Non-Operative Treatment for Lumbar Spinal Stenosis with Neurogenic Claudication: A Systematic Review.

Non-Operative Treatment for Lumbar Spinal Stenosis with Neurogenic Claudication: A Systematic Review.

Spine (Phila Pa 1976). 2011 Dec 12;

Authors: Ammendolia C, Stuber K, de Bruin LK, Furlan AD, Kennedy CA, Rampersaud YR, Steenstra IA, Pennick V

Abstract
ABSTRACT: Study Design. Systematic reviewObjective. To systematically review the evidence for the effectiveness of non-operative treatment for lumbar spinal stenosis with neurogenic claudication.Summary of Background Data. Neurogenic claudication can significantly impact functional ability, quality of life and independence in the elderly.Methods. We searched CENTRAL, Medline, EMBASE, CINAHL and ICL databases up to January 2011 for randomized controlled trials published in English in which at least one arm provided data on non-operative treatments. Risk of bias in each study was independently assessed by two reviewers using 12 criteria. Quality of the evidence was evaluated using GRADE (Grades of Recommendations, Assessment, Development and Evaluation).Results. From the 8635 citations screened, 56 were assessed and 21 trials with 1851 participants were selected. There is very low quality evidence from six trials that calcitonin is no better than placebo or paracetamol regardless of mode of administration or outcome. From single small trials, there is low quality evidence that prostaglandins, and very low quality evidence that gabapentin or methylcobalamin, improve walking distance. There is very low quality evidence from a single trial that epidural steroid injections improve pain, function and quality of life up to two weeks compared to home exercise or in-patient physical therapy. There is low quality evidence from a single trial that exercise is of short-term benefit for leg pain and function compared to no treatment. There is low and very low quality evidence from six trials that multi-modal non-operative treatment is less effective than indirect or direct surgical decompression with or without fusion.Conclusion. Moderate and high GRADE evidence for non-operative treatment is lacking and thus prohibiting recommendations to guide clinical practice. Given the expected exponential rise in the prevalence of lumbar spinal stenosis with neurogenic claudication, large high quality trials are urgently needed.

PMID: 22158059 [PubMed – as supplied by publisher]

[Non-Operative Treatment for Severe Forms of Infantile Idiopathic Scoliosis.]

[Non-Operative Treatment for Severe Forms of Infantile Idiopathic Scoliosis.]

Z Orthop Unfall. 2011 Nov 17;

Authors: Trobisch PD, Samdani A, O’Neil C, Betz R, Cahill P

Abstract
INTRODUCTION: Infantile idiopathic scoliosis (IIS) is a rare orthopaedic condition. Braces and casts are popular options in the treatment of IIS but there is a paucity of studies commenting on the outcome of non-operative treatment. The purpose of this study was to analyse failure and success after non-operative treatment for severe forms of IIS. METHODS: We retrospectively reviewed the data of all children who had been treated for IIS between 2003 and 2009 at a single institution. After calculating the failure and success rates, we additionally performed a risk factor analysis for patients who failed non-operative treatment. Chi (2) and T tests were used for statistical analysis with significance set at p?<?0.05. RESULTS: 25 children with an average age of 11 months and an Cobb angle of 46 degrees at presentation were analysed. Seven (28?%) patients were considered as having failed non-operative treatment after an average follow-up of 28 months. The pretreatment Cobb angle was identified as single significant risk factor for failure (55 versus 42) while neither age, gender, nor RVAD seem to influence the outcome. In children who were considered as successfully treated, the Cobb angle decreased from 42 to 18 degrees. CONCLUSION: Non-operative treatment for IIS is successful in 3 out of 4 patients.

PMID: 22095410 [PubMed – as supplied by publisher]

Nonoperative versus Operative Treatment for Thoracolumbar Burst Fractures Without Neurologic Deficit: A Meta-analysis.

Nonoperative versus Operative Treatment for Thoracolumbar Burst Fractures Without Neurologic Deficit: A Meta-analysis.

