The majority of studies assessing minimal clinical important difference in outcome do so for management of chronic low back pain. Those that identify MCID following spinal surgical intervention fail to differentiate between the different pathologies and treatments or use variable methods and anchors in the calculation. To identify the MCID in scores across the most common spinal surgical procedures using standardised methods of calculation.Background
Aim
Cauda equina syndrome (CES) is a physical process. There is compression of the cauda equina resulting in arrest of the electrochemical signal from the central nervous system. Previous studies have demonstrated that anthropomorphic features influence nerve conduction properties. We therefore sought to if there was an association between biophysical parameters and CES.Background
Aim
In 2009, NICE CG 88 guideline on the management of non-specific low back pain was published. We looked at whether the introduction of these guidelines has had an impact on the management of back pain within primary care. Patients with non-specific low back pain (> 6 weeks but < 12 months) attending spinal outpatient clinic in UHL between 2008 and 2011 were asked to complete questionnaires. Two groups were studied, the first prior to the publication of NICE guidelines, and the second afterwards. Patients with radicular, stenotic and red flag symptoms were excluded. Key audited treatment standards assessed included manual therapy, acupuncture, focused structured back exercise program, supervised group exercise program and lastly referral to a combined physical and psychological treatment program. Compliance with not using X-ray or MRI and treatment modalities such as injections, laser therapy, ultrasound therapy, lumbar supports, traction and TENS therapy was assessed. Secondary outcomes included VAS (back, leg pain), Oswestry Disability Index, MSP and MZD. Primary outcomes analyzed using 1-sided Fisher's exact test and secondary outcomes using two sample t tests.Background
Methods
The relationship between obesity and cauda equina syndrome (CES) has not been previously evaluated or defined. Purpose of this study was to examine the presentation, timing of surgery, peri-operative complications and outcome of Cauda Equina Syndrome in relation to Body Mass Index.Background
Aim
We investigated the effect of weekend knee arthroplasty surgery on length of inpatient stay. 341 consecutive patients undergoing primary total knee replacement were retrospectively identified. Of these 62 underwent surgery during the weekend. Length of inpatient stay, age, sex, pre-operative haemoglobin, ASA rating, and day of surgery were recorded. Multiple regression analysis was used to determine the effect of these preoperative factors on length of post-operative inpatient stay.PURPOSE OF STUDY
METHODS
To compare outcomes of revision lumbar discectomy to primary surgery in the same patient cohort. Prospective outcome data in 36 patients who underwent primary and subsequent revision surgery for lumbar disc herniation between 1995 and 2009. Outcome measures used were Visual Analogue Scores for back (VAB) and leg pain (VAL), the Oswestry Disability Index (ODI) and Low Back Outcome Score (LBO). 5 early recurrences within 3 months were excluded.Aim
Methods
Rotatory subluxation of the atlantoaxial joint has been thoroughly documented in children. However, pure traumatic atlantoaxial rotatory subluxation (TAARS) is a rare injury in adults with only a few cases reported in the English literature. To report two cases of TAARS in adults.Background
Aim
The relationship between obesity and cauda equina syndrome (CES) has not been previously evaluated or defined. The purpose of this study was to determine the effect of body habitus on the presentation and outcome of cauda equina syndrome.Background
Aim
The use of interspinous distraction devices should remain the subject of audit and research. They are a relatively new addition to the armamentarium of surgical treatment of lumbar spinal stenosis. The reported results are variable and there are a number of different devices available. It is recognised that there is an early failure rate with interspinous distraction devices. This is a report of the clinical results after conversion to segmental lumbar decompression following a failure of interspinous distraction procedure. 18 patients had removal of device and conversion to a standard lumbar decompression at an average of 13 months after the index procedure. There were 7 females and 11 males. The average age was 68 years (range 49-85). The two youngest patients had a decompression and instrumented fusion, the others had decompression alone. Prior to the Index procedure of stand alone interspinous distraction device the average Oswestry Disability Index (ODI) was 42 and Visual Analogue Score (VAS) leg 7.2. Prior to revision the average ODI was 42 and VAS leg 6.7. Complications: One intra operative myocardial infarction, one incidental durotomy and one post operative infection (pseudomonas isolated). At a mean of 9 months follow up the average ODI was 23 and VAS leg 2.1. The VAS back was 1.9. The walking distance was subjectively reported as 246 yards pre op and 1100 yards post procedure. There was a clinically significant improvement in all patients. A failed interspinous distraction device can be satisfactorily salvaged with a segmental lumbar decompression.
