Surgery for extraforaminal lumbar disc herniation: a single center comparative observational study.

BACKGROUND: Surgery on extraforaminal lumbar disc herniation (ELDH) is a commonly performed procedure. Operating on this type of herniation is known to come with more difficulties than on the frequently seen paramedian lumbar disc herniation (PLDH). However, no comparative data are available on the effectiveness and safety of this operation. We sought out to compare clinical outcomes at 1 year following surgery for ELDH and PLDH. METHODS: Data were collected through the Norwegian Registry for Spine Surgery (NORspine). The primary outcome measure was change at 1 year in the Oswestry Disability Index (ODI). Secondary outcome measures were quality of life measured with EuroQol 5 dimensions (EQ-5D); and numeric rating scales (NRSs). RESULTS: Data of a total of 1750 patients were evaluated in this study, including 72 ELDH patients (4.1%). One year after surgery, there were no differences in any of the patient reported outcome measurements (PROMs) between the two groups. PLDH and ELDH patients experienced similar changes in ODI (- 30.92 vs. - 34.00, P = 0.325); EQ-5D (0.50 vs. 0.51, P = 0.859); NRS back (- 3.69 vs. - 3.83, P = 0.745); and NRS leg (- 4.69 vs. - 4.46, P = 0.607) after 1 year. The proportion of patients achieving a clinical success (defined as an ODI score of less than 20 points) at 1 year was similar in both groups (61.5% vs. 52.7%, P = 0.204). CONCLUSIONS: Patients operated for ELDH reported similar improvement after 1 year compared with patients operated for PLDH.

Surgical Interventions for Cervical Radiculopathy Caused by a Vertebral Artery Loop: A Case Report and Review of the Literature.

BACKGROUND: Aberrant vertebral artery loops are a rare clinical condition, with sparse data regarding the optimal treatment guidelines for individual patients. The heterogeneity of treatment options in the literature creates a problem when tailoring treatments to individual patients. In this review of the literature, multiple surgical treatments for cervical vertebral artery loops were analyzed and compared. In addition, this article provides a clinical case of a patient with a vertebral artery loop. METHODS: A literature review was conducted to identify studies investigating surgical treatments for a vertebral artery loop. Different surgical techniques were examined and the involved techniques and approaches described. The outcomes were assessed for each study and the effectiveness of the treatment determined. RESULTS: Twelve articles met the inclusion criteria for this review. Six types of surgical interventions were found in the literature. Each intervention had similar postoperative results, leading to either a significant improvement or a complete resolution of symptoms. CONCLUSIONS: Multiple successful surgical interventions have been described in the medical literature. However, because of the lack of evidence-based studies, no surgical intervention protocol could be determined. Treatment should therefore be tailored to individual patients' characteristics. Because not every radiologically detected vertebral artery loop is the main reason for a patient's symptoms, a thorough multidisciplinary approach is justified and advocated in patients with an atypical presentation, before a neurosurgical intervention takes place. More deliberate clinical decisions can be made once the understanding of the pathogenesis of this rare disease entity has been established and treatment protocols formulated.

Gender Differences Between Male and Female Neurosurgeons: Is There Equality for All?

OBJECTIVE: Historically, women have been underrepresented in medicine but nowadays the underrepresentation is more applicable to surgical disciplines. Many efforts have been made to decrease the attrition rate of women in neurosurgery and to even career opportunities to be comparable to those of male colleagues. However, it is unclear if gender disparities occur between female and male neurosurgeons. Therefore, the aim of the current study is to identify gender differences in the professional and private life of neurosurgeons. METHODS: A survey consisting of 38 questions was sent to members of the Congress of Neurological Surgeons regarding demographics, career fulfillment, private life, and parenting. Comparison between female and male respondents was made. RESULTS: A total of 870 members filled in surveys, which were analyzed. Working full time, days worked weekly, and gross salary did not differ between male and female neurosurgeons. However, female neurosurgeons rated their career fulfillment worse than did male neurosurgeons (P < 0.001) and were less likely to choose a career as a neurosurgeon again (P < 0.001). Furthermore, female neurosurgeons were less likely to be married or to have children than were male colleagues (P < 0.001). CONCLUSIONS: Despite efforts to increase the amount of women enrolling into neurosurgery and despite efforts to strive for equality, the results of the current study show gender disparities in professional and private careers among neurosurgeons. Practice patterns did not differ between male and female neurosurgeons, but perceptions of career and characteristics of private life did. Program directors and chairs should focus on measures to decrease gender differences and to strive for equal career satisfaction among female and male neurosurgeons.

