A comparison of patient-reported outcome measures after spinal surgery.

Minimal clinically important differences (MCID) in the scores of patient-reported outcome measures allow clinicians to assess the outcome of intervention from the perspective of the patient. There has been significant variation in their absolute values in previous publications and a lack of consistency in their calculation. The purpose of this study was first, to establish whether these values, following spinal surgery, vary depending on the surgical intervention and their method of calculation and secondly, to assess whether there is any correlation between the two external anchors most frequently used to calculate the MCID. We carried out a retrospective analysis of prospectively gathered data of adult patients who underwent elective spinal surgery between 1994 and 2009. A total of 244 patients were included. There were 125 men and 119 women with a mean age of 54 years (16 to 84); the mean follow-up was 62 months (6 to 199) The MCID was calculated using three previously published methods. Our results show that the value of the MCID varies considerably with the operation and its method of calculation. There was good correlation between the two external anchors. The global outcome tool correlated significantly better. We conclude that consensus needs to be reached on the best method of calculating the MCID. This then needs to be defined for each spinal procedure. Using a blanket value for the MCID for all spinal procedures should be avoided.

Variations in selective nerve root block technique.

INTRODUCTION: Much literature reports on selective nerve root blocks (SNRBs) in cases of lumbosacral radiculopathy. Unfortunately, authors only inconsistently reveal the exact needle tip position relative to the causative pathology at the time of injection. Different injection sites may provide different symptomatic benefits. We investigated the variation in injection techniques of practitioners working in the UK. METHODS: A clinical scenario was devised depicting a patient with radiculopathy secondary to an L4/5 vertebral disc prolapse. Participants were questioned on their chosen management of this patient, focusing particularly on SNRB technique. Questionnaires were sent to spinal surgeons, pain management specialists and musculoskeletal radiologists. RESULTS: A total of 100 responses were detailed enough for inclusion. The majority (83%) of respondents reported they would inject local anaesthetic and steroids, 4% would inject local anaesthetic alone and 13% would inject a different substance. Over half (53%) would target the L5 nerve root, 26% the L4 nerve root, 12% the prolapsed disc itself and 9% two separate vertebral levels. Variation was also noted in needle tip location relative to the neural sheath. CONCLUSIONS: When treating lumbar radiculopathy, there are apparent variations in the use and positioning of SNRBs for a given level of disc pathology. Needle tip position may have a direct influence on clinical outcome following SNRBs. Caution is therefore required when considering the validity of previously published studies investigating SNRBs and different injectates.

A comparative study of the outcomes of primary and revision lumbar discectomy surgery.

The outcome of surgery for recurrent lumbar disc herniation is debatable. Some studies show results that are comparable with those of primary discectomy, whereas others report worse outcomes. The purpose of this study was to compare the outcome of revision lumbar discectomy with that of primary discectomy in the same cohort of patients who had both the primary and the recurrent herniation at the same level and side.A retrospective analysis of prospectively gathered data was undertaken in 30 patients who had undergone both primary and revision surgery for late recurrent lumbar disc herniation. The outcome measures used were visual analogue scales for lower limb (VAL) and back (VAB) pain and the Oswestry Disability Index (ODI).There was a significant improvement in the mean VAL and ODI scores (both p < 0.001) after primary discectomy. Revision surgery also resulted in improvements in the mean VAL (p < 0.001), VAB (p = 0.030) and ODI scores (p < 0.001). The changes were similar in the two groups (all p > 0.05).Revision discectomy can give results that are as good as those seen after primary surgery.

Is cauda equina syndrome linked with obesity?

