Acute disc herniation following surgical decompression of lumbar spinal stenosis: a retrospective comparison of mini-open and minimally invasive techniques.

BACKGROUND: Disc herniation following decompression of lumbar spinal stenosis is a less familiar surgical complication. Previous studies suggested that open lumbar decompression techniques, associated with relative segmental instability especially in the presence of degenerated disc in older patients, are more likely to result in disc herniation compared to minimally invasive techniques. The current study compares the incidence of acute disc herniation following mini-open and minimally invasive decompression of lumbar spinal stenosis. METHODS: This was a retrospective study reviewing 563 patients who underwent spinal decompression for symptomatic lumbar stenosis by mini-open bilateral partial laminectomy technique or minimally invasive laminotomy utilizing a tubular system. Demographic and clinical data were collected and compared between the groups. RESULTS: Postoperative disc herniation rate was significantly lower in the minimally invasive group with 2 of 237 cases (0.8%) versus 19 of 326 cases (5.8%) in the mini-open group (p = 0.002). This finding was more noticeable following multi-level procedures with no case of postdecompression disc herniation in the minimally invasive group compared to 8 of 39 cases (20.5%) in the mini-open group (p = 0.003). CONCLUSION: The incidence of postoperative disc herniation following spinal decompression for symptomatic lumbar stenosis was 5.8% following mini-open bilateral partial laminectomy compared to only 0.8% after minimally invasive laminotomy (p = 0.002). These findings highlight the more extensive nature of mini-open surgery associated with relative segmental instability that poses a greater risk for postoperative disc herniation.

Age-related Differences in Clinical Outcomes of Lumbar Discectomy.

INTRODUCTION: Lumbar discectomy is a common and effective treatment for symptomatic disk herniation. It has been suggested that lumbar discectomy in older patients may result in poorer clinical outcomes and lesser satisfaction. The purpose of this study was to assess age-related difference in patient reported outcomes of patients undergoing lumbar discectomy for chronic low back and radicular pain. MATERIALS AND METHODS: Patients with chronic lumbar radiculopathy without neurological deficit underwent non-urgent single level lumbar discectomy in our institution between 2014 and 2017. Pain level (using VAS score), Oswestry Disability Index, and SF-12 scores were retrospectively reviewed and compared between younger patients (<60 years, group 1) and older patients (>60 years, group 2). RESULTS: Seventy-three patients, aged between 34-76 years participated in this study. VAS, ODI, and SF-12 scores improved significantly after the surgery for each group (P < .01). When comparing between the groups, no significant differences in the outcomes measured were found after the surgery in both early post-operative follow-up and late post-operative follow-up (P > .05). DISCUSSION: Elderly patients undergoing lumbar discectomy report a significant reduction in VAS, ODI, and SF-12 scores justifying the procedure. CONCLUSION: Lumbar discectomy improved function and decreased pain level to similar extent in both younger and older patients suffering from radicular symptoms related to lumbar disc herniation.

Bilateral traumatic C6-C7 facet dislocation with C6 spondyloptosis and large disk sequestration in a neurologically intact patient.

Traumatic cervical spondyloptosis is an uncommon and severe form of facet joint dislocation that commonly leads to severe neurological damage. Decision making regarding the reduction and fixation technique is challenging, especially when a patient is neurologically intact, since an undiagnosed prolapsed disk at the involved level may lead to severe neurological consequences during reduction. A 24-year-old male was admitted after sustaining a severe direct axial blow to his head. Computed tomographic and magnetic resonance imaging scans revealed an acute C6C7 fracture dislocation with spondyloptosis of C6 vertebra and a large disk fragment posterior to C6 vertebral body. The patient was neurologically intact, apart from mild bilateral numbness over C6 distribution. The patient underwent C6 corpectomy to avoid acute cord compression related to the large sequestered disk behind C6 vertebra. Following C6 corpectomy, we were unable to exert enough axial pull to reduce the facet dislocation through the anterior approach. Therefore, the reduction was performed through a posterior approach with C5T1 posterior fusion, followed by anterior cage placement and C5-7 anterior fusion (front-back-front approach). At postoperative follow-up of 24 months, the patient demonstrated a full and pain-free cervical range-of-motion and remained neurologically intact. Follow-up radiographs of the cervical spine demonstrated good instrumental alignment with solid fusion at 6-month follow-up.

