Stand-alone Lateral Recess Decompression without Discectomy in Patients Presenting with Claudicant Radicular Pain and MRI Evidence of Lumbar Disc Herniation: A Prospective Study.

By Kamruz Zaman
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Stand-alone Lateral Recess Decompression without Discectomy in Patients Presenting with Claudicant Radicular Pain and MRI Evidence of Lumbar Disc Herniation: A Prospective Study.

Spine (Phila Pa 1976). 2016 Oct 25;

Authors: Kulkarni AG, Patel R, Dutta S, Patil V

Abstract
STUDY DESIGN: Prospective study.
OBJECTIVE: To analyze the outcomes of stand-alone lateral recess decompression without discectomy in patients with claudicant radicular pain and MRI showing LRS (lateral recess stenosis) with lumbar disc herniation.
SUMMARY OF BACKGROUND DATA: Discectomy is the gold standard treatment for symptomatic lumbar disc herniations refractory to conservative care. Typically patients with positive SLR (Straight leg raising test) and flexion dominant leg pain are the ideal candidates who can be benefited from discectomy. There is a subset of patients with morphological features of lumbar disc herniation with LRS on MRI and presenting with diametrically opposite symptoms like claudicant leg pain, extension dominant leg pain, relief on flexion and a negative SLR. Until now, no focused prospective study in the literature highlights stand-alone lateral recess decompression in this group of patients.
METHODS: From January 2007- June 2013, 55 patients having unilateral claudicant radicular pain were selected to undergo stand-alone lateral recess decompression with tubular retractors. Intra-operatively disc consistency and presence of sequestrated fragments were analyzed. Visual Analogue Scale (VAS), Oswestry Disability Index (ODI) score and Macnab’s criteria were used to measure outcomes.
RESULTS: Out of 55 patients, stand-alone lateral recess decompression was successfully executed in 51 patients and remaining four patients had sequestrated discs which required removal. Mean age at presentation was 54.5 years(41-67 years), male:female ratio was 1.12:1 and mean follow-up was 3.8 years (3-5.8 years). Significant improvement(p, < 0.0001) was noticed between pre-operative and post-operative VAS score(8.39 ± 0.84 v/s 2.5 ± 0.48) and ODI score(46.79 ± 1.85 v/s 18.71 ± 2.41). As per Macnab’s criteria 94% patients were satisfied with surgery.
CONCLUSIONS: Stand-alone lateral recess decompression without discectomy is clinically effective for a large majority of patients with claudicant radicular pain and MRI evidence of LRS with associated lumbar disc herniation. The ability to perform it with minimal invasive techniques makes it focused and targeted with minimal morbidity.
LEVEL OF EVIDENCE: 4.

PMID: 27792115 [PubMed – as supplied by publisher]

Spontaneous Spinal Epidural Hematoma in a Patient on Rivaroxaban: Case Report and Literature Review.

By Kamruz Zaman
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Spontaneous Spinal Epidural Hematoma in a Patient on Rivaroxaban: Case Report and Literature Review.

J Emerg Med. 2017 Oct;53(4):536-539

Authors: Ismail R, Zaghrini E, Hitti E

Abstract
BACKGROUND: Spinal hematomas (SHs) are rare yet potentially debilitating causes of acute back pain. Although spontaneous SHs have been described in the setting of anticoagulation with warfarin or enoxaparin, few cases of spontaneous SH on direct oral anticoagulants (DOACs) have been reported.
CASE REPORT: We report a case of spontaneous spinal epidural hematoma in a patient on rivaroxaban. A 72-year-old man on rivaroxaban and aspirin presented with a 4-day history of nontraumatic back pain. In the emergency department he developed lower-extremity weakness and numbness, followed by urinary incontinence. Magnetic resonance imaging revealed spinal epidural hematoma at T11-L2. The patient underwent emergent decompression and hematoma evacuation and was discharged home 8 days later with complete resolution of symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Early recognition and surgical intervention for SHs with neurologic compromise is key to favorable outcome. Optimal timing of surgery in patients on DOACs requires an assessment of the risk of intraoperative or postoperative bleeding, an assessment of the patient’s symptom progression, as well as an understanding of the pharmacokinetics of the DOAC used and possible reversal options available. We also review all published cases of spontaneous SHs in patients on DOACs and report on their management and outcomes.

PMID: 29079069 [PubMed – in process]

Effect of older age on treatment decisions and outcomes among patients with traumatic spinal cord injury.

By London Spine

Effect of older age on treatment decisions and outcomes among patients with traumatic spinal cord injury.

CMAJ. 2015 Jul 6;

Authors: Ahn H, Bailey CS, Rivers CS, Noonan VK, Tsai EC, Fourney DR, Attabib N, Kwon BK, Christie SD, Fehlings MG, Finkelstein J, Hurlbert RJ, Townson A, Parent S, Drew B, Chen J, Dvorak MF, Rick Hansen Spinal Cord Injury Registry Network