No previous studies have examined the physical characteristics of patients with cauda equina syndrome (CES). We compared the anthropometric features of patients who developed CES after a disc prolapse with those who did not but who had symptoms that required elective surgery. We recorded the age, gender, height, weight and body mass index (BMI) of 92 consecutive patients who underwent elective lumbar discectomy and 40 consecutive patients who underwent discectomy for CES. On univariate analysis, the mean BMI of the elective discectomy cohort (26.5 kg/m2 (16.6 to 41.7) was very similar to that of the age-matched national mean (27.6 kg/m2, p = 1.0). However, the mean BMI of the CES cohort (31.1 kg/m2 (21.0 to 54.9)) was significantly higher than both that of the elective group (p < 0.001) and the age-matched national mean (p < 0.001). A similar pattern was seen with the weight of the groups. Multivariate logistic regression analysis was performed, adjusted for age, gender, height, weight and BMI. Increasing BMI and weight were strongly associated with an increased risk of CES (odds ratio (OR) 1.17, p < 0.001; and OR 1.06, p < 0.001, respectively). However, increasing height was linked with a reduced risk of CES (OR 0.9, p < 0.01). The odds of developing CES were 3.7 times higher (95% confidence interval (CI) 1.2 to 7.8, p = 0.016) in the overweight and obese (as defined by the World Health Organization: BMI ≥ 25 kg/m2) than in those of ideal weight. Those with very large discs (obstructing > 75% of the spinal canal) had a larger BMI than those with small discs (obstructing < 25% of the canal; p < 0.01). We therefore conclude that increasing BMI is associated with CES.

The relationship of pre- and postoperative median and ulnar nerve conduction measures to a self-administered questionnaire in carpal tunnel syndrome.

STUDY AIMS: Following carpal tunnel release (CTR), only very modest correlations have been found between subjective symptoms and function indexes compared to neurophysiological measures. The objective of this study was to evaluate this relationship by comparing the self-administered Boston symptom severity score and function severity score questionnaire against nerve conduction studies (NCS) before and after CTR using two different electrophysiological techniques. PATIENTS AND METHODS: Carpal tunnel release was performed in 51 patients (62 hands). Pre- and postoperative NCS were evaluated using both conventional neurophysiological methods and by means of a new hand-held device. RESULTS: Preoperatively there was almost no correlation between symptom severity and function scores and NCS results. Following surgery however, both symptom severity and function showed a modest, but significant improvement in their correlation to NCS (at highest r=0.405, P<0.01). This improvement in the relation of subjective measures to neurophysiological results was seen in both median nerve sensory and motor conduction as well as in ulnar nerve motor conduction. CONCLUSIONS: In addition to median-nerve dysfunction, it might be suggested that ulnar nerve changes can contribute to symptoms of carpal tunnel syndrome in patients. Several associations were found using a median-ulnar sensory latency difference in the finger-wrist segment and a sensory conduction difference in the palm to wrist segment. Significant correlations were established by both conventional NCS and the new hand-held device.

Reducing the economic impact of carpal tunnel surgery.

A nurse-led carpal tunnel service was started in Leicester in 1999. Many developments in the service have been patient-driven. A large proportion of our patients are not salaried and many had expressed concerns about the amount of time taken off work after surgery. This therefore prompted us to encourage immediate hand function after surgery. Subsequently, in 494 patients studied prospectively, we have seen 93% of patients return to work by 2 weeks and 99% by 4 weeks. This has obvious benefits in terms of reducing loss of income. Furthermore there is potential for considerable economic savings.

Feedback control of unstable cellular solidification fronts.

We present a feedback control scheme to stabilize unstable cellular patterns during the directional solidification of a binary alloy. The scheme is based on local heating of cell tips which protrude ahead of the mean position of all tips in the array. The feasibility of this scheme is demonstrated using phase-field simulations and, experimentally, using a real-time image processing algorithm, to track cell tips, coupled with a movable laser spot array device to heat the tips locally. We demonstrate, both numerically and experimentally, that spacings well below the threshold for a period-doubling instability can be stabilized. As predicted by the numerical calculations, cellular arrays become stable with uniform spacing through the feedback control which is maintained with minimal heating.

The long-term outcome after central cord syndrome: a study of the natural history.