A Novel Spine Fixation System Made Entirely of Carbon-Fiber-Reinforced PEEK Composite: An In Vitro Mechanical Evaluation.

BACKGROUND: Semirigid spine fixation systems utilizing nonmetallic materials have emerged as a promising innovation to overcome the inherent disadvantages of metal instrumentation in spine surgery. This study tests the mechanical properties of a novel spine fixation system made entirely of carbon-fiber-reinforced PEEK (CFR-PEEK) composite material (CarboClear System, CarboFix Orthopedics Ltd., Israel). METHODS: An in vitro mechanical evaluation of the CFR-PEEK CarboClear system was conducted in compliance with the American Society for Testing and Materials (ASTM) F1717, F2193, and F543 standards. RESULTS: The mean bending yield load, bending ultimate load, and bending stiffness of the construct were 322 N, 363 N, and 45 N/mm, respectively. All tested samples completed 5 × 106 dynamic cycles successfully, with no evidence of fatigue failure at increasing load levels, up to 83% of ultimate bending load. The mean torsional stiffness was 1.0 Nm/deg and the mean screw axial pull-out strength was 2,037 N. CONCLUSION: The CarboClear Pedicle Screw System has mechanical properties comparable to those of other commonly used titanium-made systems, with superior fatigue properties. The fatigue resistance, modulus of elasticity which is very similar to that of bone, radiolucency, and CT/MRI artifact-free feature of this spine fixation system made entirely of CFR-PEEK may offer advantages over traditional spine fixation systems made of metal alloys.

A Reimbursement System Based on a 48-Hour Target Time for Surgery Shortens the Waiting Time for Hip Fracture Fixation in Elderly Patients.

OBJECTIVES: To evaluate whether a pay-for-performance reimbursement system, aimed at expediting surgical fixation of hip fractures in elderly patients, has, in fact, succeeded in shortening the waiting time for surgery. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Academic Level II trauma center. PATIENTS/PARTICIPANTS: One hundred fifty patients older than 70 years with femoral neck fractures (OTA/AO 31 A1-A3). INTERVENTION: Implementation of a reimbursement system which incentivizes meeting a 48-hour target time for surgical fixation of hip fractures in elderly patients. METHODS: Medical records of 75 consecutive patients operated on 1 year before the implementation of the reimbursement system were compared with records of 75 consecutive patients operated on 1 year after the implementation of the reimbursement system. The collected data included age, sex, American Society of Anesthesiologist score, time from injury to hospital admission, time from admission to surgery, reason for surgical delay beyond 48 hours, perioperative complication rate, and length of postoperative hospitalization. RESULTS: Patients' mean age, sex distribution, American Society of Anesthesiologist score, and time from injury to hospital admission were similar in both groups. The average waiting time for surgery shortened from a mean of 77 hours before implementing the reimbursement system to 28 hours after the implementation (P < 0.001). Before the reimbursement system implementation, 41% of the surgeries were delayed beyond 48 hours due to medical causes, compared with 20% only after the implementation (P < 0.001). Fewer patients developed perioperative complications in the postimplementation group in comparison with the preimplementation group (9% vs. 13%, respectively); however, because the study was not powered to examine differences in complication rate, the significance of this difference remains unclear. CONCLUSIONS: A reimbursement system which incentivizes meeting a 48-hour target time for surgery has led to a substantial shortening in the waiting time for surgical fixation of hip fractures in elderly patients in our institution.

[WAITING TIME FOR SURGICAL FIXATION OF FEMORAL NECK FRACTURES: DOES A DIAGNOSIS-RELATED GROUP PAYMENT METHOD MATTER?]

