Dural tears in primary decompressive lumbar surgery. Is primary repair necessary for a good outcome?

STUDY DESIGN: Case control series with prospective data collection. OBJECTIVE: To establish whether incidental durotomy treated without primary suture repair adversely affects the outcome following lumbar surgery in the longer term. METHOD: Outcome scores from a prospective database were used for an audit of dural tears in primary lumbar decompressive surgery. Outcome data collected includes the Short Form 36 General Health Questionnaire (SF36), the Oswestry Disability Index (ODI) and Visual Analogue Scores for leg pain (VAL) and back pain (VAB). RESULTS: Out of 200 consecutive procedures, a dural tear occurred in 19 (9.5%) patients. Of 19 patients with a dural tear, data was incomplete in 4 patients, and 1 further patient who had their dural tear sutured was excluded, leaving 14 patients to be studied. There were seven males and seven females, with an average age of 50.8 years (31-69). These 14 patients (group 1) were compared to a matched group (age, sex, surgical diagnosis and duration of follow-up) of 14 patients (group 2) with no tear. Both groups had similar pre-operative scores. At 6-month follow-up, both groups had significant improvements in all outcomes measures except for the general health domain of the SF-36. At final follow-up, patients with dural tears appeared to have better improvements in outcome measures amongst the VAB, VAL and ODI with similar scores in the SF-36 domains. CONCLUSION: Our study demonstrates that incidental durotomy in primary lumbar decompressive surgery can be successfully managed without primary suture repair with no adverse effect on surgical outcome in the longer term.

Skeletal metastases - the role of the orthopaedic and spinal surgeon.

Developments in oncological and medical therapies mean that life expectancy of patients with metastatic bone disease (MBD) is often measured in years. Complications of MBD may dramatically and irreversibly affect patient quality of life, making the careful assessment and appropriate management of these patients essential. The roles of orthopaedic and spinal surgeons in MBD generally fall into one of four categories: diagnostic, the prophylactic fixation of metastatic deposits at risk of impending fracture (preventative surgery), the stabilisation or reconstruction of bones affected by pathological fractures (reactive surgery), or the decompression and stabilisation of the vertebral column, spinal cord, and nerve roots. Several key principals should be adhered to whenever operating on skeletal metastases. Discussions should be held early with an appropriate multi-disciplinary team prior to intervention. Detailed pre-assessment is essential to gauge a patient's suitability for surgery - recovery from elective surgery must be shorter than the anticipated survival. Staging and biopsies provide prognostic information. Primary bone tumours must be ruled out in the case of a solitary bone lesion to avoid inappropriate intervention. Prophylactic surgical fixation of a lesion prior to a pathological fracture reduces morbidity and length of hospital stay. Regardless of a lesion or pathological fracture's location, all regions of the affected bone must be addressed, to reduce the risk of subsequent fracture. Surgical implants should allow full weight bearing or return to function immediately. Post-operative radiotherapy should be utilised in all cases to minimise disease progression. Spinal surgery should be considered for those with spinal pain due to potentially reversible spinal instability or neurological compromise. The opinion of a spinal surgeon should be sought early, as delays in referral directly correlate to worse functional recovery following intervention. Patients who suffer a slowly progressive deficit, present within hours of complete neurological deficit, or have compression caused by bone alone are those most likely to benefit from surgery. Back pain in the presence of MBD should be regarded as impending spinal cord compression, and investigated urgently to allow intervention prior to the development of neurological compromise.

Getting patients back to work after carpal tunnel surgery.

This article describes the condition known as carpal tunnel syndrome and reviews a carpal tunnel service that was started in Leicester in 1999. We look at how the service has developed to meet patient needs, and how we now aim to return patients back to function and employment as quickly as possible after surgery.

Nurse-led management of carpal tunnel syndrome: an audit of outcomes and impact on waiting times.

INTRODUCTION: This article describes the outcome of a nurse-led service developed to manage patients referred with a presumptive diagnosis of carpal tunnel syndrome. PATIENTS AND METHODS: We developed a rapid-access service in response to unacceptable waiting times for patients with carpal tunnel syndrome. The service was developed around the role of a nurse practitioner providing a single practitioner pathway from first clinic appointment, through surgery to discharge. RESULTS: Waiting times improved considerably whilst the standard and quality of care was maintained. CONCLUSIONS: There is a role for nurses to perform certain surgical procedures within a well-defined environment.