The role of needle tip position on the accuracy of diagnostic selective nerve root blocks in spinal deformity.

PURPOSE: The specificity of a selective nerve root block (SNRB) is dependant on isolating only the required nerve root whilst avoiding injectate flow to traversing nerves. Needle tip position is therefore crucial. Nerve root blocks (SNRBs) in the presence of deformity can be particularly technically challenging to perform. The aims of this study were to document the relationship of needle tip position and SNRB accuracy in patients with and without spinal deformity. METHODS: Over an 8-month period, all SNRBs performed by one spinal surgeon were included. Patients with radiographic evidence of spinal deformity were analysed separately and their lumbar deformity graded using the Schwab grading system. Needle tip position in relation to the superior pedicle and flow of contrast was documented. RESULTS: 76 patients received 85 injections without deformity, 26 patients with deformity underwent 30 SNRBs. In the normal spinal alignment group, there was on overall accuracy of 70.1% regardless of needle tip position, which improved to 91.8% for a lateral needle tip position (P < 0.001). In patients with deformity, the overall accuracy was significantly lower irrespective of needle tip position 36 versus 70%, respectively (P < 0.0019). CONCLUSIONS: Selective nerve root blocks are accurate in patients without deformity where a needle tip placement lateral to the middle third of the pedicle is achieved. The presence of spinal deformity significantly reduces the accuracy of SNRBs with a higher chance of epidural infiltration.

Impaired forearm rotation after tension-band-wiring fixation of olecranon fractures: evaluation of the transcortical K-wire technique.

The tension-band-wiring technique is a well-accepted method of internal fixation of olecranon fractures. In addition, it is suggested that transcortical placement of the k-wires results in lower rates wire migration. We encountered two clinical cases in which transcortical placement of the k-wires led to impairment of forearm rotation. An anatomic study was conducted to study the effect of transcortical wire placement to avoid similar future complications. Using specimens from 10 embalmed cadavers, we found that transcortical wires inserted in <30 degrees of ulnar angulation in the coronal plane to the medial ridge of the olecranon, impinged on the radial neck, supinator muscle, or biceps tendon. This was avoided in all 10 specimens when the wires were inserted, with the forearm in supination, at 30 degrees of ulnar angulation. We recommend this technique to be adopted to avoid forearm rotation impairment.

Weight-bearing radiographs in thoracolumbar fractures: do they influence management?

STUDY DESIGN: Prospective observational study. OBJECTIVE: Our objective was to compare supine and erect (weight-bearing) radiographs in patients with thoracolumbar fractures without a neurologic deficit and to determine whether the erect radiographs alter the deformity and the management plan. SUMMARY OF BACKGROUND DATA: Nonoperative treatment for thoracolumbar fracture without a neurologic deficit is safe and effective. There are some guidelines in the literature that provide objective standards to identify the patients that are suitable for nonoperative treatment. These guidelines are based on measurements on supine radiographs. The role of weight-bearing radiographs in influencing the management plan of these injuries has not been explored. METHODS: Fractures between T11 and L2 in 28 patients were considered suitable for nonoperative treatment initially. Radiographic measurements included anterior and posterior vertebral body heights, interpedicular distance, and the Cobb angle on the supine and erect radiographs. A change in the treatment from the initial nonoperative management plan, based on the radiographic findings, was recorded. RESULTS: Mean supine Cobb angle of 11 degrees increased to 18 degrees on weight-bearing films. The mean anterior vertebral compression increased from 34% to 46%. No change was noted between the posterior vertebral heights and the interpedicular distance. Seven of the 28 patients were subjected to surgical stabilization based on these findings. CONCLUSION: Performing erect radiographs in patients with thoracolumbar fractures without a neurologic deficit provides additional information and did alter the management plan in a significant proportion (25%) of our patients.

Whiplash: a biochemical study of muscle injury.

Outcome following whiplash injury of the cervical spine is variable, and the pathology of those with prolonged symptoms is uncertain. We undertook a prospective study in 25 patients to identify whether those with prolonged symptoms following whiplash injury exhibit a rise in serum creatine kinase consistent with significant muscle damage at the time of injury. Transient rise in creatine kinase level was seen in only 2 of 25 patients, neither of whom complained of prolonged symptoms. Of the 8 patients who developed chronic symptoms following whiplash injury, none demonstrated a serum creatine kinase rise. Prolonged symptoms following whiplash injury cannot be explained by biochemically measurable muscle damage.

Short segment fixation of thoracolumbar burst fractures without fusion.