BACKGROUND: Early surgical fixation of femoral neck factures in elderly patients has been suggested to decrease morbidity and mortality and to improve treatment outcome. This study evaluates the effect of the implementation of a diagnosis-related group payment method in our hospital on waiting time for surgery and the short-term outcomes of elderly patients following surgical fixation of hip fractures. METHODS: Demographic and clinical characteristics of 75 consecutive patients, who underwent surgery for hip fracture in our hospital, before the implementation of a diagnosis-related group payment method, were compared with those of 75 consecutive patients, who were operated on after the implementation of the payment system. RESULTS: Demographic characteristics were similar for both groups. Before the implementation of a diagnosis-related group payment method, 84% of the patients waited longer than 48 hours for surgery, compared to only 24% of patients after the implementation (p<0.001). Medical considerations and operation room availability were the main reasons for delaying surgery in both groups. Mortality and morbidity rates during the hospital stay remained similar, regardless of the implementation of the payment method. CONCLUSIONS: The implementation of a diagnosis-related group payment method shortened the waiting time for surgical hip fixation in elderly patients treated in our hospital, with no effect on the mortality and complication rate during the hospital stay.

[CORRELATION BETWEEN MRI AND ARTHROSCOPIC FINDINGS IN THE DIAGNOSIS OF KNEE PATHOLOGY IN YOUNG AND ADULT PATIENTS].

BACKGROUND: MRI is increasingly used as a diagnostic tool for sports injuries involving the knees before referral to arthroscopy. OBJECTIVES: Since degenerative changes increase with age, we aimed to evaluate whether age affects the accuracy of MRI. METHODS: This is a retrospective study of patients with knee injury whose evaluation included both MRI and arthroscopy. Two age groups were defined: young adults (18-39 years) and adults (40 years and above). RESULTS: Of 966 patients undergoing knee arthroscopy, 132 had preoperative MRI: 48.5% young adults and 51.5% adults. Arthroscopy identified a meniscus tear in 85% and a ligament tear in 21%. Seventeen percent had combined tears and no injury was identified in 4%. The sensitivity and specificity of MRI for ligament tears was 59%, 95%, and for meniscus tears was 91%, and 40%. The sensitivity for bucket handle tears was 86%. The sensitivity of MRI for combined injury was low, 41%. In 8% of patients no pathology was identified by MRI, which was confirmed by arthroscopy in only 4%. One patient with normal MRI had a bucket handle menisceal tear and one other patient had a tear of the anterior cruciate ligament. MRI in adults and young adults revealed that sensitivities for the different types of lesions were similar for both age groups. CONCLUSIONS: Although degenerative changes increase with age, our hypothesis that MRI will be less sensitive in adults was proven wrong. In the presence of appropriate signs and symptoms, older age should not be considered a factor affecting decisions concerning preoperative imaging workup.

Local implantation of autologous adipose-derived stem cells increases femoral strength and bone density in osteoporotic rats: A randomized controlled animal study.

BACKGROUND: Deficient osteogenic capacity of bone marrow stem cells plays a critical role in the pathophysiology of osteoporosis. Adipose-derived stem cells (ADSCs) have emerged as a promising source of skeletal progenitor cells. The capacity of ADSCs to undergo osteogenic differentiation and induce mineralized tissue formation may be beneficial in the treatment of osteoporosis. We question whether administration of autologous ADSCs into the proximal femur of osteoporotic rats will induce osteogenesis and enhance bone quality and strength. MATERIALS AND METHODS: Thirty ovariectomized female rats were randomly assigned to one of the two treatment groups: (1) percutanous implantation of autogenous ADSCs-seeded scaffold into the proximal femur and (2) percutanous implantation of non-seeded scaffold. The contralateral untreated femur served as control. The effect of treatment on bone characteristics was assessed at 12-week follow-up by micro-computed tomography analysis, mechanical testing, and histological analysis. RESULTS: The mean cortical thickness, total bone volume density, and bone load to failure in femora injected with autologous ADSCs-seeded scaffold was significantly higher compared to femora injected with non-seeded scaffold and compared to the untreated control femora ( p < 0.01). Histological examination of the injected specimens revealed complete osseo-integration of the scaffolds with direct conversion of the ADSCs into osteoblasts and no inflammatory response. CONCLUSIONS: Autogenous ADSCs implantation into the proximal femur of rats with ovariectomy-related osteoporosis promoted bone regeneration and increased bone strength at short-term follow-up. These findings highlight the potential benefit of autogenous ADSCs in the treatment of osteoporosis. LEVEL OF EVIDENCE: Level I, randomized controlled trial, animal study.

