Mini-Open Surgical Fasciotomy for Chronic Exertional Compartment Syndrome of the Forearm in Professional Motorcycling Adolescents.

OBJECTIVE: Evaluate treatment and outcome of mini-open fasciotomy (MOF) in a population of adolescent motorcycling racers affected by forearm chronic exertional compartment syndrome (CECS). DESIGN: Prospective case series. SETTING: University hospital/private practice. PATIENTS: Nine professional motorcycling adolescents were diagnosed with forearm CECS. All were treated with MOF between 2007 and 2012 and followed for a minimum of 5 years (range 5-10 years). Age, sex, body mass index, laterality, and profession were recorded. INTERVENTIONS: A MOF to obtain decompression of all compartments was performed in all patients. MAIN OUTCOME MEASURES: Visual analog scale; a subjective scale to measure strength; and Quick-DASH functional scores. Time to resume full riding capacities as the short-term evaluation. RESULTS: A significant decrease in visual analog scale (P < 0.001) and Quick-DASH (P < 0.001) scores was observed in the first 3 months, stabilizing during follow-up (P = 0.521; P = 0.217). Average time to return to sport was 2.8 ± 1 week. No symptom recurrence was reported, but one patient suffered a minor complication. There were no cases of infection, hematoma, or peripheral nerve injury. CONCLUSIONS: We assess that MOF can be a valid alternative for the treatment of forearm CECS in adolescent competitive motorcycling racers, as demonstrated by the good success rate and minimal incidence of complications during follow-up. LEVEL OF EVIDENCE: IV, case series.

Injection Pharyngoplasty With Autologous Fat as Treatment for Stress Velopharyngeal Insufficiency in Brass and Woodwind Musicians.

Importance: Stress velopharyngeal insufficiency (SVPI) is an uncommon but often career-threatening condition affecting professional brass and woodwind musicians. Objectives: To review the evaluation of and treatment for SVPI in professional musicians with lipoinjection to the posterior pharyngeal wall. Design, Setting, and Participants: A retrospective medical record and literature review. Two professional musicians with SVPI treated with autologous lipoinjection to the posterior pharyngeal wall were included. Nasopharyngoscopy was performed while patients played their instrument both before and after injection. Main Outcomes and Measures: To assess the effectiveness of autologous fat injection to the posterior pharyngeal wall to treat stress velopharyngeal insufficiency in 2 professional instrumentalists. Successful treatment was the absence of VPI during playing as visualized by flexible nasopharyngoscopy. Results: After autologous lipoinjection of the posterior pharyngeal wall, 1 patient resumed full play with complete resolution, now 3 years after lipoinjection pharyngoplasty. The other patient received temporary resolution. Both had no surgical complications. Stress VPI is often a career-threatening condition for professional brass and woodwind musicians, with a cited incidence of 34%. Various treatment options in the literature include observation, speech and language pathology referral for pharyngeal strengthening, lipoinjection of the soft palate, and more invasive options, such as sphincter pharyngoplasty, pharyngeal flaps and V-Y pushback. Conclusions and Relevance: Autologous fat injection pharyngoplasty of the posterior pharyngeal wall may be a less invasive treatment option for musicians with SVPI.

Assessing the Value of High-Quality Care for Work-Associated Carpal Tunnel Syndrome in a Large Integrated Health Care System: Study Design.

CONTEXT: Little is known about quality of care for occupational health disorders, although it may affect worker health and workers' compensation costs. Carpal tunnel syndrome (CTS) is a common work-associated condition that causes substantial disability. OBJECTIVE: To describe the design of a study that is assessing quality of care for work-associated CTS and associations with clinical outcomes and costs. DESIGN: Prospective observational study of 477 individuals with new workers' compensation claims for CTS without acute trauma who were treated at 30 occupational health clinics from 2011 to 2013 and followed for 18 months. MAIN OUTCOME MEASURES: Timing of key clinical events, adherence to 45 quality measures, changes in scores on the Boston Carpal Tunnel Questionnaire and 12-item Short Form Health Survey Version 2 (SF-12v2), and costs associated with medical care and disability. RESULTS: Two hundred sixty-seven subjects (56%) received a diagnosis of CTS and had claims filed around the first visit to occupational health, 104 (22%) received a diagnosis before that visit and claim, and 98 (21%) received a diagnosis or had claims filed after that visit. One hundred seventy-eight (37%) subjects had time off work, which started around the time of surgery in 147 (83%) cases and lasted a median of 41 days (interquartile range = 42 days). CONCLUSIONS: The timing of diagnosis varied, but time off work was generally short and related to surgery. If associations of quality of care with key medical, economic, and quality-of-life outcomes are identified for work-associated CTS, systematic efforts to evaluate and improve quality of medical care for this condition are warranted.

