Inpatient gradual diagnostics and its relevance for determining treatment strategies in lumbar back pain.

BACKGROUND: Identifying patients who will benefit from spine surgery is still a challenge. This is especially the case when patients' complaints and medical history, together with clinical observations, do not correspond to structural pathological changes. With inpatient gradual diagnostics (IGD)-the administration of analgesic and anti-inflammatory agents to a special area of interest-the effect of surgery can be temporarily simulated. From the patient's statement about the alleviation of pain, the surgeon can draw conclusions concerning its causes. The aim of this study was to evaluate the extent to which IGD influences the decision about the nature and scope of surgical treatment strategies, and the way in which it does so, in patients with chronic lumbar back pain. METHODS: Clinical history and radiologic images were analysed retrospectively in 116 patients by two spine surgeons. Two therapeutic recommendations were developed for each patient: one was based on knowledge before IGD and one on knowledge after IGD. RESULTS: IGD changed the treatment strategy in 39 % of the analysed cases. Although the rate of recommended surgery was reduced by about 10 %, the indicated surgical scope increased in 25 % of cases. CONCLUSIONS: IGD is an established concept used to determine therapeutic strategies in patients with chronic lumbar back pain. In our analysed cases, IGD led to highly relevant changes in recommendations for further surgical treatment.

The Value of Video Rasterstereography in the Detection of Alterations in Posture as a Marker of Pain Relief after Targeted Infiltrations of the Lumbar Spine.

BACKGROUND: Targeted infiltrations to the lumbar spine are used to identify the correct scope for surgery in patients with chronic lumbar back pain (CLBP) and multi-segmental pathologies, where radiologic imaging and clinical presentation do not match. Conclusions from that method have so far been based on individual statements of pain relief. The main principle for the infiltrations is the assumption that by locally administering an analgesic agent to possible surgical target areas, the effect of surgery can be temporarily simulated. The aim was to investigate the use of rasterstereographic posture measurements to substantiate reported pain reduction after infiltrations. METHODS: In this case-control study (Level II), rasterstereography was performed on 57 patients and 28 reference subjects to evaluate changes in posture during 1 week of injections under fluoroscopic guidance and correlated with changes in the Numeric Pain Rating Scale (NRS). Statistical analysis was performed with SPSS (α = .05, two-sided) and presented in the form of box, scatter, and Bland-Altman plots. RESULTS AND CONCLUSION: The CLBP patients' trunk inclination (median 6°) and absolute lateral tilt were significantly increased (p < .01 each) compared to the reference group. No significant difference was observed for trunk length, kyphotic/lordotic angle, or lateral deviation. During infiltration, no significant difference in posture could be observed. A subgroup analysis of patients reporting the highest pain improvement indicated no significant difference. No correlation was observed with pain improvement reported by the patients during injections. Subsequent rasterstereography does not seem to be able to verify results of injections in the diagnostics of lumbar spine pathologies, as patients' reported pain relief does not correlate with a relevant alteration in posture. The short-term effect of the targeted infiltrations may not suffice to change false posture being developed over years.

Interobserver Reliability When Classifying MR Imaging of the Lumbar Spine: Written Instructions Alone Do Not Suffice.

PURPOSE: Numerous classification systems have been proposed to analyze lumbar spine MRI scans. When evaluating these systems, most studies draw their conclusions from measurements of experienced clinicians. The aim of this study was to evaluate the impact of specific measurement training on interobserver reliability in MRI classification of the lumbar spine. METHODS: Various measurement and classification systems were assessed for their interobserver reliability in 30 MRIs from patients with chronic lumbar back and sciatic pain. Two observers were experienced spine surgeons. The third observer was an inexperienced medical student who, prior to the study measurements, in addition to being given the detailed written instructions also given to the surgeons, obtained a list of 20 reference measurements in MRI scans from other patients to practice with. RESULTS: Excellent agreement was observed between the medical student and the spine surgeon who had also created the reference measurements. Between the two spine surgeons, agreement was markedly lower in all systems investigated (e.g., antero-posterior spinal canal diameter intraclass correlation coefficient [ICC] [3.1] = 0.979 vs. ICC [3.1] = 0.857). CONCLUSION: These data warrant the creation of publicly available standardised measurement examples of accepted classification systems to increase reliability of the interpretation of MR images.

Using inpatient gradual diagnostics to identify the treatment strategy for lumbar back pain-Can treadmill gait analysis objectify the patients' declaration of pain relief?