Carbon-Fibre-Reinforced PEEK radiolucent intramedullary nail for humeral shaft fracture fixation: technical features and a pilot clinical study.

PURPOSE: This prospective pilot study investigated the safety and efficacy of a novel radiolucent intramedullary nail (IMN) made of Carbon-Fibre-Reinforced Polyaryl-Ether-Ether-Ketone (CFR-PEEK) for humeral shaft fracture fixation. STUDY DESIGN: A prospective, single-arm, four-centre study. PATIENTS AND METHODS: A total of 46 patients with 46 humeral fractures classified as 12 A-B were treated with a novel CFR-PEEK IMN and followed for 12 months. RESULTS: Most of the patients (65%) were female; the mean age was 65 ± 17 years. The average operating time was 66.75 ± 19.84 minutes and X-ray exposure was 104.11 ± 98.01 seconds. All patients postoperatively reported selflimiting shoulder pain and three patients developed iatrogenic transient radial palsy. Two patients required repositioning of the implant. No implant-related complications were observed. Radiological consolidation was achieved in all 43 patients who completed the 12-month follow-up. CONCLUSIONS: The CFR-PEEK IMN is user-friendly and safe. Its bone-matching elastic modulus seems to contribute to its clinical efficacy. This, together with compatibility with modern imaging techniques, can be considered a further evolution of IMN designed to stabilise humeral shaft fractures.

Staged Correction of Severe Thoracic Kyphosis in Patients with Multilevel Osteoporotic Vertebral Compression Fractures.

Study Design Technical report. Objective Multilevel osteoporotic vertebral compression fractures may lead to considerable thoracic deformity and sagittal imbalance, which may necessitate surgical intervention. Correction of advanced thoracic kyphosis in patients with severe osteoporosis remains challenging, with a high rate of failure. This study describes a surgical technique of staged vertebral augmentation with osteotomies for the treatment of advanced thoracic kyphosis in patients with osteoporotic multilevel vertebral compression fractures. Methods Five patients (average age 62 ± 6 years) with multilevel osteoporotic vertebral compression fractures and severe symptomatic thoracic kyphosis underwent staged vertebral augmentation and surgical correction of their sagittal deformity. Clinical and radiographic outcomes were assessed retrospectively at a mean postoperative follow-up of 34 months. Results Patients' self-reported back pain decreased from 7.2 ± 0.8 to 3.0 ± 0.7 (0 to 10 numerical scale; p < 0.001). Patients' back-related disability decreased from 60 ± 10% to 29 ± 10% (0 to 100% Oswestry Disability Index; p < 0.001). Thoracic kyphosis was corrected from 89 ± 5 degrees to 40 ± 4 degrees (p < 0.001), and the sagittal vertical axis was corrected from 112 ± 83 mm to 38 ± 23 mm (p = 0.058). One patient had cement leakage without subsequent neurologic deficit. Decreased blood pressure was observed in another patient during the cement injection. No correction loss, hardware failure, or neurologic deficiency was seen in the other patients. Conclusion The surgical technique described here, despite its complexity, may offer a safe and effective method for the treatment of advanced thoracic kyphosis in patients with osteoporotic multilevel vertebral compression fractures.