Preoperative MRI in Patients With Intermittent Neurogenic Claudication: Relevance for Diagnosis and Prognosis.

STUDY DESIGN: We studied baseline magnetic resonance images of 155 patients with intermittent neurogenic claudication and lumbar spinal stenosis (LSS). Magnetic resonance imaging (MRI) and patient data were gathered from participants of a randomized trial. OBJECTIVE: It is believed that the narrowness of the lumbar spinal canal correlates to the severity of complaints and that it may be a good predictor of clinical outcome if treated. However, this hypothesis has never been (prospectively) tested. SUMMARY OF BACKGROUND DATA: MRI is an important tool to confirm the diagnosis of LSS as a cause for intermittent neurogenic claudication. METHODS: Three raters were asked to evaluate the magnetic resonance images (Schizas scale). Symptom severities at baseline and 1-year follow-up were quantified. The radiological scores were correlated with clinical baseline and outcome scores to assess diagnostic and prognostic value of MRI findings at baseline. RESULTS: There was good agreement on the clinically relevant level of LSS (kappa range 0.57-0.64). MRI assessment of grading of compression (kappa 0.33-0.46) did not correlate with baseline MRDQ nor with outcome based on postoperative change in MRDQ (P = 0.61). However, both absence of epidural fat and presence of tortuous caudal nerves on magnetic resonance images (kappa 0.53-0.72 and 0.67-0.70) in patients with LSS were relatively good predictors for satisfactory recovery after surgery (P = 0.03 and P < 0.01). CONCLUSION: The grading of compression on the preoperative MRI is neither ambiguous nor correlating to severity of clinical condition. It does, furthermore, not have the ability to predict the outcome after 1 year if surgically treated. LEVEL OF EVIDENCE: 2.

Prognostic value of magnetic resonance imaging findings in patients with sciatica.

OBJECTIVE This study aimed to determine the prognostic value of MRI variables to predict outcome in patients with herniated disc-related sciatica, and whether MRI could facilitate the decision making between early surgery and prolonged conservative care in these patients. METHODS A prospective observational evaluation of patients enrolled in a randomized trial with 1-year follow-up was completed. A total of 283 patients with sciatica who had a radiologically confirmed disc herniation were randomized either to surgery or to prolonged conservative care with surgery if needed. Outcome measures were recovery and leg pain severity. Recovery was registered on a 7-point Likert scale. Complete/near complete recovery was considered a satisfactory outcome. Leg pain severity was measured on a 0- to 100-mm visual analog scale. Multiple MRI characteristics of the degenerated disc herniation were independently scored by 3 spine experts. Cox models were used to study the influence of MRI variables on rate of recovery, and linear mixed models were used to determine the predictive value of MRI variables for leg pain severity during follow-up. The interaction of each MRI predictor with treatment allocation was tested. There were no study-specific conflicts of interest. RESULTS Baseline MRI variables associated with less leg pain severity were the reader's assessment of presence of nerve root compression (p < 0.001), and assessment of extrusion compared with protrusion of the disc herniation (p = 0.006). Both variables tended to be associated, but not significantly, with satisfactory outcome during follow-up (HR 1.45, 95% CI 0.93-2.24, and HR 1.24, 95% CI 0.96-1.61, respectively). The size of disc herniation at baseline was not associated with outcome. There was no significant change in the effects between treatment groups. CONCLUSIONS MRI assessment of the presence of nerve root compression and extrusion of a herniated disc at baseline was associated with less leg pain during 1-year follow-up, irrespective of a surgical or conservative treatment. MRI findings seem not to be helpful in determining which patients might fare better with early surgery compared with a strategy of prolonged conservative care. Clinical trial registration no.: ISRCTN26872154 ( controlled-trials.com ).

