Multidisciplinary approach to L3/L4 lumbar disc prolapse masquerading as focal limb myositis-a radiological challenge.

Prolapsed intervertebral discs are commonly associated with back ache and sciatica. Management is often conservative with analgesia and physiotherapy. Nerve root injections and discectomy procedures are used where conservative measures fail. Majority of patients present with symptoms of pain and motor weakness; however, a few can present as focal myositis of lower limb muscles in the distribution of radiculopathy. MRI scans of limbs are rarely done in these cases but if done can confound the radiologist. Our case report emphasize the importance of multidisciplinary approach for a L3 nerve radiculopathy with confounding clinical presentation of focal lower limb myositis of unknown etiology.

A study investigating the validity of modified Tokuhashi score to decide surgical intervention in patients with metastatic spinal cancer.

PURPOSE: Predicted survival of a patient is the most important parameter that helps to guide the treatment of a patient with metastatic spinal cancer. We aimed to investigate the reliability of modified Tokuhashi score in the decision-making process in patients with metastatic spinal cancer. METHODS: We performed a review of our prospectively collected Metastatic Cancer Database over a period of 4 years (2007-2010). Ninety consecutive patients who were treated for metastatic spinal cancer were enrolled. Data review included demographic details, source of primary cancer, duration of symptoms, location of metastases, calculated Karnofsky's performance status, and calculated survival based on modified Tokuhashi score. We divided the patients into 3 groups. Group A included patients with expected survival less than 6 months. Group B included patients with expected survival between 6 and 12 months. Group C included patients whose expected survival was more than 12 months. We compared the calculated expected survival to the actual survival in all three groups with all patients following up to a minimum of 1 year or until death. Statistical analysis was done by Chi-square test and the Fisher Exact test. RESULTS: The survival prediction in group C was significantly accurate in 80.9 % patients (P = 0.027). However, in groups A and B, only 36.1 and 9.1 % patients survived, respectively, as per predicted. (P > 0.05). CONCLUSIONS: We can conclude from this study that, when used alone, modified Tokuhashi score may not be a reliable tool to predict survival in all patient groups.

Does rectal examination have any value in the clinical diagnosis of cauda equina syndrome?

PURPOSE: This study aims to quantify the value of digital rectal examination (DRE) in the clinical diagnosis of cauda equina syndrome. METHODS: A retrospective case note review was performed on all patients referred to a University Teaching Hospital over a one-year period with documented suspicion of cauda equina syndrome. All Patients underwent MRI scanning to either confirm or rule out the diagnosis. RESULTS: Fifty-seven such patients were identified, 13 (23%) of whom had confirmation of cauda equina syndrome on MRI scanning. The DRE did not significantly discriminate for the outcome of MRI (p = 0.897, test accuracy 51%, diagnostic odds ratio 1.42). There was no correlation between the cumulative number of positive clinical findings in an individual patient and the likelihood of MRI diagnosis and no significant link between any individual clinical feature and the MRI result. CONCLUSIONS: Digital rectal examination has no significant value in the acute diagnosis of cauda equina syndrome. This study further confirms that there is no discreet clinical protocol applicable with which to confidently confirm or rule out this diagnosis. DRE is traditionally enshrined as an essential facet of clinical assessment in suspected cauda equina syndrome but it cannot be used as a discriminator to ration urgent MRI scanning.

Spinal subdural hematoma as a complication of spinal surgery: can it happen without dural tear?

Post spinal surgery subdural hematoma is a rare entity. This is a report of a case of acute post-operative spinal subdural hematoma, without any dural injury. The case was managed expectantly and went on to complete resolution of the hematoma and full clinical recovery.

Social implications of balloon kyphoplasty: prospective study from a single UK centre.