Radiofrequency treatment has a beneficial role in reducing low back pain due to facet syndrome in octogenarians or older.

INTRODUCTION: Chronic low back pain is a disabling phenomenon that can cause a severe reduction in quality of life, especially in elderly patients. Surgical treatment is sometimes a big challenge for these elderly patients. Radiofrequency (RF) ablation is an increasingly popular method for treating low back pain caused by facet syndrome. The purpose of this study was to evaluate whether RF neurotomy is effective in terms of pain reduction and functional outcome in elderly patients. PATIENTS AND METHODS: Fifty-eight patients aged 80 years and older who had chronic mechanical low back pain were examined after they underwent RF heat lesion of the medial branch. Follow-up occurred 1, 3, 6, and 12 months after treatment. Pain was measured on the visual analog scale and functional outcome was measured using the Oswestry Disability Index. RESULTS: After 1 month, 43 patients (74%) were satisfied with the results. After 3 months, 38 patients (66%) had clinically significant pain relief. After 6 months, 33 patients (57%) had pain relief, and at the 1-year follow-up, 30 patients (52%) showed good results while 28 patients (48%) showed no effect. The Oswestry Disability Index score was substantially improved even after 1 year. Minor complications occurred in eleven patients (19%), who had transient discomfort and burning pain. CONCLUSION: RF is a safe and partially effective procedure for treating elderly patients with mechanical back pain due to facet syndrome.

Pulsed radiofrequency for the suprascapular nerve for patients with chronic headache.

BACKGROUND: Chronic shoulder or suprascapular pain is a disabling phenomenon. Chronic headache is also a disabling phenomenon for many patients. Once it was believed that chronic headache that is attributed to the cervical spine originates from the upper cervical nerve roots (C0-C3). Currently, it is suggested by some authors that the reason for headache in many patients is attributed to the lower cervical nerve roots in the cervical spine. The suprascapular nerve originates from the C5 and C6 nerve roots and supplies the suprascapular and shoulder region. Pulsed radiofrequency (PRF) has gained popularity over recent years as a good clinical tool in treating patients with shoulder/suprascapular pain. It is usually considered as a treatment option after conservative treatment has failed. The purpose of this study was to evaluate whether PRF for the suprascapular nerve has also beneficial effect for patients that have also chronic headache that is attributed to the lower cervical nerve roots. MATERIALS AND METHODS: Sixty-nine patients with a follow-up of 1 year who had chronic shoulder/suprascapular pain and chronic headache were examined after they underwent PRF procedures to the suprascapular nerve (either unilateral or bilateral). RESULTS: Forty patients (58%) reported long-term pain relief (1-y follow-up) for the shoulder/suprascapular pain and 31 patients (45%) reported long-term pain relief for the headache. This pain relief was defined as reduction of Visual Analogue Score by at least 30%. No complications were found in this study except for mild discomfort in the treated area which spontaneously resolved up to 3 weeks after the procedure. CONCLUSIONS: PRF for the suprascapular nerve is a safe and an effective procedure for patients who suffer from shoulder/suprascapular pain and also for headache that is attributed to the lower cervical nerve roots. It should be tried after conservative treatment has failed.

Nucleoplasty is effective in reducing both mechanical and radicular low back pain: a prospective study in 87 patients.