Interspinous process devices versus standard conventional surgical decompression for lumbar spinal stenosis: cost-utility analysis.

BACKGROUND CONTEXT: In the 1980s, a new implant was developed to treat patients with intermittent neurogenic claudication caused by lumbar spinal stenosis (LSS). This implant is now widely used. PURPOSE: The objective of this study is to determine whether a favorable cost-effectiveness for interspinous process devices (IPDs) compared with conventional bony decompression is attained. STUDY DESIGN/SETTING: Cost-utility analysis was performed alongside a double-blind randomized controlled trial. Five neurosurgical centers (including one academic and four secondary level care centers) included participants for this study. PATIENT SAMPLE: One hundred fifty-nine patients with LSS were treated with the implantation of IPD and with bony decompression. Eighty participants received an IPD, and seventy-nine participants underwent spinal bony decompression. OUTCOME MEASURES: Outcome measures were quality-adjusted life-years (QALYs) and societal costs in the first year (estimated per quarter), estimated from patient-reported utilities (US and The Netherlands EuroQol 5D [EQ-5D] and EuroQol visual analog scale) and diaries on costs (health-care costs, patient costs, and productivity costs). METHODS: All analyses followed the intention-to-treat principle. Given the statistical uncertainty of differences between costs and QALYs, cost-effectiveness acceptability curves graph the probability that a strategy is cost effective, as a function of willingness to pay. Paradigm Spine funded this trial but did not have any part in data analysis or the design and preparation of this article. RESULTS: According to the EQ-5D, the valuation of quality of life after IPD and decompression was not different. Mean utilities during all four quarters were, not significantly, less favorable after IPD according to the EQ-5D with a decrease in QALYs according to the US EQ-5D of 0.024 (95% confidence interval, -0.031 to 0.079). From a health-care perspective, the costs of IPD treatment were higher (difference €3,030 per patient, 95% confidence interval, €561-€5,498). This significant difference is mainly because of additional cost of implants of €2,350 apiece. From a societal perspective, a nonsignificant difference of €2,762 (95% confidence interval, -€1,572 to €7,095) in favor of conventional bony decompression was found. CONCLUSIONS: Implantation of IPD as indirect decompressing device is highly unlikely to be cost effective compared with bony decompression for patients with intermittent neurogenic claudication caused by LSS. TRIAL REGISTRATION: Dutch Trial Register Number: NTR1307.

Interspinous process device versus standard conventional surgical decompression for lumbar spinal stenosis: randomised controlled trial.

STUDY QUESTION: Is interspinous process device implantation more effective in the short term (eight weeks) than conventional surgical decompression for patients with intermittent neurogenic claudication due to lumbar spinal stenosis? SUMMARY ANSWER: The use of interspinous implants did not result in a better outcome than conventional decompression, but the reoperation rate was significantly higher. WHAT IS KNOWN AND WHAT THIS PAPER ADDS: Bony decompression and treatment with interspinous process devices are superior to conservative and non-surgical treatment for intermittent neurogenic claudication due to lumbar spinal stenosis. Interspinous implants surgery is not superior to bony decompression, and the reoperation rate is significantly higher.

Management of lumbar spinal stenosis: a survey among Dutch spine surgeons.

BACKGROUND: Various surgical and non-surgical treatments for lumbar spinal stenosis (LSS) are widely adopted in clinical practice, but high quality randomised controlled trials to support these are often lacking, especially in terms of their relative benefit and risk compared with other treatment options. Therefore, an evaluation of agreement among clinicians regarding the indications and the choice for particular treatments seems appropriate. METHODS: One hundred and six Dutch neurosurgeons and orthopaedic spine surgeons completed a questionnaire, which evaluated treatment options for LSS and expectations regarding the effectiveness of surgical and non-surgical treatments. RESULTS: Responders accounted for 6,971 decompression operations and 831 spinal fusion procedures for LSS annually. Typical neurogenic claudication, severe pain/disability, and a pronounced constriction of the spinal canal were considered the most important indications for surgical treatment by the majority of responders. Non-surgical treatment was generally regarded as ineffective and believed to be less effective than surgical treatment. Interlaminar decompression was the preferred technique by 68% of neurosurgeons and 52% orthopaedic surgeons for the treatment of LSS. Concomitant fusion was applied in 12% of all surgery for LSS. Most surgeons considered spondylolisthesis as an indication and spinal instability as a definite indication for additional fusion. CONCLUSIONS: The current survey demonstrates a wide variety of preferred treatments of symptomatic LSS by Dutch spine surgeons. To minimise variety, national and international protocols based on high-quality randomised controlled trials and systematic reviews are necessary to give surgeons more tools to support everyday decision-making.