There continues to be controversy surrounding the management of thoracolumbar burst fractures. Numerous methods of fixation have been described for this injury, but to our knowledge, spinal fusion has always been part of the stabilising procedure, whether this involves an anterior or a posterior approach. Apart from an earlier publication from this centre, there have been no reports on the use of internal fixation without fusion for this type of fracture. The aim of the study was to determine the outcome of patients with thoracolumbar burst fractures who were treated with short segment pedicle screw fixation without fusion. This is a retrospective review of 28 consecutive patients who had short segment pedicle screw fixation of thoracolumbar burst fractures without fusion performed between 1990 and 1993. All patients underwent a clinical and radiological assessment by an independent observer. Outcome was measured using the Low Back Outcome Score. The minimum follow-up period was 2 years (mean 3.1 years). Fifty percent of patients achieved an excellent result with the Low Back Outcome Score, while 12% were assessed as good, 20% fair and 16% obtained a poor result. The only significant factor affecting outcome was the influence of a compensation claim (P < 0.05). The implant failure rate (14% of patients) and the clinical outcome was similar to that from series where fusion had been performed in addition to pedicle screw fixation. The results of this study support the view that posterolateral bone grafting is not necessary when managing patients with thoracolumbar burst fractures by short segment pedicle screw fixation.

External fixation of children's fractures: use of the Orthofix Dynamic Axial Fixator.

We have reviewed 48 children's diaphyseal fractures of the femur and tibia managed with the Orthofix Dynamic Axial Fixator between 1987 and 1994. The indications for external fixation included open fractures, multiple injuries, failed conservative management, and unstable fracture configurations. All fractures healed without further surgical intervention, and the incidence of serious complications was low. Although pin track sepsis was common, compromise of the fixation as a result of this occurred in only one case. We conclude that use of the Orthofix for children's fractures is a safe and effective management option.

Ulnar variance and age.

Ulnar variance was determined on 1,023 radiographs of normal wrists taken in standardized fashion. There were 468 women and 555 men. The age range was 13 to 109 years. In both sexes, ulnar negative variance decreased significantly with increasing age. Possible reasons for this are discussed.

The influence of pregnancy on the development of degenerative spondylolisthesis.

Degenerative spondylolisthesis is most common at the L4/L5 level and in women. There are several possible reasons for its predilection at this site, but there is no satisfactory explanation for the predominance in women. We considered that pregnancy was a possible influence. We reviewed the records and radiographs of 949 women and 120 men aged 50 years and over who had attended a spinal surgeon for low back pain over a five-year period. We found that women who had borne children had a significantly higher incidence of degenerative spondylolisthesis than nulliparous women (28% v 16.7%; p=0.043). The men had a 7.5% incidence, significantly less than nulliparous women (p = 0.031). Our results suggest that pregnancy is an important factor in the aetiology of degenerative spondylolisthesis.

Long-term results of partial undercutting facetectomy for lumbar lateral recess stenosis.

STUDY DESIGN: A retrospective review of 57 consecutive patients who had a partial undercutting facetectomy for degenerative lumbar lateral recess stenosis between 1983 and 1988. OBJECTIVES: To evaluate the long-term results of this procedure. SUMMARY OF BACKGROUND DATA: Few studies have been published on the long-term outcome of decompression for lumbar stenosis. Most studies have included central as well as lateral recess stenosis and have not differentiated between the two. Furthermore, no study has looked at the long-term results of partial undercutting facetectomy. METHODS: All patients were assessed by standard questionnaire, clinical examination, and radiography by an independent observer. The minimum follow-up period was 5 years (mean, 8.4 years). RESULTS: Overall, 72% had no leg pain, 16% had some leg pain needing occasional analgesia, and 12% had severe leg pain needing continual analgesia. CONCLUSIONS: The long-term results of partial undercutting facetectomy are very satisfying.

Compensation, work status, and disability in low back pain patients.

STUDY DESIGN: A prospectively designed study was performed to assess the influence of employment status and a compensation claim on patients experiencing low back pain. OBJECTIVES: To determine the factor that most influences disability arising from low back pain, unemployment or a compensation claim. SUMMARY OF BACKGROUND DATA: Two hundred sixty-nine consecutive patients were assessed from a low back pain clinic. METHODS: Disability was assessed using the Oswestry Disability Score, and employment, and compensation status were recorded. RESULTS: Both unemployment and patients involved in compensation had higher disability scores. However, by controlling the data for employment and assessing only the compensation group it was found that those claiming compensation, but still working had significantly less disability than those claiming compensation who were unemployed. CONCLUSIONS: Both unemployment and compensation claims influence disability, but employment status is the most important factor.