STUDY DESIGN: A prospective study of all patients with either mechanical back pain or radicular back pain who underwent nucleoplasty and were followed up prospectively. OBJECTIVE: To investigate the effectiveness of nucleoplasty procedure in terms of pain and quality of life using the visual analog scale and Oswestry disability questionnaires. SUMMARY OF BACKGROUND DATA: Nucleoplasty is a method of increasing popularity in the past few years. It has a role when dealing with pain of spinal origin either radicular or both radicular and mechanical after conservative treatment has failed and before open procedure. METHODS: Eighty-seven patients with a minimal follow-up of 1 year were prospectively followed after they underwent nucleoplasty procedure for either radicular or a combination of radicular and mechanical low back pain. All patients underwent physical examination and completion of visual analog scale score and Oswestry Disability questionnaires after 1, 3, 6, and 12 months. Thirty-nine of them were followed after 2 years. RESULTS: After 1 month, 66 patients (76%) were satisfied with the results. After 3 months, 60 patients (69%) had significant pain relief, whereas in 27 cases (31%) there was no improvement. After 6 months of follow-up, 57 patients (66%) had pain relief and in 30 cases (34%) there was no effect. At 12 months of follow-up, 55 patients (65%) showed good results and 30 patients (35%) had no effect. In the case of the 39 patients who were followed for 24 months, 23 patients (59%) had significant pain relief. A statistically significant reduction in the Oswestry index was also noted for the series in all intervals. Minor complication occurred in 23 patients (26%) who had transient discomfort and burning pain at the insertion site of the nucleoplasty wire. CONCLUSIONS: We concluded that the nucleoplasty technique is a safe and effective procedure for radicular or combined radicular and mechanical low back pain and should be used in selected cases before open surgery after conservative treatment has failed.

The correlation between Spurling test and imaging studies in detecting cervical radiculopathy.

BACKGROUND: Cervical spine symptoms are a major cause of visits to general or spinal orthopedic surgeons or even primary care physicians. Although in this era the imaging studies can precisely rule out or diagnose pathologies in the spine, all of these studies have limitations. Computerized tomography (CT) scan consists of radiation exposure to the patients and it should be done with caution. Magnetic resonance imaging (MRI) is a highly effective imaging tool, but in many countries it is still costly. The goal of our study was to determine whether a simple clinical test can help the clinician to identify the patients who need to be sent for these imaging studies. METHODS: Two hundred fifty-seven patients with clinical cervical radiculopathy underwent complete physical examination that also included the Spurling test. After that, all patients were sent to imaging studies of the cervical spine (CT and/or MRI). Correlation between the physical examination using the Spurling test to the imaging studies was done. RESULTS: Sensitivity of the Spurling test to nerve root pathology was 95% and specificity was 94%. CONCLUSION: This paper demonstrate that patients with positive Spurling test have probable nerve root pressure and should be sent for further imaging studies. In patients with negative Spurling test, the possibility of nerve root pressure is less likely.

A comparison of two new technologies for percutaneous vertebral augmentation: confidence vertebroplasty vs. sky kyphoplasty.

BACKGROUND: Cement vertebroplasty has been performed for over a decade to treat painful osteoporotic vertebral compression fractures (OVCFs). Kyphoplasty is considered a further step in the evolution of vertebral augmentation. OBJECTIVES: To evaluate the efficiency and safety of two systems to treat OVCF: Confidence Vertebroplasty (CV) compared to Sky Kyphoplasty (SK). METHODS: This prospective study included 45 patients with OVCF. Fourteen were treated with CV and 31 with SK. An imaging evaluation using a compression ratio (height of anterior vs. posterior wall) and local kyphotic deformity (Cobb angle) was performed prior to the procedure and 12 months later. Evaluation of pain was carried out using a visual analogue scale. RESULTS: The mean compression repair was 12% in the CV group compared to 25% in the SK group. Mean kyphotic deformity restoration achieved using CV was 41% compared to 67% using SK. In both groups the pain severity was equally reduced by a mean of 43%. CONCLUSIONS: The SK system is technically superior in restoring the vertebral height and repairing the kyphotic deformity, an advantage that was not manifested in pain relief - the most important variable. Both systems have a high level of safety. The cost-benefit balance clearly favors the CV system.

Long-term follow-up of revision decompressive lumbar spinal surgery in elderly patients.