Influence of low back pain and prognostic value of MRI in sciatica patients in relation to back pain.

BACKGROUND: Patients with sciatica frequently complain about associated back pain. It is not known whether there are prognostic relevant differences in Magnetic Resonance Imaging (MRI) findings between sciatica patients with and without disabling back pain. METHODS: The study population contained patients with sciatica who underwent a baseline MRI to assess eligibility for a randomized trial designed to compare the efficacy of early surgery with prolonged conservative care for sciatica. Two neuroradiologists and one neurosurgeon independently evaluated all MR images. The MRI readers were blinded to symptom status. The MRI findings were compared between sciatica patients with and without disabling back pain. The presence of disabling back pain at baseline was correlated with perceived recovery at one year. RESULTS: Of 379 included sciatica patients, 158 (42%) had disabling back pain. Of the patients with both sciatica and disabling back pain 68% did reveal a herniated disc with nerve root compression on MRI, compared to 88% of patients with predominantly sciatica (P<0.001). The existence of disabling back pain in sciatica at baseline was negatively associated with perceived recovery at one year (Odds ratio [OR] 0.32, 95% Confidence Interval 0.18-0.56, P<0.001). Sciatica patients with disabling back pain in absence of nerve root compression on MRI at baseline reported less perceived recovery at one year compared to those with predominantly sciatica and nerve root compression on MRI (50% vs 91%, P<0.001). CONCLUSION: Sciatica patients with disabling low back pain reported an unfavorable outcome at one-year follow-up compared to those with predominantly sciatica. If additionally a clear herniated disc with nerve root compression on MRI was absent, the results were even worse.

Reliability of gadolinium-enhanced magnetic resonance imaging findings and their correlation with clinical outcome in patients with sciatica.

BACKGROUND CONTEXT: Gadolinium-enhanced magnetic resonance imaging (Gd-MRI) is often performed in the evaluation of patients with persistent sciatica after lumbar disc surgery. However, correlation between enhancement and clinical findings is debated, and limited data are available regarding the reliability of enhancement findings. PURPOSE: To evaluate the reliability of Gd-MRI findings and their correlation with clinical findings in patients with sciatica. STUDY DESIGN: Prospective observational evaluation of patients who were enrolled in a randomized trial with 1-year follow-up. PATIENTS SAMPLE: Patients with 6- to 12-week sciatica, who participated in a multicentre randomized clinical trial comparing an early surgery strategy with prolonged conservative care with surgery if needed. In total 204 patients underwent Gd-MRI at baseline and after 1 year. OUTCOME MEASURES: Patients were assessed by means of the Roland Disability Questionnaire (RDQ) for sciatica, visual analog scale (VAS) for leg pain, and patient-reported perceived recovery at 1 year. Kappa coefficients were used to assess interobserver reliability. METHODS: In total, 204 patients underwent Gd-MRI at baseline and after 1 year. Magnetic resonance imaging findings were correlated to the outcome measures using the Mann-Whitney U test for continuous data and Fisher exact tests for categorical data. RESULTS: Poor-to-moderate agreement was observed regarding Gd enhancement of the herniated disc and compressed nerve root (kappa<0.41), which was in contrast with excellent interobserver agreement of the disc level of the herniated disc and compressed nerve root (kappa>0.95). Of the 59 patients with an enhancing herniated disc at 1 year, 86% reported recovery compared with 100% of the 12 patients with nonenhancing herniated discs (p=.34). Of the 12 patients with enhancement of the most affected nerve root at 1 year, 83% reported recovery compared with 85% of the 192 patients with no enhancement (p=.69). Patients with and without enhancing herniated discs or nerve roots at 1 year reported comparable outcomes on RDQ and VAS-leg pain. CONCLUSIONS: Reliability of Gd-MRI findings was poor-to-moderate and no correlation was observed between enhancement and clinical findings at 1-year follow-up.