The effect of prior lumbar surgeries on the flexion relaxation phenomenon and its responsiveness to rehabilitative treatment.

BACKGROUND CONTEXT: Abnormal pretreatment flexion-relaxation in chronic disabling occupational lumbar spinal disorder patients has been shown to improve with functional restoration rehabilitation. Little is known about the effects of prior lumbar surgeries on flexion-relaxation and its responsiveness to treatment. PURPOSE: To quantify the effect of prior lumbar surgeries on the flexion-relaxation phenomenon and its responsiveness to rehabilitative treatment. STUDY DESIGN/SETTING: A prospective cohort study of chronic disabling occupational lumbar spinal disorder patients, including those with and without prior lumbar spinal surgeries. PATIENT SAMPLE: A sample of 126 chronic disabling occupational lumbar spinal disorder patients with prior work-related injuries entered an interdisciplinary functional restoration program and agreed to enroll in this study. Fifty-seven patients had undergone surgical decompression or discectomy (n=32) or lumbar fusion (n=25), and the rest had no history of prior injury-related spine surgery (n=69). At post-treatment, 116 patients were reevaluated, including those with prior decompressions or discectomies (n=30), lumbar fusions (n=21), and no surgery (n=65). A comparison group of 30 pain-free control subjects was tested with an identical assessment protocol, and compared with post-rehabilitation outcomes. OUTCOME MEASURES: Mean surface electromyography (SEMG) at maximum voluntary flexion; subject achievement of flexion-relaxation (SEMG≤3.5 µV); gross lumbar, true lumbar, and pelvic flexion ROM; and a pain visual analog scale self-report during forward bending task. Identical measures were obtained at pretreatment and post-treatment. METHODS: Patients entered an interdisciplinary functional restoration program, including a quantitatively directed, medically supervised exercise process and a multimodal psychosocial disability management component. The functional restoration program was accompanied by a SEMG-assisted stretching training program, designed to teach relaxation of the lumbar musculature during end-range flexion, thereby improving or normalizing flexion-relaxation and increasing lumbar flexion ROM. At 1 year after discharge from the program, a structured interview was used to obtain socioeconomic outcomes. RESULTS: At pre-rehabilitation, the no surgery group patients demonstrated significantly better performance than both surgery groups on absolute SEMG at maximum voluntary flexion and on true lumbar flexion ROM. Both surgery groups were less likely to achieve flexion-relaxation than the no surgery patients. The fusion patients had reduced gross lumbar flexion ROM and greater pain during bending compared with the no surgery patients, and reduced true lumbar flexion ROM compared with the discectomy patients. At post-rehabilitation, all groups improved substantially on all measures. When post-rehabilitation measures were compared with the pain-free control group, with gross and true lumbar ROM corrected by 8° per spinal segment fused, there were no differences between any of the patient groups and the pain-free control subjects on spinal ROM and only small differences in SEMG. The three groups had comparable socioeconomic outcomes at 1 year post-treatment in work retention, health-care utilization, new injury, and new surgery. CONCLUSIONS: Despite the fact that the patients with prior surgery demonstrated greater pretreatment SEMG and ROM deficits, functional restoration treatment, combined with SEMG-assisted stretching training, was successful in improving all these measures by post-treatment. After treatment, both groups demonstrated ROM within anticipated limits, and the majority of patients in all three groups successfully achieved flexion-relaxation. In a chronic disabling occupational lumbar spinal disorder cohort, surgery patients were nearly equal to nonoperated patients in responding to interdisciplinary functional restoration rehabilitation on measures investigated in this study, achieving close to normal performance measures associated with pain-free controls. The responsiveness and final scores shown in this study suggests that flexion-relaxation may be a useful, objective diagnostic tool to measure changes in physical capacity for chronic disabling occupational lumbar spinal disorder patients.

Is surgical debridement and topical 5 fluorouracil the optimum treatment for woodworkers' adenocarcinoma of the ethmoid sinuses? A case-controlled study of a 20-year experience.

