PURPOSE OF STUDY

We investigated the effect of weekend knee arthroplasty surgery on length of inpatient stay.

Introduction

Brachial plexus blocks are used widely to provide intra-operative and post-operative analgesia. Their efficacy is well established, but little is known about discharging patients with a numb or weak arm. We need to quantify the risk of complications for improved informed consent.

Objectives

The main objective of our study was to determine the treatment effect of corticosteroids in peri-radicular infiltration for radicular pain. We also examined whether there was any effect on the need for subsequent interventions such as additional root blocks and/or surgery.

Introduction: Etanercept is a selective competitor of TNF alpha which is a pro-inflammatory cytokine. It is currently used alone or in combination with other medication for the treatment of chronic inflammatory disease.

Aim: To establish the treatment effect of etanercept in acute sciatica secondary to lumbar disc herniation.

Method: Triple blind randomised controlled study. Inclusion criteria were acute unilateral radicular leg pain secondary to herniated nucleus pulposus confirmed on MRI scan. Exclusions were previous back surgery, spinal stenosis and any contraindications to the use of etanercept such as immunosuppression. The patient, the injector and assessor were blinded to the agent being used. Follow up was at 6 weeks and 3 months post treatment. Oswestry Disability Index (ODI) and Visual analogue scores (VAS) were among the assessment criteria.

Results: 15 patients were recruited in a 4 year period with a 3 month follow up of 80%. The Etanercept group had 8 patients whilst the placebo group had 7. The average ODI for the Etanercept group pre-intervention was higher than that in the placebo group (56.1 vs. 50.4) and this remained the same after 6 weeks (50.5 vs 31) and 3 months of follow up (39.2 vs. 27.3). VAS was also higher in the Etanercept group vs. placebo; pre-injection (8.5 vs. 7.4), 6 weeks (5.6 vs. 3.8), and 3 months (7.0 vs. 4.5).

Conclusion: Small numbers of trial participants limited statistical analysis. The trend appears to show no benefit to the use of Etanercept over placebo in the pharmacological treatment of sciatica.

Objectives: To determine the treatment effect of corticosteroids in peri-radicular infiltration for radicular pain. Secondary investigations were on the requirement for subsequent interventions such as root blocks and/or surgery. A sub group analysis between sciatica and stenosis was undertaken.

Study Design: A randomised, double blind controlled trial.

Subjects: 150 eligible patients with radicular pain and unilateral chronic symptoms were randomised for a single injection with bupivacaine and methylprednisolone (b+s) or bupivacaine (b) alone.

Outcome measures: The outcome measures included the Oswestry Disability Index (ODI), Low Back Outcome Score (LBOS), Visual Analogue Score (VAS) for leg pain and back pain and patient’s subjective level of satisfaction of the outcome.

Results: 76 patients in the b only group and 74 patients in the b+s group.

Clinically useful improvements of greater than 10 points on the ODI occurred in 54%, deterioration of 10 points or more occurred in 17%. Visual analogue for leg improved by 2 or more in 63%.

There was no statistically significant difference between the groups at 3 months (change in ODI [p=0.2], change in VAS [back pain, p=0.28; leg pain, p=0.67]. Subgroup analysis revealed no statistically significant difference in the change in scores between the stenotic group and disc herniation group at 3 months. At 1 year follow-up data was available for 86% of the patients. There was no statistically significant difference in the rate of further interventions.

Conclusion: Clinical improvement occurs in both groups of patients. Corticosteroids did not provide additional benefit. There is no difference in the need for further root blocks or surgery.

Aim: This study aimed at investigating the diagnostic value of local anaesthetic hip injection test to differentiate between hip and spinal pain in patients presenting with symptoms attributable to both hip and spine pathology.

Study design: Prospective cohort.

Materials and Methods: 48 patients with such diagnostic dilemma under one the care of one spinal surgeon in one centre were carefully selected. All patients had radiographs of the hip joint confirming varying degrees of osteoarthritis. Most of the patients also had different types of spinal imaging showing degenerative spinal changes. The hip injection test involved intraarticular injection of 0.5% Bupivacaine under strict aseptic precautions in a laminar airflow theatre under fluoroscopic control.

