Previous studies have stated that presence of concomitant back pain has a negative effect on the outcome of lumbar decompression/microdiscectomy but none have actually defined what level of back pain should be considered as significant. This is a study of consecutive patients who underwent a primary single level lumbar micro decompression /microdiscectomy performed by thirty nine surgeons at a single tertiary spinal centre between August 2011 and December 2014. The aim was to determine the differential effect of the intensity of back pain and leg pain as a predictor of outcome. Data was prospectively collected using SpineTango COMI questionnaires pre-operatively and at 3 months postoperatively. 995 patients who had a complete dataset were included in the analysis. Multivariate regression analysis and ROC curves were used to evaluate factors associated with poor outcome. At 3 months follow up 72.16% of patients were satisfied with the outcome of surgery. The VAS for low back pain was a significant predictor of poor outcome. Of patients with a VAS of 6 or more 34% had a poor outcome following surgery while of patients with a VAS of less than 6, 17% had a poor outcome at three months.Back ground:
Method and Result:
To define how pre-operative evaluation guides surgical planning in patients with atlanto-axial subluxation secondary to rheumatoid arthritis and to measure clinical outcome for the same group. Prospective evaluation of a consecutive cohort of 26 patients undergoing C1/2 fusion over 5 years (2004-2009). Pre-operative evaluation of posterior atlanto-dens interval (PADI), C1 lateral mass and C2 pedicle dimensions. Pre- and post-op Ranawat scores and visual analogue scores for neck and C2 pain C1/2 instability resulted from rheumatoid arthritis (21), trauma (4) and infection (1). C1 lateral mass mean height 4.4mm, C2 pedicle mean height 5.1mm and mean width 3.4mm (30% width <3mm). Ranawat scale improved Grade II to Grade I (p=0.07). Neck pain (pre-op mean 5.5, s.d. 2.8; post-op mean 1.6, s.d. 2.1, t<0.05) and C2 pain (pre-op mean 2.1, s.d. 3.3; post-op mean 0.5, s.d. 1.2, t<0.05) improved. No instrumentation failure. In the rheumatoid group, 17/21 patients had C1 lateral mass and C1/2 transarticular screws. 1 patient had a cranio-cervical fusion and 3 patients had other constructs. 3 patients had C2 numbness. No other neurological deficit. In a rheumatoid population, pre-operative evaluation often precludes the use of C2 pedicle screws. Rigid fixation with a C1 lateral mass and C1/2 transarticular polyaxial screw-rod system is associated with good clinical outcomes.
The primary outcome measure was the presence of clinical adverse events during the first 30 days. The secondary outcome was the extent of radiological soft tissue swelling at the C6 level as measured on plain radiographs in the early post-operative period and compared to a historical post-operative anterior cervical fusion cohort. There was no mortality and no re-operation in this series. 2.4% of patients experienced complications: transient brachalgia (1/123), persistent dysphagia (1/123), sudden dysphagia and dysphonia (1/123). Mean pre-vertebral soft-tissue measurement in 20 patients from the BMP-7 group was 20.9 mm (16–27 mm). This compared with 18.7 mm (15–25 mm) in 7 patients from the non-BMP-7 group, and 18 mm in the historical control group.
Neck pain scores improved from 5.1 pre-operatively (range 0–10, s.d. 4) to 2.8 post-operatively (range 0–10, s.d.5), t=3.7, P<
0.0002. Arm pain scores improved from 5.3 pre-operatively (range 0–10, s.d. 5) to 2.5 post-operatively (range 0–8, s.d. 3), t=2.8, P<
0.009. Pre-operative myelopathy scores averaged 10.6 (range 7–16, s.d. 4.7) rising to 12.8 post-operatively (range 10–17, s.d. 3.9). Although there was no statistically significant change in myelopathy scores, no patient experienced a worsening of their myelopathy score after surgery. There were no operative complications. Radiological follow-up demonstrated early improvement in disc space heights (pre-op 3.1 mm, range 1–6 mm; post-op 5.6 mm, range 4–9 mm) but, at 12 months, two patients demonstrated asymptomatic evidence of cage settling and loss of disc height. There was no incidence of pseudarthrosis. No patient has thus far required further surgery.