Recovery of motor deficit accompanying sciatica--subgroup analysis of a randomized controlled trial.

BACKGROUND CONTEXT: In patients with sciatica due to a lumbar disc herniation, it is generally recommended to reserve surgical treatment for those who suffer from intolerable pain or those who demonstrate persistent symptoms after conservative management. Controversy exists about the necessity of early surgical intervention for those patients that have an additional motor deficit. PURPOSE: The aim of this study was to compare the recovery of motor deficit among patients receiving early surgery to those receiving prolonged conservative treatment. STUDY DESIGN: Subgroup analysis of a randomized controlled trial. PATIENT SAMPLE: This subgroup analysis focuses on 150 (53%) of 283 patients with sciatica due to a lumbar disc herniation and whose symptoms at baseline (before randomization) were accompanied by a motor deficit. OUTCOME MEASURES: Motor deficit was assessed through manual muscle testing and graded according to the Medical Research Council (MRC) scale. METHODS: In total, 150 patients with 6 to 12 weeks of sciatica due to a lumbar disc herniation and whose symptoms were accompanied by a moderate (MRC Grade 4) or severe (MRC Grade 3) motor deficit were randomly allocated to early surgery or prolonged conservative treatment. Repeated standardized neurologic examinations were performed at baseline and at 8, 26, and 52 weeks after randomization. This study was supported by a grant from the Netherlands Organization for Health Research and Development (ZonMW) and the Hoelen Foundation The Hague. RESULTS: Sciatica recovered among seven (10%) of the 70 patients assigned to early surgery before surgery could be performed, and of the 80 patients assigned to conservative treatment, 32 patients (40%) were treated surgically because of intolerable pain. Baseline severity of motor deficit was graded moderate in 84% of patients and severe in 16% of patients. Motor deficit recovered significantly faster among patients allocated to early surgery (p=.01), but the difference was no longer significant at 26 (p=.21) or 52 weeks (p=.92). At 1 year, complete recovery of motor deficit was found in 81% of patients allocated to early surgery and in 80% of patients allocated to prolonged conservative treatment. Perceived overall recovery of sciatica was directly related to the presence of an accompanying motor deficit. Severe motor deficit at baseline (odds ratio, 5.4; confidence interval, 1.7-17.4) and a lumbar disc herniation encompassing ≥25% of the cross-sectional area of the spinal canal (odds ratio, 6.4; confidence interval, 1.3-31.8) were the most important risk factors for persistent deficit at 1 year. CONCLUSIONS: Early surgery resulted in a faster recovery of motor deficit accompanying sciatica compared with prolonged conservative treatment but the difference was no longer significant during the final follow-up examination at 1 year.

Diagnostic accuracy of history taking to assess lumbosacral nerve root compression.

BACKGROUND CONTEXT: The diagnosis of sciatica is primarily based on history and physical examination. Most physical tests used in isolation show poor diagnostic accuracy. Little is known about the diagnostic accuracy of history items. PURPOSE: To assess the diagnostic accuracy of history taking for the presence of lumbosacral nerve root compression or disc herniation on magnetic resonance imaging in patients with sciatica. STUDY DESIGN: Cross-sectional diagnostic study. PATIENT SAMPLE: A total of 395 adult patients with severe disabling radicular leg pain of 6 to 12 weeks duration were included. OUTCOME MEASURES: Lumbosacral nerve root compression and disc herniation on magnetic resonance imaging were independently assessed by two neuroradiologists and one neurosurgeon blinded to any clinical information. METHODS: Data were prospectively collected in nine hospitals. History was taken according to a standardized protocol. There were no study-specific conflicts of interest. RESULTS: Exploring the diagnostic odds ratio of 20 history items revealed a significant contribution in diagnosing nerve root compression for "male sex," "pain worse in leg than in back," and "a non-sudden onset." A significant contribution to the diagnosis of a herniated disc was found for "body mass index <30," "a non-sudden onset," and "sensory loss." Multivariate logistic regression analysis of six history items pre-selected from the literature (age, gender, pain worse in leg than in back, sensory loss, muscle weakness, and more pain on coughing/sneezing/straining) revealed an area under the receiver operating characteristic curve of 0.65 (95% confidence interval, 0.58-0.71) for the model diagnosing nerve root compression and an area under the receiver operating characteristic curve of 0.66 (95% confidence interval, 0.58-0.74) for the model diagnosing disc herniation. CONCLUSIONS: A few history items used in isolation had significant diagnostic value and the diagnostic accuracy of a model with six pre-selected items was poor.

