Aims. Cauda equina syndrome (CES) can be associated with chronic severe lower back pain and long-term autonomic dysfunction. This study assesses the recently defined core outcome set for CES in a cohort of patients using validated questionnaires. Methods. Between January 2005 and December 2019, 82 patients underwent surgical decompression for acute CES secondary to massive lumbar disc prolapse at our hospital. After review of their records, patients were included if they presented with the clinical and radiological features of CES, then classified as CES incomplete (CESI) or with painless urinary retention (CESR) in accordance with guidelines published by the British Association of Spinal Surgeons. Patients provided written consent and completed a series of questionnaires. Results. In total, 61 of 82 patients returned a completed survey. Their mean age at presentation was 43 years (20 to 77; SD 12.7), and the mean duration of follow-up 58.2 months (11 to 182; SD 45.3). Autonomic dysfunction was frequent: 33% of patients reported bladder dysfunction, and 10% required a urinary catheter. There was a 38% and 53% incidence of bowel and sexual dysfunction, respectively: 47% of patients reported genital numbness. A total of 67% reported significant back pain: 44% required further investigation and 10% further intervention for the management of lower back pain. Quality of life was lower than expected when corrected for age and sex. Half the patients reported moderate or worse depression, and 40% of patients of working age could no longer work due to problems attributable to CES. Urinary and faecal incontinence, catheter use, sexual dysfunction, and genital numbness were significantly more common in patients with CESR. Conclusion. This study reports the long-term outcome of patients with CES and is the first to use validated patient-reported outcome measures to assess the CES Core Outcome Set. Persistent severe back pain and on-going autonomic dysfunction were frequently reported at a mean follow-up of five years. Cite this article: Bone Joint J 2021;103-B(9):1464–1471

Introduction. Recent studies suggested that the progression of osteoarthritis (OA), a chronic degenerative joint disease, may be affected by the autonomic nervous system (ANS). Under healthy conditions, the sympathetic (SNS) and parasympathetic (PNS) branches of the ANS are well coordinated to maintain homeostasis. However, pathological conditions are frequently associated with a disturbance of this fine-tuned balance. Therefore, we analyzed whether an autonomic dysfunction occurs in OA patients. Method. 225 participants with early- or late-stage knee OA as well as 40 healthy age-matched probands were included in this study. Autonomic activity was investigated by analyzing heart rate variability (HRV), which decreases under chronic sympathetic overactivity. Time- and frequency-domain HRV indices SDRR, RMSSD, pRR50 and LF were examined. Linear regression analysis was performed to adjust for clinical characteristics, such as age, sex, BMI, or medication. Moreover, perceived chronic stress (PSQ) and pain (WOMAC) were assessed via questionnaires. In addition, the serum stress hormones cortisol, DHEA-S and IL-6 were analyzed via ELISA. Result. SDRR, RMSSD, and pRR50 were slightly reduced in the early stage of OA and showed significant decrease in the later stage of the disease. Also LF decreased significantly with OA progression. HRV was significantly influenced by the grade of OA, but not other patient characteristics. Moreover, late-stage OA patients demonstrated significantly higher PSQ and WOMAC levels compared to healthy controls. In addition, cortisol/DHEA-S ratio and IL-6 serum concentrations were significantly higher in late-stage than in early-stage OA patients and healthy controls. Conclusion. Reduced HRV, increased cortisol/DHEA-S ratio and PSQ level as well as elevated systemic IL-6 concentration indicated an autonomic shift towards a more pronounced SNS activity due to PNS deficiency in OA patients, particularly in the late-stage of the disease. Therefore, modulation of the ANS, for example by vagus nerve stimulation, might be a potential treatment strategy for of knee OA patients

Osteoarthritis (OA) is the most common degenerative joint disorder. Its multifactorial etiology includes age, sex, joint overloading, genetic or nervous influences. In particular, the autonomic nervous system is increasingly gaining in importance. Its two branches, the sympathetic (SNS) and parasympathetic nervous system, are well-balanced under healthy conditions. OA patients seem to be prone to an autonomic imbalance and therefore, we analyzed their autonomic status. More than 200 participants including patients with early and late stage knee OA (before and 1 year after knee replacement surgery) and healthy probands (age-matched) were analyzed. Heart rate variability was measured via electrocardiogram to assess long-term sympathetic (low-frequency=LF) and parasympathetic (high-frequency=HF, pRR50) activities or general variability (RMSSD, SDRR). Serum cortisol concentrations were measured by ELISA. Perceived chronic stress (PSQ) was assessed via questionnaire. Multivariant regression was performed for data analysis. LF/HF value of early OA was slightly increased compared to healthy controls but significantly higher compared to late OA patients before (p>0.05) and after TKR (p>0.01). HF in late OA patients before TKR was significantly decreased compared to patients after TKR (p>0.001) or healthy controls (p>0.05). Healthy probands exhibited the highest SDRR values, early OA patients had slightly lower levels and late OA patients before TKR displayed significantly reduced SDRR (p>0.001). The same differences were observed in pRR50 and RMSSD. Serum cortisol concentrations and PSQ scores increased in late OA patients before TKR. At the time point of TKR, women with beta blocker medication had significantly higher age (71 ± 9 years) than those without (63 ± 12 years)(p>0.01). An autonomic dysfunction with sympathetic dominance occurs in OA patients. The fact that beta blocker medication in women delayed the need of TKR indicates that SNS inhibition might counteract OA. Future therapeutic interventions for OA should consider a systemic approach with special regard on the ANS