Results: 37 patients had a significant relief of pain to the injection. Of these, 33 (89%) underwent successful total hip replacement with relief of pain. The patients with a negative response to the test responded satisfactorily to treatment directed towards their spinal pathology. The sensitivity of this test is at least 97% and specificity 90%. These results are similar to those of previous studies on this topic.

Conclusion: Local anaesthetic hip injection test is a safe, inexpensive and reliable diagnostic tool in identifying the source of the pain in patients with attributable dual pathology.

Purpose: To assess the effectiveness of nasal salmon cal-citonin in the treatment of lumbar spinal stenosis

Methods: Forty patients with symptoms of neurogenic claudication and MRI proven lumbar spinal stenosis were enrolled into the study. They were randomly assigned to either nasal salmon calcitonin 200 i.u or placebo nasal spray (sodium chloride) for the first 4 weeks. At the end of the 4 weeks of initial treatment the patients were given a 6 weeks washout period, during which they received no further nasal spray and were instructed to continue with their normal analgesics. At the end of this period all patients received a further 6 weeks of active nasal salmon calcitonin.

Outcome measures: Oswestry Disability Index (ODI), Low Back Outcome Score (LBOS), Visual Analogue Score (VAS) for leg and back pain, Shuttle Walking Test Distance in metres.

Results: In the 4 weeks during which patients received active/placebo nasal salmon calcitonin there was no statistically significant difference in the change in outcome scores between the two groups (change in ODI [p=0.51], change in VAS for leg pain [p=0.51] and change in shuttle walking distance [p=0.78]) There is a minimal improvement in the mean ODI at the end of only 3.7 points in the calcitonin group and 3.8 points in the placebo group [p=0.44]. The VAS for leg pain deteriorated in both groups. There was a minimal improvement in the VAS for back pain in the calcitonin group of 5 mm, it deteriorated in the placebo group by 11mm [p=0.03]. At the end of the trial 9 patients (23%) reported either an excellent or good outcome, 6 reported a fair outcome (15%) and 17 patients (43%) reported a poor outcome.

Conclusion: This dose of Nasal salmon calcitonin is not effective in the treatment of patients with lumbar spinal stenosis.

Introduction: Lumbar spinal stenosis commonly affects elderly patients with multiple co-morbidities. They are at increased risk of complications following surgical interventions. Non-operative strategies for treating them are desirable and previous studies have shown some benefit of subcutaneous salmon calcitonin for the treatment of spinal stenosis.

Objectives: To assess the effectiveness of nasal salmon calcitonin for the treatment of lumbar spinal stenosis in a cohort of patients.

Study design: Prospective cohort study

Methods: 34 patients with MRI proven lumbar spinal stenosis were enrolled into the trial. They received salmon calcitonin in the form of a nasal spray for 6 weeks. All the patients had multiple co-morbidities making them high risk for any surgical intervention. They were followed up at 6 weeks and at 12 weeks. The main outcome measures were oswestry disability index (ODI), low back outcome score (LBOS) and visual analogue scale (VAS). The patient’s were also subjectively asked to rate the treatment excellent, good, fair or poor.

Results: The mean age was 73.5 years (range 51–92 years). The mean duration of symptoms was 32.6 months (range 3–120 months) The mean ODI pre-treatment was 50 and after 6 weeks of treatment decreased to 47 (p=0.14). The mean LBOS was 18 pre-treatment and increased to 21 (p=0.02) after 6 weeks of treatment. The mean VAS for leg pain was 76mm pre-treatment and decreased to 64mm (p=0.001) after treatment and the mean VAS for back pain only decreased from 64mm to 61mm (p=0.5). 11 patients (32%) had a minimum 20mm change in VAS scores after treatment and 7 patients (21%) improved their ODI score by a minimum of 10 points. All results remained stable at 12 weeks follow-up, suggesting a longer effect than the duration of treatment. With regards to patient’s subjective outcome 9 patients (27%) rated the treatment as fair, 3 rated it as good (9%) and 17 reported no change (50%).