Back pain's association with vertebral end-plate signal changes in sciatica.

BACKGROUND CONTEXT: Patients with sciatica frequently experience disabling back pain. One of the proposed causes for back pain is vertebral end-plate signal changes (VESC) as visualized by magnetic resonance imaging (MRI). PURPOSE: To report on VESC findings, changes of VESC findings over time, and the correlation between VESC and disabling back pain in patients with sciatica. STUDY DESIGN/SETTING: A randomized clinical trial with 1 year of follow-up. PATIENTS SAMPLE: Patients with 6 to 12 weeks of sciatica who participated in a multicenter, randomized clinical trial comparing an early surgery strategy with prolonged conservative care with surgery if needed. OUTCOME MEASURES: Patients were assessed by means of the 100-mm visual analog scale (VAS) for back pain (with 0 representing no pain and 100 the worst pain ever experienced) at baseline and 1 year. Disabling back pain was defined as a VAS score of at least 40 mm. METHODS: Patients underwent MRI both at baseline and after 1 year follow-up. Presence and change of VESC was correlated with disabling back pain using chi-square tests and logistic regression analysis. RESULTS: At baseline, 39% of patients had disabling back pain. Of the patients with VESC at baseline, 40% had disabling back pain compared with 38% of the patients with no VESC (p=.67). The prevalence of type 1 VESC increased from 1% at baseline to 35% 1 year later in the surgical group compared with an increase from 3% to 11% in the conservative group. The prevalence of type 2 VESC decreased from 40% to 29% in the surgical group while remaining almost stable in the conservative group at 41%. The prevalence of disabling back pain at 1 year was 12% in patients with no VESC at 1 year, 16% in patients with type 1 VESC, 11% in patients with type 2 VESC, and 3% in patients with both types 1 and 2 VESC (p=.36). Undergoing surgery was associated with increase in the extent of VESC (odds ratio [OR], 8.6; 95% confidence interval [CI], 4.7-15.7; p<.001). Patients who showed an increase in the extent of VESC after 1 year did not significantly report more disabling back pain compared with patients who did not show any increase (OR, 1.2; 95% CI, 0.6-2.6; p=.61). CONCLUSION: In this study, undergoing surgery for sciatica was highly associated with the development of VESC after 1 year. However, in contrast with the intuitive feeling of spine specialists, those with and those without VESC reported disabling back pain in nearly the same proportion. Therefore, VESC does not seem to be responsible for disabling back pain in patients with sciatica.

Injury pattern, hospital triage, and mortality of 1250 patients with severe traumatic brain injury caused by road traffic accidents.