Background & Objectives. Sensory and motor manifestations in carpal tunnel syndrome (CTS) are well documented, whereas the associated autonomic dysfunction is often overlooked. The aim of this study is to demonstrate that autonomic dysfunction of the CTS hands can be quantified by measuring skin capacitance. Methods. Patients with clinical and electrophysiological signs of idiopathic carpal tunnel syndrome meeting the inclusion criteria were recruited. The patients were also scored based on the Brigham carpal tunnel severity score. Skin capacitance was measured using Corneometer CM825 (C&K Electronic, GmbH). The measurements were taken from the palmar aspect of distal phalanx of the index and little finger of the affected hand. Normal healthy patients with no signs and symptoms of carpal tunnel syndrome were recruited as controls and skin capacitance was measured in a similar fashion as the CTS group. Results. The CTS group consisted of 25 patients (18 female & 7 male) and 35 hands with an average age of 59.2 years (33-83 years). The mean symptom severity score was 2.80 (1.27-4.18; SD 0.82) and functional status score was 2.53 (1-4.26; SD 1.08). The mean ratio of skin hydration between the index and little finger was 0.85 (0.6-1.25; SD 0.155). Using the paired t-test to determine paired differences between index and little finger measurements, the mean difference was 12.6 (p<0.001). The control group consisted of 15 people (9 female and 6 male) and 30 hands. The average age was 47.3 years. The mean ratio of skin hydration between the index and little finger was 0.97 (0.77-1.42 SD 0.105). Using the paired t-test to determine paired differences between index and little finger measurements, the mean difference was 1.31 (p=0.317). The difference in skin hydration between the index and little finger was directly compared between the controls and CTS group, this difference was statistically significant, p=0.002. Conclusion. A simple method to determine dysautonomia, using Corneometer CM825, by the clinician has been demonstrated. Measurement of skin capacitance will reduce the dependence on electrophysiological studies, thus reducing the time for arriving at a diagnosis, improved patient satisfaction and cost-effectiveness

Between 1944 to 2003, eighty nine cases were registered with a diagnosis of Paget’s sarcoma in the Scottish Bone and Soft Tissue Tumour Registry. We found thirteen cases of sarcomatous degeneration of the spine (0.26% of the total bone tumour registry case) which were analysed in this study elaborating clinical, radiological and histopathological features. The mean age was 66.9 years (range 56 to 79 years). There were ten males and three females. There were seven cases involving sacral spine (63.6%), three cases involving lumbar vertebrae and two affecting dorsal spine. One case had diffuse dorso-lumbar involvement from D11 to L3 vertebrae. The mode of presentation was increasing low back pain (in all 13), unilateral sciatica (6, left sided-5, right sided-1), bilateral sciatica (2), lower limb weakness (8) and autonomic dysfunction (4, presented as chronic cauda equina syndrome). The majority of the cases (69.23%) were osteosarcomas. Out of these osteosarcomas, two showed giant cell rich matrix and one revealed predominant telengiectatic areas. Rest of the histological types was shared by chondrosarcoma, fibrosarcoma and malignant fibrous histiocytoma. Decompression laminectomy was performed in three cases. Eight patients had received radiotherapy. The mean survival was 3.93 months (range, 1 week to 7 months), nearly half to the whole Scottish Paget’s sarcoma series with a mean survival of 7.5 months. We found a constellation of symptomatology due to radiculo-medullary compression with a fatal evolution, predominantly lumbosacral involvement, predominantly osteosarcomatous histopathology with a poorest prognosis of all Paget’s sarcoma. Although, decompression laminectomy and adjuvant radiotherapy provided reasonable pain relief and palliation; however, there was no significant influence on the overall prognosis of the patients with Paget’s sarcoma of spine in the last six decades