Conclusion: Our results suggest the benefits of nasal salmon calcitonin treatment are marginal, with a minimal improvement in symptoms of patients with lumbar spinal stenosis.

Objectives: To assess the outcome of patients undergoing anterior lumbar interbody fusion with the Hartshill Horseshoe cage device.

Study Design: Prospective cohort of patients from a single centre in the UK

Methods: 20 patients underwent anterior lumbar inter-body fusion from September 1994 to November 2002. All patients underwent primary anterior fusion alone. The diagnosis was back pain alone in 10 patients, instability and back pain post discectomy in 9 patients and pseudoarthrosis in the remaining patient. The main outcome measures were oswestry disability index, low back outcome score, visual analogue scale for back and leg pain, modified somatic perception and modified zung depression score.

Results: Follow-up data was available for 17 patients at two years (85%). There were 11 females and 9 males and there average age at operation was 39 years (range 30–50 years). The mean ODI pre-op was 56 and this improved to 30 post-op (p=0.004). The mean LBOS pre-op was 21 and this improved to 41 post-op (p=0.005). The VAS pre-op was 83mm and improved to 48mm postop (p=0.01). Overall 13 of the patients (76%) improved their ODI by a minimum of 10 points. When comparing the groups according to diagnosis, the patients with back pain alone had a 17 point improvement in ODI whereas the patients with back pain post discectomy had a 29 point improvement in ODI (p=0.33). The main complication of surgery was common iliac vein tear occurring in two patients which was repaired intra-operatively.

Conclusion: Anterior lumbar interbody fusion using the Hartshill horseshoe cage device is a safe and effective method of achieving spine stabilisation in patients with back pain. It seems to be particularly effective for those patients who have instability and back pain post-discectomy.

Study design: Prospective cohort study.

Objective: Despite wide acceptance of decompression surgery for spinal stenosis, the reported success rates remain variable. Our aim is to investigate the value of various predictors of functional outcome in patients undergoing primary lumbar decompression surgery secondary to degenerative spinal stenosis.

Subjects: Eligible patients who had primary posterior lumbar decompression surgery for degenerative spinal stenosis with follow up for 2 years.

Outcome measures: Oswestry Disability index (ODI), Low Back Outcome Score (LBOS), Visual Analogue Score (VAS), claudication walking distance and patient’s subjective assessment of the outcome of the surgery.

Results: Ninety-nine patients who had primary lumbar decompression surgery were recruited between July 1994 and December 2001. The follow up rate was 100% at one year and 76% at two years. There is a statistical significant association between duration of symptoms and the change in ODI, change in LBOS, change in VAS and change in walking distance both at one year and two years follow up. One-way analysis of variance also showed that the groups of patients with symptoms less than 33 months have a much better functional outcome at two years follow up. We have not found modified somatic perception score, modified zung depression score and gender to influence the outcome of the surgery.

Conclusion: This study indicates that patients with a prolonged duration of symptoms have a less favourable functional outcome. Patient’s satisfaction is greatest if surgery occurs within 33 months.

Objectives: To assess whether peri-radicular infiltration of corticosteroids has any effect on the need for subsequent interventions such as additional root blocks and/or surgery.

Study Design: A double blinded randomised controlled trial

Methods: 81 patients with unilateral radicular pain and failed conservative management were randomised to two groups (B and S). Group B received a single peri-radicular injection with bupivacaine and group S received bupivacaine and methylprednisolone. Both patient and surgeon were blinded to the method of treatment. Statistical analysis involved the use of a Chi Square test.

Outcome measures: 1. Number of additional root blocks required and 2. Requirement for surgery.

Results: At a median follow-up of 20 months (range 12–31 months) follow-up data was available for 70 patients (86%) with 35 patients in each group. There were an equal number of males and females in the groups. In group B, 10 patients required a further root block (29%) compared with 6 patients in group S (17%) [p=0.39]. Similarly 8 patients in group B required subsequent surgery (23%) compared with 3 in group S (9%) [p=0.19]. These differences did not achieve statistical significance probably due to the modest size of this study.

Conclusion: Our findings suggest that adding corticosteroid to bupivacaine nerve root blocks may reduce the need for further root blocks and surgery.