palsy as a rare complication of spinal surgery: a case report.

We describe a case of diplopia due to abducens nerve palsy after upper cervical spinal surgery. A 22-year-old woman presented with a chief complaint of numbness and weakness in her left hand. A spinal cord tumor was detected at the C1/2 level. These complaints disappeared after resection of the spinal cord tumor; however, she presented with diplopia due to abducens nerve palsy 3 days after surgery. Brain computed tomography and magnetic resonance imaging revealed no abnormalities. Within 1 month there was complete spontaneous resolution of the abducens nerve dysfunction. It is important for spinal surgeons to be aware of cranial nerve palsy as a potential complication of cervical spinal surgery.

Idiopathic spinal cord herniation associated with a large erosive bone defect: a case report and review of the literature.

We report a case of idiopathic spinal cord herniation associated with a large bone defect. MRI and computed tomographic myelography revealed ventral deviation of the spinal cord and erosion of the vertebral body at T6-T7. Microscopic surgery revealed a dural defect. The etiology of this condition has not been clarified. In most previously reported cases, the peak portion of the herniation was around the intervertebral disc space. In addition, in our patient, it was hard to think that the intervertebral disc has become depressed due to the pressure exerted by the spinal cord. We considered that a certain condition of the intervertebral disc, such as herniation, was one of the causes of the dural defect, and cerebrospinal fluid pulsation pushed the spinal cord toward that portion, causing herniation.

The accuracy and safety of image-guidance system using intraoperative fluoroscopic images: an in vitro feasibility study.

The "virtual fluoroscopy" is a new navigation system that combines image-guided surgery and C-arm fluoroscopy. The purpose of this study was to evaluate the accuracy of this system in the case of pedicle screwing. The angular deviation in the axial and sagittal planes was measured using the bodies of 50 vertebral models. Another type of model was used to evaluate the positional deviation (two dimension and three dimension). The mean angular deviation on the axial plane was 1.3 degrees and that on the sagittal plane was 1.0 degree. The positional deviation was not recognised. This system provides quite accurate information. Using this system, the surgeon can insert surgical instruments, such as pedicle screws, while confirming the real time virtual image on the monitor displaying the surgical field, including the position and direction of the instruments, without being disturbed by his own hands or instruments and without radiation exposure.

Microendoscopic discectomy (MED) for lumbar disc prolapse.

Microendoscopic discectomy (MED), which combines traditional lumbar microsurgical techniques with endoscopy, is being used as a minimally invasive procedure for lumbar disc herniation. We reviewed 30 patients who underwent MED at our institution and compared their outcome with that of patients subjected to the conventional method. Laboratory data suggested that MED was less invasive surgery. Moreover, MED allowed an early return to work. However, the difficulties of this endoscopic procedure were evident, because of the limited exposure and two-dimensional video display. The potential injury of the nerve root and prolonged surgical time remain as matters of serious concern. To overcome this problem, we used an operative magnifying glass during surgery and this helped us to accomplish the procedure comfortably. We recommend the use of an operative magnifying glass in the early stage of the introduction of MED, for it is quite useful to identify the three-dimensional relationships of the structures.