STUDY DESIGN: A retrospective study of elderly patients (more than 65 y of age) who underwent surgery for lumbar spinal stenosis between 1990 and 2000 was carried out. Among all these patients, the patients who underwent revision surgery were studied. OBJECTIVE: To quantify the risk of reoperation in patients who underwent decompressive lumbar surgery and to analyze the connection between different variables before the primary surgery to the risk of surgical revision. SUMMARY OF BACKGROUND DATA: Lumbar decompressive spinal surgery is a very common procedure. However, the tendency of restenosis with clinical effect on the patients increases with time. Outcome studies reported that rate of reoperation has ranged from 0% to 23%. No studies so far analyzed the rate of reoperation in elderly patients in long-term follow-up and the different variables that contributed to it. METHODS: Between 1990 and 2000, 357 patients more than 65 years of age underwent decompressive surgery for lumbar spinal stenosis with a mean follow-up of 64 months. Thirty-one patients (8.7%) were reoperated at least once. Twenty-five of them (81%) were followed. Demographic data, body mass index, associated comorbidities, preoperative risk as assessed by the scale of the American Society of Anesthesiology, type of surgery, pain perception by Visual Analog Scale, duration of symptoms, clinical presentation, walking ability (distance in meters), the level of basic activities of daily living was evaluated by the Barthel index, and overall satisfaction from the surgery were recorded and analyzed. For comparison between the reoperated patients and patients who were not reoperated, another group of 25 patients who were not reoperated (of our cohort) was studied. These patients were matched to the reoperated patients in terms of age (±2 y), sex, body mass index, and time elapsed since surgery (±3 mo). RESULTS: Overall rate of revision surgery was 8.7% in a period of 70 months follow-up. Twenty-one patients (80%) underwent 1 revision surgery, 4 patients (16%) underwent 2 revisions, and 1 patient (4%) had 3 revisions. The mean pain-free interval was 26 months. There were no sex differences in the rate of reoperation (10% in females and 7% in males, P>0.05). Although that only 36% of the patients were very or somewhat satisfied with overall revision results, significant improvement in pain perception (change in Visual Analog Scale score of 4.84, P<0.001) and in functional status (Barthel index increased in 15.2 points, P<0.001) were found after revision surgery. Six cases (19%) were operated in the first 2 years, 16 cases (52%) in the first 4 years, 24 cases (77%) in the first 6 years, and additional 7 cases (23%) were reoperated more than 6 years after the first operation. CONCLUSIONS: Even in reoperated elderly patients with spinal stenosis without spinal fusion, an improvement in functional status and somewhat in pain perception can be anticipated.

The Fixion expandable stem hemiarthroplasty for displaced femoral neck fracture: technical features and pilot study.

BACKGROUND: Management of displaced femoral neck fracture in elderly patients is challenging due to the patient's high risk profile, poor quality bone stock and muscle weakness. MATERIALS AND METHODS: Fifty-one patients with displaced (Garden 3-4) intracapsular femoral neck fractures were treated with a newly designed Fixion expandable stem hemiarthroplasty implant and followed thereafter for a minimum of 6 months. RESULTS: Thirty patients (58.8%) had concomitant diseases graded 3-4 by the ASA scoring system. Two patients (4.8%) incurred deep wound infections that necessitated hardware removal. One case (2.6%) of dislocation was treated by closed reduction. Forty-two patients (82.4%) survived >6 months and cooperated with the study protocol. Mild groin/thigh pain was reported by 11 patients (26.2%). Twenty-six (61.9%) had lost 1-2 out of 4 grades of mobility. CONCLUSIONS: Fixion implant may be considered a further step in the evolution of femoral joint hemiarthroplasty. In the short term, it has proven to be as effective as cemented implant and to be user-friendly for the surgeon. It is also anticipated to be feasible whenever revision is required.

Late results of surgery for herniated lumbar disk as related to duration of preoperative symptoms and type of herniation.

