To determine presenting features, treatment modalities and associated outcome following treatment of spinal dural arteriovenous fistulas in a tertiary centre.

Retrospective cohort study of patients with SDAVF assessed at a single tertiary referral centre, between 1999 and 2009. Medical records were used to identify intervention type, pre- and post-intervention Aminoff-Logue disability score (ALDS), recurrence rate, follow-up time and discharge status. Statistical analysis was performed using Wilcoxon signed rank.

26 patients were identified with 23 receiving intervention. Two were unavailable for follow up. Endovascular embolization was performed successfully in 13 patients, recurrence occurred in 6 of these, 3 of which were subsequently treated surgically. Surgery was the initial treatment for 10 patients due to either unsuccessful embolization attempt or proximity of the fistula to spinal artery feeders; only 1 of these recurred. ALDS-gait reduced (improved) by a mean of 0.33 points following intervention but this was not statistically significant (P=0.0645). There was negligible change in micturition and bowel ALDS. Improvement in ALDS was greater in patients treated with surgery first and also in patients whose fistula did not recur. Mean follow-up was 38 months with 56% of working age patients returning to work.

Both embolisation and surgery achieved the primary aim of reducing disease progression, leading to an improved ALDS. Outcome was superior if initially treated surgically and recurrence occurred more frequently in patients treated endovascularly. The small number of patients in our cohort emphasise the need for further studies into this group of patients.

Purpose: Only 30% or less of patients who see an orthopaedic surgeon are surgical candidates. Thus, orthopaedic surgeons’ role in the management of musculoskeletal conditions is wider than surgery and, accordingly, their treatment recommendations include much more than surgery as well. This paper examines the delivery of recommendations not for surgery (NFS) in routine orthopaedic surgery consultations.

Method: Audio-recordings of routine consultations between 121 patients and 14 surgeons from two tertiary care hospitals in a large Canadian city were collected and analyzed using Conversation Analysis, a rigorous, empirical approach to the study of interaction which seeks to reveal sequential structures and patterns in naturally occurring talk, and to explain why these patterns are important.

Results: In contrast to recommendations for surgery, which tend to be delivered fairly quickly and straightforwardly, the delivery of NFS recommendations tends to be elaborate and complex. Orthopaedic surgeons recurrently utilize a cluster of interactional devices in the lead-up to NFS recommendations, including:

projecting turns – turns which indicate that the surgeon will produce an extended turn;

Additionally, even though surgery is not being recommended, NFS recommendations are positioned in relation to surgery. Surgeons use this cluster of devices to manage a range of competing demands, for example, showing that they are taking the patient’s problem seriously, being attentive to the patient’s treatment expectations, explaining the rationale for the recommendation, and positioning the recommendation not for surgery in relation to surgery – e.g., explaining why surgery is not being recommended now, and/or the conditions under which surgery would be offered in the future. Through this cluster of devices, surgeons forecast the nature of the recommendation to come, lay bare the evidential basis for the recommendation and work to obtain patients’ subsequent acceptance of the recommendation. The cluster, as a whole, constitutes a persuasive argument for the upcoming recommendation.

Conclusion: Delivering not for surgery recommendations is a complex task, one which surgeons handle skillfully using several interactional devices. Surgeons treat these recommendations as requiring a persuasive case. An appreciation for the complexities and constraints of delivering NFS recommendations can be used to inform clinical practice and the teaching of communication skills.