This epidemiological study analyzed the incidence, risk factors, hospital triage, and outcome of patients with severe traumatic brain injuries (sTBIs) caused by road traffic accidents (RTAs) admitted to hospitals in the Trauma Center West-Netherlands (TCWN) region. Trauma registry data were used to identify TBI in all RTA victims admitted to hospitals in the mid-West region of the Netherlands from 2003 to 2011. Type of head injury and severity were classified using the Abbreviated Injury Scale (AIS). Head injuries with AIS severity scores ≥ 3 were considered sTBI. Ten percent of all 12,503 hospital-admitted RTA victims sustained sTBI, ranging from 5.4% in motorcyclists, 7.4% in motorists, 9.6% in cyclists, and 12.7% in moped riders to 15.1% in pedestrians (p<0.0001). Among RTA victims admitted to hospital, sTBI was most prevalent in pedestrians (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.78-2.86) and moped riders (OR, 1.86; 95% CI, 1.51-2.30). Injury patterns differed between road user groups. Incidence of contusion ranged from 46.6% in cyclists to 74.2% in motorcyclists, whereas basilar and open-skull fractures were least common in motorcyclists (22.6%) and most common in moped riders (51.5%). Hemorrhage incidence ranged from 44.9% (motorists) to 63.6% (pedestrians). Subdural and -arachnoid bleedings were most frequent. Age, Glasgow Coma Scale, and type of hemorrhage were independent prognostic factors for in-hospital mortality after sTBI. In-hospital mortality ranged from 4.2% in moped riders to 14.1% in motorists. Pedestrians have the highest risk to sustain sTBI and, more specifically, intracranial hemorrhage. Hemorrhage and contusion both occur in over 50% of patients with sTBI. Specific brain injury patterns can be distinguished for specific road user groups, and independent prognostic risk factors for sTBI were identified. This knowledge may be used to improve vigilance for particular injuries in specific patient groups and stimulate development of focused diagnostic strategies.

Interspinous process device versus standard conventional surgical decompression for lumbar spinal stenosis: randomized controlled trial.

OBJECTIVE: To assess whether interspinous process device implantation is more effective in the short term than conventional surgical decompression for patients with intermittent neurogenic claudication due to lumbar spinal stenosis. DESIGN: Randomized controlled trial. SETTING: Five neurosurgical centers (including one academic and four secondary level care centers) in the Netherlands. PARTICIPANTS: 203 participants were referred to the Leiden-The Hague Spine Prognostic Study Group between October 2008 and September 2011; 159 participants with intermittent neurogenic claudication due to lumbar spinal stenosis at one or two levels with an indication for surgery were randomized. INTERVENTIONS: 80 participants received an interspinous process device and 79 participants underwent spinal bony decompression. MAIN OUTCOME MEASURES: The primary outcome at short term (eight weeks) and long term (one year) follow-up was the Zurich Claudication Questionnaire score. Repeated measurements were made to compare outcomes over time. RESULTS: At eight weeks, the success rate according to the Zurich Claudication Questionnaire for the interspinous process device group (63%, 95% confidence interval 51% to 73%) was not superior to that for standard bony decompression (72%, 60% to 81%). No differences in disability (Zurich Claudication Questionnaire; P=0.44) or other outcomes were observed between groups during the first year. The repeat surgery rate in the interspinous implant group was substantially higher (n=21; 29%) than that in the conventional group (n=6; 8%) in the early post-surgical period (P<0.001). CONCLUSIONS: This double blinded study could not confirm the hypothesized short term advantage of interspinous process device over conventional "simple" decompression and even showed a fairly high reoperation rate after interspinous process device implantation. TRIAL REGISTRATION: Dutch Trial Register NTR1307.

Predictive value of MRI in decision making for disc surgery for sciatica.

OBJECT: In a randomized controlled trial comparing surgery and prolonged conservative treatment for sciatica of 6-12 weeks' duration, more than one-third of patients assigned to conservative treatment underwent surgery. The objective of the present study was to evaluate whether MRI at baseline could have predicted this delayed surgery. METHODS: Independently evaluated qualitative and quantitative MRI findings were compared between those patients who did and those who did not undergo surgery during follow-up in the conservative care group. In addition, area under the receiver operating characteristic (ROC) curve analysis was used to assess how well MRI parameters discriminated between those who did and those who did not undergo delayed surgery (0.5-0.7 poor discrimination, ≥ 0.7 acceptable discrimination). RESULTS: Of 142 patients assigned to receive prolonged conservative care, 55 patients (39%) received delayed surgery. Of the 55 surgically treated patients, 71% had definite nerve root compression at baseline compared with 72% of conservatively treated patients (p = 0.76). Large disc herniations (size > 50% of spinal canal) were nearly equally distributed between those who did and those who did not undergo surgery (25% vs 21%, p = 0.65). The size of the dural sac was smaller in the patients who underwent surgery (101.2 vs 122.9 mm(2), p = 0.01). However, the size of the dural sac discriminated poorly between those who did and those who did not undergo delayed surgery (area under ROC curve, 0.62). CONCLUSIONS: In patients who suffered from sciatica of 6-12 weeks' duration, MRI at baseline did not distinguish between patients who did and those who did not undergo delayed surgery.