Clin Orthop Relat Res. 2011 Nov 5;

Authors: Gnanenthiran SR, Adie S, Harris IA

Abstract
BACKGROUND: Decision-making regarding nonoperative versus operative treatment of patients with thoracolumbar burst fractures in the absence of neurologic deficits is controversial. Lack of evidence-based practice may result in patients being treated inappropriately and being exposed to unnecessary adverse consequences. PURPOSE: Using meta-analysis, we therefore compared pain (VAS) and function (Roland Morris Disability Questionnaire) in patients with thoracolumbar burst fractures without neurologic deficit treated nonoperatively and operatively. Secondary outcomes included return to work, radiographic progression of kyphosis, radiographic progression of spinal canal stenosis, complications, cost, and length of hospitalization. METHODS: We searched MEDLINE, EMBASE(®), and the Cochrane Central Register of Controlled Trials for ‘thoracic fractures’, ‘lumbar fractures’, ‘non-operative’, ‘operative’ and ‘controlled clinical trials’. We established five criteria for inclusion. Data extraction and quality assessment were in accordance with Cochrane Collaboration guidelines. The main analyses were performed on individual patient data from randomized controlled trials. Sensitivity analyses were performed on VAS pain, Roland Morris Disability Questionnaire score, kyphosis, and return to work, including data from nonrandomized controlled trials and using fixed effects meta-analysis. We identified four trials, including two randomized controlled trials consisting of 79 patients (41 with operative treatment and 38 with nonoperative treatment). The mean followups ranged from 24 to 118 months. RESULTS: We found no between-group differences in baseline pain, kyphosis, and Roland Morris Disability Questionnaire scores. At last followup, there were no between-group differences in pain, Roland Morris Disability Questionnaire scores, and return to work rates. We found an improvement in kyphosis ranging from means of 12.8º to 11º in the operative group, but surgery was associated with higher complication rates and costs. CONCLUSIONS: Operative management of thoracolumbar burst fractures without neurologic deficit may improve residual kyphosis, but does not appear to improve pain or function at an average of 4 years after injury and is associated with higher complication rates and costs. LEVEL OF EVIDENCE: Level II, therapeutic study. See the Guidelines for Authors for a complete description of level of evidence.

PMID: 22057820 [PubMed – as supplied by publisher]

[Results of operative treatment thoraco-lumbar fractures by posterior lumbar interbody fusion, Daniaux reconstruction or combination of both methods].

[Results of operative treatment thoraco-lumbar fractures by posterior lumbar interbody fusion, Daniaux reconstruction or combination of both methods].

Chir Narzadow Ruchu Ortop Pol. 2011 Mar-Apr;76(2):83-90

Authors: Weg?owski R, Godlewski P, Blacha J, Ko?odziej R, Mazurkiewicz T

Abstract
The aim of the study was to compare clinical and radiological results of treatment thoraco-lumbar spine fractures by short segment transpedicular stabilization accompanied by three techniques of reconstruction: posterior lumbar interbody fusion, vertebral body Daniaux reconstruction and combination of both methods. AO system was used to classify the fractures. Frankel’s grade system was used for assessment of neurological deficit on admission and subsequently in the postoperative and follow-up period. The height of the fractured vertebral body and angle of segmental kyphotic deformation was measured on lateral X-ray pre- and post-operatively and at last follow-up. To the retrospective analysis we included 167 patients operated in the Orthopaedic and Traumatology Department, Medical University of Lublin in years 1998-2007. Posterior lumbar interbody fusion was performed in 69 patients (41%), isolated vertebral body Daniaux reconstruction in 82 patients (49%) and combination of both methods was performed in 16 patients (10%). The follow-up period has ranged from 3 to 13 years (mean 6.9 years). The most common type of the fracture was a B type (104 patients -62%), followed by type A (43 patients–26%), and type C (20–patients 12%). The neurological deficit was present in 80 patients. The postoperative neurological improvement was noticed in 37 patients (46%), whereas in 46 patients (54%) neurological status has not changed after the treatment. From 87 patients without neurological symptoms, we observed postoperatively contemporary neurological complications in 11 (12.6%) cases. The biggest correction of fractured vertebral height (mean 0.15) and correction of segmental kyphotic deformity (mean 6.3 degrees) we have noticed in the group of isolated vertebralbody Daniaux reconstruction with use of bone grafts. However in every group of patients we observed significant loss of correction during follow-up period. At the latest follow-up assessment there were no differences in vertebral body height of segmental kyphotic deformation between the analyzed groups of patients. None of analyzed methods of treatment: posterior lumbar interbody fusion, vertebral body Daniaux reconstruction or combination of these methods did not protect from recurrence of kyphotic deformity.