PURPOSE: The incidence of osteoporotic fractures is increasing with an ageing population. This has potential consequences for health services, patients and their families. Treatment of osteoporotic vertebral compression fractures (OVCFs) has been limited to non-surgical measures so far. The social and functional consequences of balloon kyphoplasty, a recent development for the treatment of VCF, were assessed in this cohort study. METHODS: Data collected prospectively from 53 patients undergoing balloon kyphoplasty for symptomatic OVCF in our hospital's spinal unit were compared with data from an historical age-matched group of 51 consecutive patients treated conservatively for symptomatic OVCF. Social functionality was recorded prior to the injury, and at 6-month and 1-year follow-up; mortality was recorded at 6 months and 1 year. RESULTS: The mortality rate in the balloon kyphoplasty group was 11 % (6/53) at 1 year post-OVCF, versus 22 % (11/51) in the conservatively treated controls. A drift to a lower level of social functionality (defined by a lower level of independence) was observed at 1 year in 21 % of patients in the balloon kyphoplasty group versus 53 % of patients in the conservatively treated group. A drift to a lower level of independence was noted in 67 % of the conservatively treated patients who started at a lower level of functionality versus 20 % drift in a similar group who were treated with balloon kyphoplasty. CONCLUSIONS: The reduction in mortality and drift in social functionality at 1 year following treatment with balloon kyphoplasty suggests that it is a viable option for the management of OVCFs.

Orthopaedic trauma care: a two-tier system?

Orthopaedic trauma requiring surgical admission presents to our hospitals right throughout the week. However, the level of service provided to trauma patients appears to fluctuate with more surgery facilities available during weekday "office-hours" with reduced facilities at the weekend. The National Confidential Enquiry into Peri-operative Deaths (NCEPOD) in 1999 laid down guidelines for orthopaedic trauma surgery in elderly patients clearly stating that no elderly patient requiring an urgent operation should have to wait for more than 24 h once fit for surgery. We see no reason to exclude the younger population from such a directive and have hence applied the same standard of "surgery within 24 h of admission" as our index of appropriate practice. Audit of our consultant delivered performance confirmed that while an average 88% of "weekday service" patients admitted Sunday through Thursday achieved this standard, only an average of 64% of weekend service patients admitted on Friday or Saturday achieved the same standard. The purpose of this report is to increase awareness of what we believe to be a widespread dilemma. The day of the week should not dictate the treatment of the patient.

The mannequin sign.

STUDY DESIGN: Prospective observational study. OBJECTIVES: The critical appraisal of the mannequin sign in the validation of patients with symptoms of sciatica. SUMMARY OF BACKGROUND DATA: Sixty-five consecutive patients with magnetic resonance imaging-proven lumbar disc herniation and symptoms of sciatica. Mean patient age was 48 (range 28-62) years. Thirty-seven patients were male and 28 were female. METHODS: The mannequin sign is positive when a patient adopts an antalgic posture with the relevant lower limb flexed at the hip and knee with the pelvis tilting towards the affected side, in the classic manner of a mannequin's pose. Reproducibility of the sign was recorded when all patients were examined by a second clinician. Lumbar disc herniation with nerve root impingement was confirmed by magnetic resonance imaging. RESULTS: The mannequin sign had 100% reproducibility and 80% sensitivity in diagnosing lumbar disc herniations with nerve root impingement. Twenty-four patients had L4-L5 disc herniations and 41 had L5-S1 disc herniations. CONCLUSION: Astute clinical examination can minimize inaccurate diagnosis, unnecessary investigations, and even inappropriate surgical intervention. The mannequin sign, first observed and anecdotally reported by the senior author (D.C.), has now been critically appraised.

Cervical cord compression in an elderly patient with Hurler's syndrome: a case report.

STUDY DESIGN: A case of cervical cord compression in an elderly lady with Hurler's syndrome is reported. OBJECTIVE: To report the occurrence of cervical cord compression in a 56-year-old patient of Hurler's syndrome, making her the oldest patient with Hurler's. The case report also highlights the appropriate management that could be given to this group of difficult patients. SUMMARY OF BACKGROUND DATA: The literature on Hurler's syndrome is reviewed in terms of long-term survival and surgical management of spinal compression. No report in the literature describes cervical spine decompression in Hurler's syndrome in a patient this old. METHOD: Clinical and radiologic features of Hurler's induced cervical cord compression are described. Pathologic changes of Hurler's myleopathy are also reported. RESULTS: The patient underwent cervical spine decompression and tolerated the procedure well. The patient was able to mobilize free of the wheel chair and showed significant neurologic recovery. CONCLUSION: The case report highlights the success of surgery in Hurler's induced cervical cord compression. It also adds to the literature the oldest patient of Hurler's syndrome to undergo any form of spinal surgery.We present here a 59-year-old lady with Hurler's syndrome, who underwent a successful cervical spine decompression and stabilization for cervical myelopathy. At 59 years of age, she was the oldest case of Hurler's to undergo spinal surgery. The case highlights the importance of undertaking major spinal surgeries in these difficult inherited disorders with reasonable success, as against common belief.