Surgery for lumbar spinal stenosis in old people.

We have reviewed 31 consecutive patients, aged 65 years or more, after surgical decompression for degenerative lumbar spinal stenosis. The average follow-up was 42 months. Assessment included a standard questionnaire, a pain diagram which was completed by the patient, and clinical and radiological examination. Patients were considered in three groups; degenerative spondylolisthesis (19), lateral recess stenosis (5), and central-mixed stenosis (7). The indication for surgery was leg pain: no patient had an operation for back pain alone. Fusion was never performed. Overall, 64% of the patients had an excellent result, 17% a good result and 19% a poor result. We conclude that the long-term outcome of decompressive surgery in the elderly is good; it does not differ from that reported for younger patients.

The gymnast's wrist: acquired positive ulnar variance following chronic epiphyseal injury.

Five cases of symptomatic acquired positive ulnar variance are described. All cases occurred due to premature physeal closure of the growth plate in teenage girl gymnasts. All cases demonstrated ulnocarpal impingement, for which we describe a clinical test. Arthroscopic assessment of the wrist allowed us to assess the integrity of the TFCC (triangular fibrocartilaginous complex) and decide on the most appropriate surgery. Two patients needed distal ulna recession and one needed shaving for a TFCC perforation, with a good result.

Lipids and Dupuytren's disease.

We studied prospectively the relationship between serum lipids and Dupuytren's disease of the hand in 85 patients, 65 men and 20 women. The Dupuytren patients had significantly higher fasting serum cholesterol and triglyceride levels than did the controls (p < 0.001). The raised levels of serum lipids appeared to be associated with the pathogenesis of Dupuytren's disease, and this may help to explain the high incidence of Dupuytren's disease in alcoholic, diabetic and epileptic patients, since these conditions are also associated with raised serum lipid levels.

Reversal of digital vasospasm by glyceryl trinitrate patch.

Localized digital ischaemia following tourniquet deflation is an event producing considerable concern after surgical procedures on the hand, and is more common when severe pre-operative deformity has been radically corrected. We describe three such cases of digital ischaemia, occurring immediately after the release of severe flexion contractures of the digits. Our cases were treated successfully by the application of a proximal cutaneous glyceryl trinitrate patch, which produced prompt recovery of the circulation in the affected digits. We suggest that this simple technique has an important role as theraputically, and possibly also as a diagnostic aid, in the evaluation and management of the post-operative ischaemic digit prior to re-exploration being undertaken.

Complications of metalwork removal.

A total of 188 patients who had metalwork removed were reviewed. There was an overall 20 per cent complication rate. The highest complication rate of 42 per cent was seen with forearm fractures. Infection was the most common complication, and was particularly high in those fractures which were originally open (43 per cent) and where infection developed after the initial internal fixation (32 per cent). We suggest using prophylactic antibiotics for these two groups. All nerve injuries were permanent and were produced by junior surgeons.

A long-term review of the Harrison-Nicolle peg in digital arthrodesis.

Fifty arthrodeses of the digital joints using the Harrison-Nicolle peg in 22 patients have been reviewed at a mean of 8.5 years after operation. 96% of these operations were judged to have been successful by our patients, most of whom were suffering from inflammatory joint disease. 66% went on to bony union, 30% to fibrous union and 4% to non-union. There was no difference in clinical outcome between the bony and fibrous union groups and only those with non-union were disappointed. All arthrodeses remained in the same angle of flexion as that in which they were originally fixed.

A new technique in the management of the ring avulsion injury.

There is universal agreement that microvascular repair is the only way to salvage class II ring avulsion injuries. We report on two patients who sustained this type of injury and were treated successfully by extensive fasciotomy. The circulatory compromise following class II ring injuries deteriorates rapidly due to the tourniquet-like effect by the progressive swelling of the soft tissue envelope. Fasciotomy eliminates this effect and allows adequate inspection of the neurovascular bundles. Microvascular repair is still feasible if considered necessary.

Idiopathic spontaneous haemoperitoneum.

A case is described of bleeding arising from the falciform ligament which occurred in the absence of obvious local pathology. Spontaneous bleeding from this site hitherto has not been reported. Previously described cases of idiopathic spontaneous haemoperitoneum and factors implicated in the aetiology of this rare condition are reviewed.