OBJECTIVES: Woodworkers' adenocarcinoma of the ethmoid sinuses is an extremely rare occupational malignancy with a locally aggressive course. Treatment with surgical exenteration and topical 5 fluorouracil (5FU) packs has become standard treatment over the last 10 years in this ENT unit. This study presents level 2 evidence that 5FU provides improved survival over previous management with primary radiotherapy and salvage craniofacial resection. DESIGN: Retrospective case series with historical control group. SETTING: District General Hospital. PARTICIPANTS: The records of 31 consecutive patients with the disease were analysed. Five patients died prior to treatment. One patient was treated with surgery alone and therefore excluded. Twenty-five patients were included in the analysis. Fourteen were treated with primary radiotherapy and 11 with surgery and topical 5FU. OUTCOME MEASURES: Disease free survival was measured using Kaplan-Meier survival analysis. RESULTS: Five-year disease free survival improved from 50% with primary radiotherapy to 86% with surgery and 5FU. This improvement is statistically significant (P = 0.03). CONCLUSION: Topical 5FU treatment improves survival of Woodworker's adenocarcinoma of the ethmoid sinuses. This finding may be useful in the treatment of other locally aggressive sinonasal malignancies.

[Carpal tunnel syndrome treatment]. / La terapia della sindrome del tunnel carpale.

Carpal tunnel syndrome, the most common peripheral neuropathy, results from compression of the median nerve at the wrist, and is a cause of pain, numbness and tingling in the upper extremities and an increasingly recognized cause of work disability. If carpal tunnel syndrome seems likely, conservative management with splinting should be initiated. Moreover, it has suggested that patients reduce activities at home and work that exacerbate symptoms. Pyridoxine and diuretics, since are largely utilised, are no more effective than placebo in relieving the symptoms. Non steroidal anti-inflammatory drugs and orally administered corticosteroids can be effective for short-term management (two to four weeks), but local corticosteroid injection may improve symptoms for a longer period. Injection is especially effective if there is no loss of sensibility or thenar-muscle atrophy and weakness, and if symptoms are intermittent rather than constant. If symptoms are refractory to conservative measures, the option of surgical therapy may be considered.

High-pressure grease injury of the face.

We describe a rare case of high-pressure grease injury of the face in a 48-year-old man with severe facial edema, soft palate swelling, and bleeding from the nose and mouth. Preoperative computed tomography (CT) revealed multiple low-density areas in nasal cavity, subcutaneous tissue of the cheek, soft palate, right maxillary sinus, and right infratemporal fossa. The patient complained of a dyspnea feeling, and immediate tracheostomy was performed. The grease was removed by the Caldwell-Luc incision approach but was partially left in the infratemporal fossa. After the operation, the patient still complained cheek and temporal pain. CT and magnetic resonance imaging were useful to diagnose the remaining grease, and the remnant of the grease was completely removed by the Weber-Fergusson incision approach.

Endoscopic carpal tunnel release.

OBJECTIVE: To assess the efficacy and safety of a new technique for carpal tunnel release. DESIGN: A single-group prospective cohort study. SETTING: A referral-based hand-surgery university practice. PATIENTS: Ninety-five consecutive adults; 1 patient was excluded (35 men, 59 women). They underwent 108 surgical procedures. No patients were lost to follow-up. INTERVENTIONS: Endoscopic carpal tunnel release. Outpatient surgery with neuroleptic anesthesia. Two-portal Chow technique of release. MAIN OUTCOME MEASURES: Symptom relief, return to work, medication use and complication rate. RESULTS: The average preoperative duration of symptoms was 3.9 years. Nerve conduction studies were positive in 101 of the 108 hands. Only two patients required open release. Only eight patients complained of intraoperative pain. Six patients failed to obtain relief of symptoms; two of them required secondary open release owing to persistent symptoms. Of the 61 patients who were employed, 52 returned to their previous jobs without restriction. The mean time for return to work was 36.4 days for patients who were Workers' Compensation Board cases and 19.5 days for patients who were not (p < 0.01). Men returned to work in 17.7 days and women in 24.7 days (p < 0.05). Complications occurred in four patients (3.8%). No nerve injury, vascular injury or reflex sympathetic dystrophy was noted. Patients who had undergone previous contralateral open release noted less pain and earlier return to work after endoscopic carpal tunnel release. CONCLUSIONS: Endoscopic carpal tunnel release was effective in relieving symptoms and had a low complication rate. The technique was associated with early return to work and minimal palmar pain.