Ossified lumbar ligamentum flavum in a caucasian - A case report and literature review.

To our best knowledge, this is the first reported case of ossified ligamentum flavum in the lumbar spine in a Caucasian patient from the United Kingdom. It is an important risk factor to recognise during spinal operation as it can significantly increase its difficulty and the rate of complications.

Is NICE guidance for identifying lumbar nerve root compression misguided?

PURPOSE: To determine the extent to which the clinical manifestations of a cohort of people undergoing surgery for lumbosacral nerve root compression satisfy those described in The National Institute for Health and Care Excellence (NICE) guidance. METHOD: We studied consecutive admissions for lumbar nerve root decompression surgery at two neurosurgical units. Pre-operatively, each person's clinical manifestations were documented and compared with NICE's description. Post-operatively, at three time points (within 48 h, 3 months, 12 months), each person rated their symptoms as either better, the same, or worse. RESULTS: Pre-operatively, one person (0.8%), from 123 admissions, under 20 different consultant neurosurgeons, had manifestations consistent with NICE's clinical description of lumbar nerve root compression. Post-operatively, self-reported benefit associated with surgery appeared high, at all three time points (78-91%), supporting the diagnosis of symptomatic nerve root compression and the value of surgery. CONCLUSIONS: In this small sample, from two units, NICE's description of the clinical manifestations of lumbar nerve root compression did not describe 99% of people having surgery for it. Using NICE's definition to triage people with low back pain could result in prolonged symptoms and delayed treatment. Diagnosing lumbar nerve root compression is complex. NICE's guidance requires examination.

Interspinous spacers for lumbar foraminal stenosis: formal trials are justified.

PURPOSE: To determine whether preliminary evidence supports X-STOP implants as an effective treatment for lumbar radiculopathy secondary to foraminal stenosis, and if larger formal trials are warranted. METHODS: Participants had a clinical diagnosis of lumbar radiculopathy supported by MRI findings of foraminal stenosis and relevant nerve root compression. Self-reported disability and pain were measured pre-operation, early and late post-operation using the widely used Oswestry Disablity Index (ODI) and the bodily pain scale of the Medical Outcomes Study 36-item Short Form Health Survey (SF-36BP). The statistical significance (paired samples t test; Wilcoxon signed ranks test), and clinical significance (Cohen's effect size; Standardised response means) of change scores was determined. RESULTS: Fifteen people had X-STOP implants. Data pre- early- and late post-operation were available for ten. Self-reported disability and pain improved substantially by the early post operative measurement. Mean change scores (ODI = 29; SF-36BP = -45), significant at the p < 0.05 but not significant at the p < 0.001, were very large and effect sizes exceeded notably criteria for large clinical improvements (>0.80). Improvements were maintained at 2-3 years. Both scales had floor and ceiling effects implying changes may be underestimated. There were no surgical complications. CONCLUSIONS: In this small study, X-STOP appeared safe and effective. It is less invasive than other established surgical procedures, but does not jeopardise other options in the event of failure. Large scale clinical trials are justified but floor and ceiling effects suggest that the ODI and SF-36 may not be the best choice of outcome measures for those studies.

Usefulness of antero-posterior radiograph and variability of management in non-major thoracolumbar injuries: a single centre pilot study and review of literature.

BACKGROUND: Most adult trauma protocols suggest that where there has been a dangerous mechanism of injury or the patient exhibits abnormal physiology, CT scan is the primary radiological investigation. Other patients who may have suffered thoraco-lumbar (T-L) trauma initially have antero-posterior (AP) and lateral plain X-rays performed. Our clinical experience suggests AP views are not particularly useful in the management of these relatively low-velocity injuries. This is the first study intended to determine the contribution made by AP X-rays in these cases. METHODS: Adults with a history of T-L trauma referred to our tertiary spinal service over 20 weeks were reviewed. Those with a CT scan performed prior to X-rays were excluded. Four spine surgeons and four neuroradiologists were independently shown lateral X-rays along with the clinical details and asked to provide a management plan. Then they were shown the AP X-rays and asked if they would like to change their advice. RESULTS: Fifty-two patients were identified. Thirty-four sets of supine and 40 sets of erect X-rays were included (four people only had lateral X-rays performed), yielding 1152 film views. Average patient age was 58.3 years with 30 (58%) males. Forty-five (87%) were AO type A (compression-type) fractures. Seven (13%) had been erroneously referred with a diagnosis of acute fracture, which on review was not considered to be the case. Fifty-four percent of fractures were between T11 and L2. Forty-six percent appeared osteoporotic.In no instance did evaluation of the AP X-ray change the management plan which had been suggested following the evaluation of the lateral X-ray alone. However, there was significant variation in advice on further management between consultants. CONCLUSIONS: Our results suggest AP X-rays do not contribute to the management of low-velocity thoraco-lumbar traumas. Larger studies are required to support these findings, but there appears to be a potential to reduce both cost and radiation exposure. More importantly, it demonstrates there is large variability in the management of such patients due to the lack of evidence-based protocols.