The use of nerve root blocks is common in the management of radicular pain due to lumbar disc prolapse. However, most papers reporting their use do not necessarily specify the position or level at which the needle is positioned with respect to the level of pathology. We therefore set out to investigate this. We performed a survey of medical practitioners across the UK with an interest or involvement in the management of radicular pain secondary to lumbar disc prolapse The survey depicted the clinical scenario of a patient with radicular pain from an L4/5 disc prolapse and a number of questions were asked in relation to the use of nerve root blocks. Questionnaires were sent to 319 practitioners. We received 153 responses of which, 120 (37.6%) were sufficiently complete to be analysed. Of those who responded, 83% used a combination of local anaesthetic and steroids together with or without contrast. There were variations across the respondents in terms of the level injected with 22.5% injecting at the level of the L4/5 foramen, while 45% injected at the level of the L5/1 foramen. Differences were also noted when respondents were subgrouped according to their speciality. Of those who worked in pain management, 34.1% injected at the L4/5 foramen while 31.8% injected at the L5/1 foramen. For spine surgeons the respective figures were 20.5% and 43.2% and for radiologists 9.4% and 65.6%. In the treatment of radicular leg pain, there are apparent variations in the use and positioning of root blocks for a given level of disc pathology. This suggests that caution is necessary when considering the validity of published studies on the use of root blocks relative to an individual clinician's practice.
A large proportion of our patients are not salaried and many had expressed concerns about the amount of time taken off work following carpal tunnel surgery. Impressions were formed from information given by other health professionals or by friends and relatives who had previously undergone surgery. Some patients declined surgery because of their concerns over this particular issue. We therefore set out to challenge these traditional beliefs. This prompted us to adopt a more aggressive postoperative approach by encouraging immediate and unrestricted hand use following surgery. We found that patients were able to tolerate early activity and were able to return to work sooner than they had expected. For the purposes of this study, our aim was to identify when a return to any form of meaningful employment occurred, such that the individual was earning a salary. Consequently, we did not differentiate between the individual returning to either light or full duties. Subsequently, in a cohort of 494 patients prospectively studied, we have seen 93.1% patients return to work by two weeks and 99.4% by four weeks. This has obvious benefits in terms of reducing loss of income. Individuals undergoing surgery now do not have to be concerned with taking lengthy periods of time off work with the financial implications for them and their families. There are obvious economic implications to our findings. An individual back at work should not be claiming related sickness benefit. The Confederation of British Industry (May 2007) report a cost of £76.70 for each day an employee is off work due to sickness. An individual who is able to return to work even one week earlier than previously would have been expected following carpal tunnel surgery could theoretically produce a saving to the economy of £383. In this series there were 318 (64.4%) patients in employment indicating a potential economic saving of £121,794. Given that nationally there are about 50 000 carpal tunnel procedures carried out each year then the potential savings are significant. There may be a number of reasons for our observations. The absence of a bulky restrictive dressing and sling following surgery clearly allows immediate mobilization to occur. Our service allows the development of a close professional relationship based on trust between the operator and the patient. This ultimately reassures patients who, we believe, feeling more involved in decisions about their post-operative care, are consequently well-motivated and have the confidence to use their hand immediately following surgery. We have seen a low postoperative complication rate in this group of patients, in particular, a low incidence of swelling, stiffness and scar sensitivity. Reasons for these low complication rates are unclear, but we would suggest that early mobilisation protects patients against these particular problems.
A cohort of 69 patients having clinical and radiological evidence of spinal stenosis. Selected according to recommendations of clinical trials groups for the x-stop, i.e. sitting tolerance of greater than 30 minutes. Clinical outcome data at average of 10 month (6–24) available for 66 patients (95% FU). Average age 67 years ( Range 49–84). The average outcomes were Pre op ODI 42, Post op ODI 27. A change from baseline of 15 points. Pre op VAS leg 7.2 post op 4.4, and VAS Back Pre 4.8, post op 3.6 Taking a 16 point change in ODI as representing a clinically significant improvement half the study group failed to achieve this. A small number (17 patients 25%) had a dramatic improvement of greater than 24 points, which significantly skews the average change from baseline. 17 Revisions have occurred so far (24% failure rate)
21 patients required knee replacement at an average of 24 months (range: 6–48 months) from the initial microfracture. 17 out of 21 patients had kissing lesion and all showed grade 4 degenerative changes