Magnetic resonance imaging interpretation in patients with sciatica who are potential candidates for lumbar disc surgery.

BACKGROUND: Magnetic Resonance Imaging (MRI) is considered the mainstay imaging investigation in patients suspected of lumbar disc herniations. Both imaging and clinical findings determine the final decision of surgery. The objective of this study was to assess MRI observer variation in patients with sciatica who are potential candidates for lumbar disc surgery. METHODS: Patients for this study were potential candidates (n = 395) for lumbar disc surgery who underwent MRI to assess eligibility for a randomized trial. Two neuroradiologists and one neurosurgeon independently evaluated all MRIs. A four point scale was used for both probability of disc herniation and root compression, ranging from definitely present to definitely absent. Multiple characteristics of the degenerated disc herniation were scored. For inter-agreement analysis absolute agreements and kappa coefficients were used. Kappa coefficients were categorized as poor (<0.00), slight (0.00-0.20), fair (0.21-0.40), moderate (0.41-0.60), substantial (0.61-0.80) and excellent (0.81-1.00) agreement. RESULTS: Excellent agreement was found on the affected disc level (kappa range 0.81-0.86) and the nerve root that most likely caused the sciatic symptoms (kappa range 0.86-0.89). Interobserver agreement was moderate to substantial for the probability of disc herniation (kappa range 0.57-0.77) and the probability of nerve root compression (kappa range 0.42-0.69). Absolute pairwise agreement among the readers ranged from 90-94% regarding the question whether the probability of disc herniation on MRI was above or below 50%. Generally, moderate agreement was observed regarding the characteristics of the symptomatic disc level and of the herniated disc. CONCLUSION: The observer variation of MRI interpretation in potential candidates for lumbar disc surgery is satisfactory regarding characteristics most important in decision for surgery. However, there is considerable variation between observers in specific characteristics of the symptomatic disc level and herniated disc.

Magnetic resonance imaging in follow-up assessment of sciatica.

BACKGROUND: Magnetic resonance imaging (MRI) is frequently performed during follow-up in patients with known lumbar-disk herniation and persistent symptoms of sciatica. The association between findings on MRI and clinical outcome is controversial. METHODS: We studied 283 patients in a randomized trial comparing surgery and prolonged conservative care for sciatica and lumbar-disk herniation. Patients underwent MRI at baseline and after 1 year. We used a 4-point scale to assess disk herniation on MRI, ranging from 1 for "definitely present" to 4 for "definitely absent." A favorable clinical outcome was defined as complete or nearly complete disappearance of symptoms at 1 year. We compared proportions of patients with a favorable outcome among those with a definite absence of disk herniation and those with a definite, probable, or possible presence of disk herniation at 1 year. The area under the receiver-operating-characteristic (ROC) curve was used to assess the prognostic accuracy of the 4-point scores regarding a favorable or unfavorable outcome, with 1 indicating perfect discriminatory value and 0.5 or less indicating no discriminatory value. RESULTS: At 1 year, 84% of the patients reported having a favorable outcome. Disk herniation was visible in 35% with a favorable outcome and in 33% with an unfavorable outcome (P=0.70). A favorable outcome was reported in 85% of patients with disk herniation and 83% without disk herniation (P=0.70). MRI assessment of disk herniation did not distinguish between patients with a favorable outcome and those with an unfavorable outcome (area under ROC curve, 0.48). CONCLUSIONS: MRI performed at 1-year follow-up in patients who had been treated for sciatica and lumbar-disk herniation did not distinguish between those with a favorable outcome and those with an unfavorable outcome. (Funded by the Netherlands Organization for Health Research and Development and the Hoelen Foundation; Controlled Clinical Trials number, ISRCTN26872154.).