Introduction: Although well-recognized in adults, RSD is rarely diagnosed in children. Management is still controversial and includes, mobilization and physical therapy, spinal cord stimulation, transcutaneous electrical nerve stimulation, steroids, tricyclic antidepressants, anticonvulsants, non-steroidal anti-inflammatory drugs, injections of calcitonin, vasodilators and calcium channel blocker or alpha-sympathetic blocker. In this study, we describe the treatment of RSD in children using Iloprost, a pros-tacyclin analog that mimics sympathicolysis. We report our treatment regime, the clinical course, complications and the outcome in our first seven patients. Patients and Methods: Seven female patients with a mean age of 9 years (6 to 11 years) suffering from reflex sympathetic dystrophy (RSD) stage II were included in this prospective study. Inclusion criteria were RSD stage II – III, an age between 4 to 12 years, no previous operative procedures and duration of symptoms for a minimum of 6 months. Diagnosis of RSD was based on the presence of neuropathic pain, such as burning, dysaesthesia, paresthesia, and hypalgesia to cold, and physical signs of autonomic dysfunction such as skin cyanosis, mottling, hyperhidrosis, edema and coldness of the extremity. Treatment regime consisted of two infusions of Iloprost (IlomedinÒ, Schering AG, Germany) administered over 6 hours on two consecutive days. Additionally, all patients underwent physiotherapy as part of their inpatient treatment and were offered psychological counselling. Results: One day after the last infusion, all seven patients were free of pain and full weight-bearing was possible. The side-effects of Iloprost were a headache in all patients and vomiting in two patients. Two patients relapsed, one 3 months and one 5 months after primary treatment. These two patients received a second series of infusions and were again free of pain within two days. During a mean follow-up period of 30 months all patients remained asymptomatic. Conclusion: These preliminary results indicate that the treatment of RSD with Iloprost in combination with psychological counselling is a safe and effective treatment regime. Infusion therapy is a non-frightening procedure which may be an important factor considering the possible psychogenic etiology of RSD in children. Additional psychological counselling helps patients and their parents to develop coping strategies which may help to avoid relapses

The diagnostic sub-categorization of cauda equina syndrome (CES) is used to aid communication between doctors and other healthcare professionals. It is also used to determine the need for, and urgency of, MRI and surgery in these patients. A recent paper by Hoeritzauer et al (2023) in this journal examined the interobserver reliability of the widely accepted subcategories in 100 patients with cauda equina syndrome. They found that there is no useful interobserver agreement for the subcategories, even for experienced spinal surgeons. This observation is supported by the largest prospective study of the treatment of cauda equina syndrome in the UK by Woodfield et al (2023). If the accepted subcategories are unreliable, they cannot be used in the way that they are currently, and they should be revised or abandoned. This paper presents a reassessment of the diagnostic and prognostic subcategories of cauda equina syndrome in the light of this evidence, with a suggested cure based on a more inclusive synthesis of symptoms, signs, bladder ultrasound scan results, and pre-intervention urinary catheterization.

Cite this article: Bone Joint J 2024;106-B(3):227–231.

Introduction: To determine the aetiology of peripheral nerve injuries presenting to a specialist centre, identify the management strategies employed and discuss the functional outcome achieved. Methods: Retrospective review of all children referred to this hospital between 1996–2003 with an acquired nerve injury. Obstetrical brachial plexus palsy was excluded. Results: 100 nerve injuries (94 patients) were identified. The mean age was 9.9yrs (0.5–16yrs). 81 injuries involved the upper limb, 19 the lower limb. Most were due to low energy trauma and associated with fractures or their surgical management. 16% presented with autonomic sympathetic dysfunction, 10% with neuropathic pain. 43 patients underwent at least one surgical procedure. The operation was classified diagnostic in 5 (no surgically remediable lesion identified), therapeutic in 33 (surgical procedure could be expected to aid recovery) and reconstructive in 5 (no improvement in nerve function could be achieved; functional improvement achieved by other means). Excellent functional outcome only occurred in conservatively treated cases and in some treated by neurolysis. Nerve grafts and direct repairs were associated with good outcomes. Delayed surgery was associated with fair outcomes. Discussion: Peripheral nerve injuries in children as in adults require careful, prompt attention to obtain the best outcome. Iatropathic injuries must be acknowledged

Aims

The aim of this study was to report our experience at 3.5 years with outpatient total hip arthroplasty (THA).

The aim of this study was to define the microcirculation of the normal rotator cuff during arthroscopic surgery and investigate whether it is altered in diseased cuff tissue.

Blood flow was measured intra-operatively by laser Doppler flowmetry. We investigated six different zones of each rotator cuff during the arthroscopic examination of 56 consecutive patients undergoing investigation for impingement, cuff tears or instability; there were 336 measurements overall.

The mean laser Doppler flowmetry flux was significantly higher at the edges of the tear in torn cuffs (43.1, 95% confidence interval (CI) 37.8 to 48.4) compared with normal cuffs (32.8, 95% CI 27.4 to 38.1; p = 0.0089). It was significantly lower across all anatomical locations in cuffs with impingement (25.4, 95% CI 22.4 to 28.5) compared with normal cuffs (p = 0.0196), and significantly lower in cuffs with impingement compared with torn cuffs (p < 0.0001).

Laser Doppler flowmetry analysis of the rotator cuff blood supply indicated a significant difference between the vascularity of the normal and the pathological rotator cuff. We were unable to demonstrate a functional hypoperfusion area or so-called ‘critical zone’ in the normal cuff. The measured flux decreases with advancing impingement, but there is a substantial increase at the edges of rotator cuff tears. This might reflect an attempt at repair.