Common peripheral nerve entrapments in the upper limb.

Entrapment of peripheral nerves can occur as they travel through restrictive spaces. This nerve compression can result in a constellation of signs and symptoms, which are often called syndromes. Patients initially report pain, paraesthesia and numbness, followed by weakness and clumsiness and, ultimately, muscle wasting. The specific region of paraesthesia and pain and the specific muscle weakness is determined by the peripheral nerve involved and the location of the entrapment. Diagnosis is mainly based on history and examination. Further investigations are available for atypical presentations. Each syndrome has its own set of risk factors, but repetitive action and muscle overuse are commonly associated with most syndromes. The treatment is activity modification followed by steroid injection and finally surgical decompression for ongoing persistent symptoms or severe initial presentation. This article outlines the history, examination, possible investigations and management for common peripheral nerve entrapments of the median, ulnar and radial nerves.

Lordosis loss in degenerative spinal conditions.

PURPOSE: To establish whether common degenerative lumbar spine conditions have a predictable sagittal profile and associated range of lordosis. The spinopelvic balance of a normal population and normal ranges are well described in the literature. There is also evidence that certain degenerative conditions can lead to a preponderance of loss of lordosis at specific spinal levels. There is limited literature on the range and magnitude of loss of lordosis for known degenerative lumbar spine pathologies. METHODS: A retrospective analysis of prospectively obtained radiographs from a dual surgeon database was performed and imaging analysed for spinopelvic parameters. Degenerative conditions studied were; Lumbar degenerative spondylolisthesis (L3/4 and L4/5 analysed separately), L5/S1 degenerative disc disease, L5/S1 isthmic spondylolisthesis. Pelvic incidence, sacral slope, pelvic tilt, segmental and global lumbar lordosis, vertebral lordosis and lumbar vertical axis were measured. RESULTS: The range of change in segmental lordosis was normally distributed for all studied degenerative spinal conditions except L5/S1 isthmic spondylolisthesis. L5/S1 degenerative disc disease affected younger adults (mean age 37), whilst degenerative spondylolisthesis at L3/4 and L4/5 affected older adults (mean ages 69.5 and 68.9 respectively). Removing an outlying high-grade L5/S1 isthmic spondylolisthesis made the data distribution approach a normal distribution. CONCLUSION: Most degenerative spinal pathologies cause a normally distributed spectrum of deformity which should be addressed and corrected with a tailored, individualised surgical plan for each patient. Universal treatment recommendations should be interpreted with caution.

Radicular arm pain.

Cervical radiculopathy is a neurological condition caused by dysfunction or compression of a cervical nerve root. Patients often report unilateral neck pain with radiation to the ipsilateral arm, often with sensory changes in a dermatomal distribution. Weakness and reflex changes are also commonly found and can be very troubling for patients. Careful history and examination is important to identify any more concerning features such as progressive symptoms and features of myelopathy, which could prompt surgical management. Although the majority of patients will see an improvement in their symptoms over time with conservative management, surgery is indicated in patients with debilitating pain, progressive neurology, significant weakness, instability or myelopathy. Advancements in surgical techniques offer a range of potential operations that should be considered carefully for each patient. This article outlines the clinical approach to presentation, pathophysiology, diagnosis and management.

Metastatic spinal cord compression.

Metastatic spinal cord compression is compression of the spinal cord or cauda equina as a result of metastatic deposits in the spinal column. It affects approximately 4000 cases per year in England and Wales. Prompt identification and treatment of metastatic spinal cord compression is necessary to prevent irreversible neurological injury, treat pain and maintain patients' mobility, function and independence. Survival of patients with common malignancies has improved significantly with the ongoing development of radiotherapy and chemotherapy, as well as improved surgical treatment of resectable primary tumours. This article outlines the clinical approach to presentation, pathophysiology, diagnosis and management.

Lordosis Recreation With PLIF Surgery-What Is the Influence on Adjacent Segment Lordosis?: An Observational Study of Radiological Alignment Change.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: We aimed to assess the changes in adjacent segmental lordosis (SL) across the intervertebral disc space following single level posterior lumbar interbody fusion (PLIF). SUMMARY OF BACKGROUND DATA: Adjacent segment degeneration is well documented following fusion surgery as are the spinopelvic parameters. What isn't known is the effect of fusion surgery on the adjacent SL of the lumbar spine following PLIF. METHODS: Preoperative and 1-year postoperative erect lateral radiographs were analyzed for lordotic angulation of all lumbar segments and pelvic incidence (PI) in patients undergoing L4/5 or L5/S1 PLIF. RESULTS: Fourty seven PLIFs achieved a mean of 7° increase in SL at L4/5 (P < 0.05) and 11° at L5/S1 (P < 0.05). In L5/S1 PLIF the lordosis gain was associated with lordosis reduction at adjacent segments 3° at L4/5 (P < 0.05); 1° at L3/4 (P < 0.05), 0° at L2/3(NS); 0° at L1/2(NS), and modest gain in overall lordosis (3°). At L4/5 PLIF the global lordosis increased by 5°, but less so at the adjacent discs (L5/S1 = 1°; L3/4 ≤ 1°; L2/3 ≤ -1°, and; L1/2 = <-1°). 19% of cases had a PI-LL > 10° preoperatively, reducing to 4° postoperatively. CONCLUSION: SL increased significantly at the PLIF level. At L5/S1 minimal overall lordosis change occurred however there was reduction in lordosis at adjacent levels representing reduced adjacent segment "compensation." Conversely L4/5 PLIF showed minimal change at adjacent levels but greater overall lordosis increase. Lumbar lordosis (LL) assessment requires monosegmental assessment as well as overall measure of the LL. PLIF surgery changes both LL and SL at adjacent levels. LEVEL OF EVIDENCE: 3.

The results of total hip arthroplasty for fractured neck of femur in octogenarians.

The role of total hip arthroplasty (THA) for fracture in octogenarians remains unclear. Over a two-year period, 354 patients aged > 80 years were admitted with a displaced intracapsular hip fracture. Using defined clinical guidelines, 38 patients underwent THA with a median age of 84 years, mean follow-up of 20 months. Primary outcomes were dislocation, 30-day and one-year mortality, revision surgery and periprosthetic fracture. There were no dislocations or periprosthetic fractures and patient survival was 97% at 30 days and 87% at one year. There was one revision for deep infection. This study demonstrates that THA for selected octogenarians can be performed safely, allows the majority of patients to return to independent living and has a low complication rate.

Migratory abdominal pain.

A 63 year old woman, presenting as an emergency provides an useful example of the difficulties in diagnosing acute appendicitis when faced with an atypical history. This patient underwent plain radiography, computed tomography, repeat biochemical investigations and finally an exploratory laparotomy before the diagnosis of acute appendicitis was made. The case was confounded by a highly mobile caecal pole which brought the inflamed appendix to lie over the pancreas highlighting the need for vigilance in diagnosing acute appendicitis.