The value of lumbar dorsal root ganglion blocks in predicting the response to decompressive surgery in patients with diagnostic doubt.

BACKGROUND CONTEXT: Pain as a consequence of nerve root compression may not be easy to diagnose. Degenerative changes causing nerve root compression on magnetic resonance imaging (MRI) are common but not necessarily symptomatic while the distribution of pain attributable to a particular nerve root is variable. Selective dorsal root ganglion blocks (DRGBs) have been used in these situations to aid the diagnostic process, although their use remains controversial. PURPOSE: We sought to investigate the positive predictive value of DRGBs in predicting response to decompressive surgery on a particular nerve root in a patient cohort with diagnostic uncertainty after clinical examination and MRI. STUDY DESIGN/SETTING: This was a retrospective review of prospectively collected data on 100 consecutive patients. METHODS: One hundred consecutive patients who underwent diagnostic DRGB under the senior author were identified retrospectively. Clinical records were reviewed for the reason for diagnostic uncertainty, level assessed, whether the DRGB reproduced pain typical for the patient's symptoms, whether there was anatomically appropriate sensory and motor disturbance, whether good pain relief was achieved, and whether they had good response to surgery. RESULTS: Of 100 patients recruited, four were removed from analysis owing to inadequate surgical decompression proven on postoperative MRI. Of the remaining 96 patients, 74 achieved immediate relief in their symptoms after DRGB. Fifty-one patients underwent surgical decompression after a successful root block; 41 patients achieved a good result from this surgery, and 10 did not. Nine patients who had no relief in their symptoms from DRGB still underwent surgery to decompress the same nerve root; six patients had relief of their symptoms from surgery, two did not respond, and one was lost to follow-up. The most common reason for diagnostic uncertainty was multilevel disease (74%) followed by patients with atypical pain (23%). The most common level assessed was the L5 nerve root. The positive predictive value was found to be 80.4%, the negative predictive value was 22.2%, with a sensitivity of 85.4% and a specificity of 16.7%. CONCLUSIONS: In patients with diagnostic doubt, a positive DRGB is a good predictor of a positive outcome after surgery to decompress that nerve root. However, the negative predictive value is poor. This result could almost certainly be improved if there was a better definition of what constitutes a positive, and more importantly a negative, DRGB result. In the meantime, DRGBs are a useful adjunct in predicting the outcome of decompressive surgery in people with pain as a consequence of potential lumbosacral nerve root compression.

Measuring outcomes in cervical spine surgery: think twice before using the SF-36.

STUDY DESIGN: Psychometric evaluation of a patient-reported scale for measuring health status. OBJECTIVE: To evaluate the ability of the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) to satisfy the clinical and research needs of cervical spine surgeons. SUMMARY OF BACKGROUND DATA: Although the SF-36 has been shown to be a reliable measure in the general population, the fundamental assumptions underpinning the generation of scale and summary scores must be rigorously tested before it can be considered a suitable measure for use in specific populations. METHODS: Data from 147 patients undergoing cervical spine surgery were examined. We examined the assumptions underpinning the generation of SF-36 scale and summary measures, targeting to the sample, and the scale's ability to detect change. RESULTS.: Evidence supports the reporting of SF-36 scale scores, but not SF-36 summary measures. Three of the 8 scales had notable floor/ceiling effects indicating poor targeting. Responsiveness was good for all scales except those with high floor/ceiling effects. CONCLUSIONS: The SF-36 fails to satisfy the measurement needs of cervical spine surgeons. Scale scores are valid, but floor and ceiling effects mean that changes in quality of life associated with surgery are underestimated. SF-36 summary scores are not valid. Neurosurgeons need better and more sophisticated scales to measure their outcomes.