Abstract
BACKGROUND: Older people are at increased risk of traumatic spinal cord injury from falls. We evaluated the impact of older age (= 70 yr) on treatment decisions and outcomes.
METHODS: We identified patients with traumatic spinal cord injury for whom consent and detailed data were available from among patients recruited (2004-2013) at any of the 31 acute care and rehabilitation hospitals participating in the Rick Hansen Spinal Cord Injury Registry. Patients were assessed by age group (< 70 v. ≥ 70 yr). The primary outcome was the rate of acute surgical treatment. We used bivariate and multivariate regression models to assess patient and injury-related factors associated with receiving surgical treatment and with the timing of surgery after arrival to a participating centre.
RESULTS: Of the 1440 patients included in our study cohort, 167 (11.6%) were 70 years or older at the time of injury. Older patients were more likely than younger patients to be injured by falling (83.1% v. 37.4%; p < 0.001), to have a cervical injury (78.0% v. 61.6%; p = 0.001), to have less severe injuries on admission (American Spinal Injury Association Impairment Scale grade C or D: 70.5% v. 46.9%; p < 0.001), to have a longer stay in an acute care hospital (median 35 v. 28 d; p < 0.005) and to have a higher in-hospital mortality (4.2% v. 0.6%; p < 0.001). Multivariate analysis did not show that age of 70 years or more at injury was associated with a decreased likelihood of surgical treatment (adjusted odds ratio [OR] 0.48, 95% confidence interval [CI] 0.22-1.07). An unplanned sensitivity analysis with different age thresholds showed that a threshold of 65 years was associated with a decreased chance of surgical treatment (OR 0.39, 95% CI 0.19- 0.80). Older patients who underwent surgical treatment had a significantly longer wait time from admission to surgery than younger patients (37 v. 19 h; p < 0.001).
INTERPRETATION: We found chronological age to be a factor influencing treatment decisions but not at the 70-year age threshold that we had hypothesized. Older patients waited longer for surgery and had a substantially higher in-hospital mortality despite having less severe injuries than younger patients. Further research into the link between treatment delays and outcomes among older patients could inform surgical guideline development.

PMID: 26149702 [PubMed – as supplied by publisher]

A randomised trial of all-polyethylene and metal-backed tibial components in unicompartmental arthroplasty of the knee.

By London Spine
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A randomised trial of all-polyethylene and metal-backed tibial components in unicompartmental arthroplasty of the knee.

Bone Joint J. 2015 Jun;97-B(6):786-92

Authors: Hutt JR, Farhadnia P, Massé V, LaVigne M, Vendittoli PA

Abstract
This randomised trial evaluated the outcome of a single design of unicompartmental arthroplasty of the knee (UKA) with either a cemented all-polyethylene or a metal-backed modular tibial component. A total of 63 knees in 45 patients (17 male, 28 female) were included, 27 in the all-polyethylene group and 36 in the metal-backed group. The mean age was 57.9 years (39.6 to 76.9). At a mean follow-up of 6.4 years (5 to 9.9), 11 all-polyethylene components (41%) were revised (at a mean of 5.8 years; 1.4 to 8.0) post-operatively and two metal-backed components were revised (at one and five years). One revision in both groups was for unexplained pain, one in the metal-backed group was for progression of osteoarthritis. The others in the all-polyethylene group were for aseptic loosening. The survivorship at seven years calculated by the Kaplan-Meier method for the all-polyethylene group was 56.5% (95% CI 31.9 to 75.2, number at risk 7) and for the metal-backed group was 93.8% (95% CI 77.3 to 98.4, number at risk 16) This difference was statistically significant (p < 0.001). At the most recent follow-up, significantly better mean Western Ontario and McMaster Universities Arthritis Index Scores were found in the all-polyethylene group (13.4 vs 23.0, p = 0.03) but there was no difference in the mean Knee injury and Osteoarthritis Outcome scores (68.8; 41.4 to 99.0 vs 62.6; 24.0 to 100.0), p = 0.36). There were no significant differences for range of movement (p = 0.36) or satisfaction (p = 0.23). This randomised study demonstrates that all-polyethylene components in this design of fixed bearing UKA had unsatisfactory results with significantly higher rates of failure before ten years compared with the metal-back components.

PMID: 26033058 [PubMed – indexed for MEDLINE]

Effect of therapeutic infra-red in patients with non-specific low back pain: A pilot study.

By London Spine
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Effect of therapeutic infra-red in patients with non-specific low back pain: A pilot study.

J Bodyw Mov Ther. 2014 Jan;18(1):75-81

Authors: Ansari NN, Naghdi S, Naseri N, Entezary E, Irani S, Jalaie S, Hasson S

Abstract
The purpose of this study was to investigate the effect of infra-red (IR) in patients with chronic non-specific low back pain (NSLBP). Ten patients with NSLBP (5 men and 5 women) and disease duration of 21.7 ± 11.50 months participated in this pilot study. Patients had a mean age of 36.40 ± 10.11 years (range = 25-55). Patients were treated with infra-red (IR) for 10 sessions, each for 15 min, 3 days per week, for a period of 4 weeks. Outcome measures were the Numerical Rating Scale (NRS), the Functional Rating Index (FRI), the Modified-Modified Schober Test (MMST), and the Biering-Sorensen test to assess pain severity, disability, lumbar flexion and extension range of motion (ROM), and back extensor endurance, respectively. Data were collected at: baseline – study entry (T0); end of 5th treatment session after 2 weeks (T1); and end of the treatment after 4 weeks (T2). The results of the ANOVA demonstrated a statistically significant main effect of IR on all outcomes of pain, function, lumbar flexion-extension ROM, and back extensor endurance. The treatment effect sizes ranged from large to small. IR was effective in improving pain, function, lumbar ROM, and back extensor endurance in a sample of patients with NSLBP. Treatment effect sizes ranged from large to small indicating clinically relevant improvements primarily in pain and function for patients with NSLBP.

PMID: 24411153 [PubMed – in process]