PMID: 21853908 [PubMed – indexed for MEDLINE]

Outcomes following nonoperative and operative treatment for cervical disc herniations in National Football League athletes.

Outcomes following nonoperative and operative treatment for cervical disc herniations in National Football League athletes.

Spine (Phila Pa 1976). 2011 May 1;36(10):800-5

Authors: Hsu WK

Abstract
STUDY DESIGN: Retrospective cohort study.
OBJECTIVE: To determine the performance-based outcomes in elite athletes of the National Football League (NFL) after a cervical disc herniation.
SUMMARY OF BACKGROUND DATA: Because outcomes after the treatment of cervical disc herniations (CDH) in elite athletes are currently unknown, the treatment decisions for this injury in professional football players are often controversial.
METHODS: NFL players diagnosed with a CDH were identified through previously published protocols using team injury reports and newspaper archives. The “Performance Score” for each player was calculated on the basis of pertinent statistical data, before and after diagnosis of CDH. Data analysis was performed for players with at least a 2-year follow-up.
RESULTS: A total of 99 NFL athletes met the inclusion criteria. In the operative group, on average, 38 of 53 (72%) players successfully returned to play for 29 games over a 2.8-year period, which was significantly greater than that of the nonoperative group, in which only 21 of 46 (46%) players successfully returned to the field to play after treatment for 15 games over a 1.5-year period (P < 0.04). Performance scores and the percentage of games started were not statistically significantly different for either cohort, before and after treatment. Notably, defensive backs had a significantly poorer outcome after treatment for CDH than any other position, playing in only 10 games over a 1.2-year period compared with all others (P < 0.0008). Age at diagnosis demonstrated a negative effect on career longevity after treatment.
CONCLUSION: The data in this study suggest that players have higher return-to-play rates and longer careers after operative treatment than players treated with nonoperative means. Although confounding variables such as concomitant cervical stenosis could have affected these data, these performance-based outcomes after surgical treatment for CDH are better than previously thought. Defensive backs have a poorer prognosis after CDH compared with players of all other positions.

PMID: 20714275 [PubMed – indexed for MEDLINE]

Harvey Cushing’s Operative Treatment of Metastatic Breast Cancer to the Central Nervous System in the Early 1900s.

Harvey Cushing’s Operative Treatment of Metastatic Breast Cancer to the Central Nervous System in the Early 1900s.

Arch Surg. 2011 Aug;146(8):975-9

Authors: Latimer K, Pendleton C, Cohen-Gadol AA, Gokaslan ZL, Quinones-Hinojosa A

Abstract
BACKGROUND: A review of the surgical cases of Harvey Cushing, MD, at The Johns Hopkins Hospital provided insight into his early work treating breast cancer metastasis to the central nervous system (CNS). At the time, neurologic surgery was in its infancy. Metastases of breast carcinoma to the CNS were recognized; however, many surgeons of the era adhered to a general principle of not operating in these situations.
METHODS: The Johns Hopkins Hospital surgical records from 1896 to 1912 were reviewed. Four cases in which Cushing treated patients with a history of breast cancer who were diagnosed as having CNS metastasis were selected for further study.
RESULTS: Cushing performed surgery on 4 patients with suspected CNS metastasis in the early 1900s. For a spinal metastasis, Cushing performed a laminectomy and intradural exploratory surgery. His treatments in cerebral cases sought to relieve increased intracranial pressure through decompression. He resected the lesions when they could be located.
CONCLUSIONS: From the start of his career as a neurosurgeon, Cushing chose to perform surgery on patients with suspected CNS metastasis in an attempt to palliate some of their symptoms. Although his patients did not survive long after the procedures, they did experience temporary relief of symptoms that likely encouraged Cushing’s continued operations in such situations and laid the foundation for future therapies for these patients.

PMID: 21844440 [PubMed – in process]