We studied 32 patients with central cord syndrome who were managed conservatively. Six were under 50 years of age (group 1), 16 between 50 and 70 years (group 2) and ten over 70 years (group 3). At the time of discharge all patients in group 1 could walk independently and had good bladder control compared with 11 (69%) and 14 (88%) in group 2 and four (40%) and two (20%) in group 3, respectively. At follow-up after a mean of 8.6 years (4 to 15), ten patients had died leaving 22 in the study. All those in group 1 were alive, could walk independently and had bladder control. In group 2, 13 were alive of whom ten (77%) could walk independently and nine (69%) had bladder control. In group 3 only three were alive of whom only one was independent and none had bladder control. Function at discharge as measured by the ASIA motor scoring system was usually maintained or improved at follow-up, but patients over 70 years of age at injury did poorly.

Delayed focal neurological deficit secondary to a cervico-thoracic spinal cord epidural haematoma.

This is a report of an elderly woman who developed focal neurological deficit in association with a cervico-thoracic spinal epidural haematoma. Symptoms developed several days after the initial injury and subsequently resolved without surgical intervention. The unusual features of this presentation are discussed.

Deep hand infection complicating chickenpox in an otherwise healthy infant.

Chickenpox is a common childhood infection, and complications are rare in the healthy child. This report describes a significant complication of varicella in an otherwise healthy infant.

Pain relief following tennis elbow release.

We studied the outcome of tennis elbow release in 27 patients at an average of 29.6 months after surgery. We found that 44% of patients had obtained complete pain relief, 37% of patients experienced occasional pain and 19% of patients still experienced moderate pain. Pain relief was significantly better in those patients with the shorter duration of preoperative symptoms. We therefore conclude that surgery for tennis elbow should be employed at an earlier stage than is currently practised.

Markers of data quality in computer audit: the Manchester Orthopaedic Database.

This study investigates the efficiency of the Manchester Orthopaedic Database (MOD), a computer software package for record collection and audit. Data is entered into the system in the form of diagnostic, operative and complication keywords. We have calculated the completeness, accuracy and quality (completeness x accuracy) of keyword data in the MOD in two departments of orthopaedics (Departments A and B). In each department, 100 sets of inpatient notes were reviewed. Department B obtained results which were significantly better than those in A at the 5% level. We attribute this to the presence of a systems coordinator to motivate and organise the team for audit. Senior and junior staff did not differ significantly with respect to completeness, accuracy and quality measures, but locum junior staff recorded data with a quality of 0%. Statistically, the biggest difference between the departments was the quality of operation keywords. Sample sizes were too small to permit effective statistical comparisons between the quality of complication keywords. In both departments, however, the poorest quality data was seen in complication keywords. The low complication keyword completeness contributed to this; on average, the true complication rate (39%) was twice the recorded complication rate (17%). In the recent Royal College of Surgeons of England Confidential Comparative Audit, the recorded complication rate was 4.7%. In the light of the above findings, we suggest that the true complication rate of the RCS CCA should approach 9%.

The AO classification of long bone fractures: an early study of its use in clinical practice.

Over a period of 6 months, 543 long bone fractures were classified using the AO classification system. Factors important in determining the management of fractures occurring in three regions; hip, forearm and tibia, were identified. In hip fractures, we found that the anatomical configuration of the fracture, and therefore its classification, generally determined management. However, there were other factors that influenced the more specific form of surgical treatment used. In forearm fractures, the age of the patient was the most important factor determining treatment, while many factors, including consultant preference, determined the treatment of tibial fractures. While we found the system useful for audit purposes, we also found that it was unnecessarily complicated and often fell short of playing a useful role in the planning of management.

Fenoterol plus ipratropium ('Duovent') aerosol therapy delivered by a tube spacer.

A randomized crossover study was carried out in 12 patients with reversible airflow obstruction to investigate the bronchodilator effects of a single metered dose of fenoterol hydrobromide (200 micrograms) plus ipratropium bromide (80 micrograms) delivered by the standard aerosol inhaler or by the inhaler with an extension tube spacer. The results of lung function tests showed that there were significant increases from baseline values in FEV1, FVC and PEFR by 15 minutes using both drug delivery methods, and the improvement in PEFR was maintained for at least 8 hours in 11 of the 12 patients. Although no significant differences in the results was demonstrated between the two methods, which were used correctly by all the participants, it is suggested that the spacer device method would be particularly useful for patients who have difficulty in co-ordinating drug delivery with inhalation.