BACKGROUND: Ten to 40% of patients who have undergone state-of-the-art surgery for HLD do not obtain relief of pain. The relationship among timing of surgery for HLD, type of herniation, and clinical outcome, questioned in the present study, has rarely been referred to as an individual medical factor. METHODS: Sixty-three patients belonging to a single ethnic group were called in 2 to 5 years after surgery and scored for change in severity of HLD-related pain (VAS) and current disability as scored by a functional rating system (Spangfort). RESULTS: Patients with noncontained herniation (group 1), as compared with those with contained herniation (group 2), had had more intense radicular pain preoperatively (mean VAS, 8.3 vs 6.5), had a shorter history of pain (mean, 7.4 vs 15.8 weeks), and enjoyed a better functional outcome (good or fair in 96.4% vs 74.3%). Those in group 1 with a preoperative pain history of 6 weeks or less showed a greater decrease in pain intensity than those with a pain history of 6 to 12 weeks. Group 2 patients had had a longer preoperative history of symptoms than any in group 1 (>12 weeks in all) and showed an intermediate decrease in pain intensity. CONCLUSIONS: Patients with noncontained herniation who do not show signs of improvement should be offered elective surgery after 6 to 8 weeks of observation; those having contained herniation should be advised that a certain degree of benefit can be expected from surgery, however late.

Long-term outcome of decompressive surgery for lumbar spinal stenosis in octogenarians.

The purpose of our prospective study is to evaluate the surgical outcome among patients aged 80 years and above, who underwent surgery for lumbar spinal stenosis. We assessed patients' clinical and demographic data, procedures, perioperative complications, preoperative and postoperative pain intensity, basic activities of daily living (BADL), patients' satisfaction, the need for repeated surgery, and overall mortality. Thirty-nine patients more than 80 years of age were operated in our institution in the last decade. Twenty-five of them were followed-up with a mean 36.8 months after the operation. The Barthel index was used to evaluate pre and postsurgery ADL, and the visual analogue scale (VAS) was used to evaluate pain. The satisfaction rate of the patients before and after the operation and the complication rate were also evaluated. A significant reduction in VAS (P < 0.001) and a significant increase in the Barthel index (P < 0.001) were recorded. Seventy-six percent of the patients were very satisfied or somewhat satisfied with the operative results. Fifty-two percent of the patients had complications (0.9 complications per patients), however, about half of them were minor. No operative or perioperative mortality was noticed and the overall hospital stay for these elderly patients was 3.6 days on average. Surgery in very old elderly patients is safe and effective in the treatment of spinal stenosis, who did not respond well to the conservative treatment. The surgery did not increase the associated morbidity and mortality and most of the patients benefited from the surgery in terms of reduction in pain, increase in ADL and walking ability and overall increase in the satisfaction rate.

Treatment of postdiscectomy low back pain by percutaneous posterior lumbar interbody fusion versus open posterior lumbar fusion with pedicle screws.

BACKGROUND CONTEXT: Up to a fifth of the patients who had discectomy undergo spinal fusion because of disabling low back pain. PURPOSE: To compare the clinical outcome of percutaneous posterior lumbar interbody fusion (PPLIF) to that of open posterior lumbar fusion (PLF). STUDY DESIGN/SETTING: Two surgical methods that were tried in sequence at a university affiliated hospital. PATIENT SAMPLE: Sixty patients with disabling postdiscectomy low back pain. OUTCOME MEASURES: Pain intensity was scored on a visual analog scale (VAS) and the degree of disability was scored by the Oswestry disability index (ODI). METHODS: Thirty patients were treated by PPLIF. The outcome, after 24 months or more, was compared retrospectively with that of 30 consecutive suitable subjects who had been treated by PLF with pedicle screw fixation by the same surgeons for the same indication. RESULTS: In the PPLIF group, as compared with PLF group, mean operating time was shorter, blood loss was negligible, and mean hospital time was halved. By the last follow-up visit (greater than or equal to 2 years), pain and disability in PLF group had diminished by 31.9% and 20.1%, respectively. The corresponding figures in PPLIF group were 55.4% and 42.7%, respectively. CONCLUSIONS: In the context of postdiscectomy low back pain, PPLIF has proven, thus far, to be a safe procedure with improved clinical results.