BACKGROUND: Patients with chronic lumbar back pain (CLBP) often present with an altered gait profile, which is a crucial element of good functioning in everyday life. In patients with multisegmental spinal pathologies and incongruity between radiologic imaging and clinical presentation, inpatient gradual diagnostics (IGD) is performed to determine the precise origin of the disabling pain. The underlying principle of IGD is the assumption that by locally administering an analgesic and anti-inflammatory agent to possible surgical target areas, the surgical effect can be temporarily simulated. The conclusions drawn from IGD are, however, mostly based on the patients' subjective feedback about pain relief. RESEARCH QUESTION: The aim of this study was to evaluate whether reported pain relief during IGD can be objectified by gait analysis. We hypothesized that patients with greater pain relief during IGD would show greater improvement in their pathologic gait and stance. METHODS: Treadmill gait and stance analyses were prospectively performed on CLBP patients before and after a one-week IGD. Self-report measures included the numeric pain rating scale (NRS) and the Oswestry Disability Index (ODI). RESULTS AND SIGNIFICANCE: Compared with a reference group (n = 28), IGD patients (n = 57) at admission showed reduced velocity, cadence, step length, and swing phase (p < .01 each). Their stance phase was increased by 5% of the gait cycle, and a more asymmetrical total load distribution during stance was observed. No difference was seen in stride width or foot rotation. While many patients reported good pain relief during IGD, no correlation was observed between subjective improvement and treadmill measures. We can thus confirm a pathologic gait profile in patients with CLBP. Based on our findings, gait analysis would not yet seem suitable to objectify IGD results. The short time interval between admission and discharge may not suffice to change a pathological gait that has developed over years.

Using video rasterstereography and treadmill gait analysis as a tool for evaluating postoperative outcome after lumbar spinal fusion.

BACKGROUND: The rise in the number of patients with lumbar back pain has led to an increase in the number of spinal surgeries. To avoid unfavorable outcomes, high accuracy and reliability of indication for surgery are essential. This requires critical evaluation of postoperative outcomes with its two key dimensions pain and function. While imaging findings give details about the technical dimension of the intervention, they are prone to high inter-/intra-observer variability, with limited relation to functional outcomes. Pain improvement can be directly asked from patients or documented by questionnaires. There is abundant literature on postoperative function based on questionnaires, but quantifiable data such as gait or posture analysis are scarce. Highprecision measurement tools are available and easy to implement in a clinician's work routine. OBJECTIVE: This study evaluates whether lumbar fusion surgery changes gait and postural variables and how these changes are related to patients' descriptions of alterations in their levels of pain. METHODS: Back profiles and gait analyses were measured by video rasterstereography and treadmill gait analysis. Measurements were recorded before surgery, at discharge, after 3 months in a longitudinal (n = 30), and after 12 months in a cross-sectional group (n = 29). A reference group was formed (n = 28). The improvement on the Numeric Pain Rating Scale was documented and compared with changes in gait and posture. RESULTS: A significant reduction in kyphotic (52-43°, p = 0.014) and lordotic (28-11°, p < 0.001) angles was observed. The values again increased after 3 months, with a significant reduction in cadence (98-91 steps/min, p = 0.006). While improvements in pain were also obtained by surgery (p < 0.001), no clear correlation could be detected between 3-month alleviation in pain and changes in kyphotic/lordotic angle or cadence. CONCLUSIONS: Although both methods offer high-precision measurement, changes in gait and posture were not related with the patients' reported pain relief after lumbar fusion surgery.

Closed Suction Drainage after Primary Total Knee Arthroplasty: A Prospective Randomized Trial.

The discussion as to whether or not to use closed suction drainage (CSD) after total knee arthroplasty (TKA) is still ongoing. A multitude of surgical techniques makes comparison between studies difficult. The aim of the present study was to investigate the benefit of CSD versus nondrainage following primary TKA when operating after exsanguination (by means of a rubber Esmarch bandage) with a tourniquet and without any form of hemostasis. A prospective randomized trial was performed with a homogeneous sample of 36 patients with strict inclusion and exclusion criteria. Patients were evaluated preoperatively, on a daily basis during their hospital stay, and at 6 weeks, 3 months, 6 months, and 1 year postoperatively. The use of CSD led to a significantly stronger drop in hemoglobin levels by approximately 1 g/dL (p = 0.012). Knee circumference, wound secretion, wound healing, and postoperative range of motion did not show significant differences. All discharge criteria were met in both groups by day 9. Interestingly, patients without CSD reported higher pain levels during the entire postoperative inpatient stay and also at the 6-week follow-up (p = 0.012). These differences could not be observed in longer follow-up. The use of CSD after primary TKA in this study did not lead to indispensable advantages but did lead to increased postoperative blood loss. When evaluating the advantages and disadvantages of the use of CSD after TKA from the data in the literature, special attention must be paid to the operating technique, as it has a strong impact on the results obtained.

[Predictability of Postoperative Pain and Satisfaction. How Precise Are We and What Is the Role of Professional Experience?] / Die ärztliche Vorhersagepräzision eines OP-Erfolgs. Wie genau sind wir und welche Rolle spielt Berufserfahrung?

Background The indication for surgery is justified by an expected improvement for the patient. To evaluate the probability and extent of individual postoperative patient benefit, the surgeon needs to elaborate numerous parameters of potential relevance for the outcome beyond his key competence, that is the technical dimension of the operation. Despite the highest medical standards, individual postoperative satisfaction with surgery is highly variable, even in cases with a technically good result. The aim of the present study was to investigate the individual predictability of postoperative pain and satisfaction in patients with elective musculoskeletal surgery. Moreover, it was analysed whether the quality of the prediction of the outcome depends on professional experience and if a better prediction can be obtained in such a highly standardised procedure as primary total arthroplasty. Patients/Material and Methods In our hospital on the day before surgery, patients with their medical history are presented to the head of department and a short clinical examination is performed as well as a joint analysis of radiographic images. During this grand round, doctors gave a written preoperative estimation of both expected postoperative satisfaction and pain at 6 months after surgery on a scale from 0 - 10. At 6 months postoperatively, patients were asked to give their actual level for these two parameters. Preoperative estimations were obtained from both senior and resident physicians and compared with the values actually reported by the patient. Results A total of 194 physicians' predictions of 63 patients were analysed. Preoperative pain levels were reduced markedly by surgery from a median NRS of 6.25 to 2.5 (p < 0.001). Median prediction for postoperative pain was 2 (IQR 2), which is only slightly more optimistic than reported. On an individual level, the discrepancy between prediction and actual outcome was, however, considerable - with a median absolute difference of 2 (IQR 3) values on the scale. This means that only 50% of all predictions were close enough to the actual value to be at least in the correct half of the entire scale. When looking at prediction precision as a function of professional experience, no difference could be observed between senior and junior doctors (p = 0.738 for postoperative pain and p = 0.370 for satisfaction with surgery). Even in primary arthroplasty patients (n = 17), precision of outcome prediction for pain was no better that in the remaining collective (p = 0.634). With respect to postoperative satisfaction, precision of prediction was even worse (p = 0.042), as satisfaction was slightly underestimated by the physicians in the primary arthroplasty group, by a median of 1. Conclusion While general prediction showed almost perfect agreement with actual postoperative values, individual predictability showed highly variable results. Even in such a standardised collective as primary arthroplasty, this scattering of deviation was observed. Since professional experience did not lead to improved results, it can be speculated that, beside the technical dimension of surgery, other factors such as patient expectation are of crucial relevance for postoperative outcome. To further improve outcome and patient satisfaction with surgery we therefore recommend developing an individualised and realistic prognosis together with each patient, but bearing in mind own limits of outcome prediction.

Charcot arthropathy of the first metatarsophalangeal joint.

Charcot arthropathy is an acute or subacute, often indolent, non-infectious or tumorous osteoarticular destruction of weightbearing skeletal structures in patients with reduced pain perception due to peripheral neuropathy. The authors present a rare case of progressive Charcot arthropathy of the first metatarsophalangeal joint with accompanying ulcer and foot deformity due to peripheral neuropathy. An arthrodesis of the first metatarsophalangeal joint with resection of the hypertrophic bone and osteophytes using a locking plate was performed. Also a condylectomy of the base of the proximal phalanx digitus II and III as well as a shortening osteotomy of the third metatarsal were conducted. The ulcer was debrided and primarily closed by suture. Mobilization was performed without weightbearing in a postoperative shoe for 6 weeks, the ulcer was completely healed and the arthrodesis had fused. Owing to the complexity of Charcot arthropathy careful preoperative evaluation, timing and dimension of surgery as well as treatment of associated comorbidities and sufficient postoperative care is important to reduce the complication rate and improve long-term results.

Validity and reliability of an adapted german version of scoliosis research society-22 questionnaire.

STUDY DESIGN: Study to determine the internal consistency and validity of adapted German version of Scoliosis Research Society-22 (SRS-22) questionnaire. OBJECTIVE: To evaluate the validity and reliability of adapted German version of SRS-22 questionnaire. SUMMARY OF BACKGROUND DATA: The SRS-22 questionnaire was developed to assess the health-related quality of life for English-speaking patients with idiopathic scoliosis. For scientific purpose and standardized comparison of outcome studies for the treatment of idiopathic scoliosis its adaptation into German is necessary to respect cultural and lingual differences. METHODS: Translation/retranslation of the English version of the SRS-22 was conducted, and all steps for cross-cultural adaptation process were performed. Thus, SRS-22 questionnaire and previously validated Roland-Morris score were mailed to 222 patients who had been treated surgically or conservatively for idiopathic scoliosis. Seventy-eight patients (35%) responded to the first set of questionnaires and 54 of the first time responder returned their second survey. The median age of all patients who joined the study was 19 years. Measures of reliability namely, selectivity, internal consistency, and reproducibility were determined by Cronbach's alpha statistics and intraclass correlation coefficient, respectively. Concurrent validity was measured by comparing with an already validated questionnaire (Roland-Morris score). Measurement was made using the Spearman correlation coefficient. RESULTS: The study demonstrated satisfactory internal consistency with high Cronbach's alpha values for 4 of the corresponding domains (pain, 0.75; self-image, 0.84; mental health, 0.88; and satisfaction, 0.61). However, the Cronbach's alpha value for function/activity domain (0.67) was considerably lower than the original English questionnaire. For the same domains intraclass correlation coefficient demonstrating satisfactory test/retest reproducibility. CONCLUSION: The adapted German version of the SRS-22 questionnaire can be used to assess the outcome of treatment for German-speaking patients with idiopathic scoliosis.