Aims

To compare the efficacy of decompression alone (DA) with i) decompression and fusion (DF) and ii) interspinous process device (IPD) in the treatment of lumbar stenosis with degenerative spondylolisthesis. Outcomes of interest were both patient-reported measures of postoperative pain and function, as well as the perioperative measures of blood loss, operation duration, hospital stay, and reoperation.

Symptomatic lumbar spinal stenosis is a common entity and increasing in prevalence. Limited evidence is available regarding patient reported outcomes comparing primary vs revision surgery for those undergoing lumbar decompression, with or without fusion. Evidence available suggest a lower rate of improvement in the revision group. The aim of this study was to assess patient reported outcomes in patients undergoing revision decompression, with or without fusion, when compared to primary surgery.

Patient data was collected from the Canadian Spine Outcomes Research Network (CSORN) database. Patients undergoing lumbar decompression without or without fusion were included. Patients under 18, undergoing discectomy, greater than two level decompressions, concomitant cervical or thoracic spine surgery were excluded. Demographic data, smoking status, narcotic use, number of comorbidities as well as individual comorbidities were included in our propensity scores. Patients undergoing primary vs revision decompression were matched in a four:one ratio according to their scores, whilst a separate matched cohort was created for those undergoing primary vs revision decompression and fusion. Continuous data was compared using a two-tailed t-test, whilst categorical variables were assessed using chi-square test.

A total of 555 patients were included, with 444 primary patients matched to 111 revision surgery patients, of which 373 (67%) did not have fusion. Patients undergoing primary decompression with fusion compared to revision patients were more likely to answer yes to “feel better after surgery” (87.8% vs 73.8%, p=0.023), “undergo surgery again” (90.1% vs 76.2%, P=0.021) and “improvement in mental health” (47.7% vs 28.6%, p=0.03) at six months. There was no difference in either of these outcomes at 12 or 24 months. There was no difference between the groups ODI, EQ-5D, SF 12 scores at any time point. Patients undergoing primary vs revision decompression alone showed no difference in PROMs at any time point.

In a matched cohort, there appears to be no difference in improvement in PROMS between patients undergoing primary vs revision decompression, with or without fusion, at two year follow-up. This would suggest similar outcomes can be obtained in revision cases.

Spinal stenosis is a condition resulting in the compression of the neural elements due to narrowing of the spinal canal. Anatomical factors including enlargement of the facet joints, thickening of the ligaments, and bulging or collapse of the intervertebral discs contribute to the compression. Decompression surgery alleviates spinal stenosis through a laminectomy involving the resection of bone and ligament. Spinal decompression surgery requires appropriate planning and variable strategies depending on the specific situation. Given the potential for neural complications, there exist significant barriers to residents and fellows obtaining adequate experience performing spinal decompression in the operating room. Virtual teaching tools exist for learning instrumentation which can enhance the quality of orthopaedic training, building competency and procedural understanding. However, virtual simulation tools are lacking for decompression surgery. The aim of this work was to develop an open-source 3D virtual simulator as a teaching tool to improve orthopaedic training in spinal decompression. A custom step-wise spinal decompression simulator workflow was built using 3D Slicer, an open-source software development platform for medical image visualization and processing. The procedural steps include multimodal patient-specific loading and fusion of Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) data, bone threshold-based segmentation, soft tissue segmentation, surgical planning, and a laminectomy and spinal decompression simulation. Fusion of CT and MRI elements was achieved using Fiducial-Based Registration which aligned the scans based on manually placed points allowing for the identification of the relative position of soft and hard tissues. Soft tissue segmentation of the spinal cord, the cerebrospinal fluid, the cauda equina, and the ligamentum flavum was performed using Simple Region Growing Segmentation (with manual adjustment allowed) involving the selection of structures on T1 and/or T2-weighted scans. A high-fidelity 3D model of the bony and soft tissue anatomy was generated with the resulting surgical exposure defined by labeled vertebrae simulating the central surgical incision. Bone and soft tissue resecting tools were developed by customizing manual 3D segmentation tools. Simulating a laminectomy was enabled through bone and ligamentum flavum resection at the site of compression. Elimination of the stenosis enabled decompression of the neural elements simulated by interpolation of the undeformed anatomy above and below the site of compression using Fill Between Slices to reestablish pre-compression neural tissue anatomy. The completed workflow allows patient specific simulation of decompression procedures by staff surgeons, fellows and residents. Qualitatively, good visualization was achieved of merged soft tissue and bony anatomy. Procedural accuracy, the design of resecting tools, and modeling of the impact of bone and ligament removal was found to adequately encompass important challenges in decompression surgery. This software development project has resulted in a well-characterized freely accessible tool for simulating spinal decompression surgery. Future work will integrate and evaluate the simulator within existing orthopaedic resident competency-based curriculum and fellowship training instruction. Best practices for effectively teaching decompression in tight areas of spinal stenosis using virtual simulation will also be investigated in future work

Study Design. A prospective cohort study was carried out looking at the functional outcome and post-procedure translational segmental instability after multi-level lumbar decompression using a Hinge osteotomy technique. Objective. The Hinge osteotomy technique involves unilateral subperiosteal muscle dissection with osteotomy of the base of the spinous processes thereby preserving the integrity of the posterior elements. The objective of this study was to demonstrate the results of this technique clinically and radiologically. Methods. Between February 2005 and February 2007, 120 patients (51 male and 69 female) diagnosed with degenerative and/or congenital lumbar stenosis with a mean age of 64 years, underwent central and bilateral canal decompression using the hinge osteotomy technique. A mean of 2 segments (range 2-4) was decompressed. All patients were followed up for a minimum of three years. Five outcome measures were used: visual analogue scale for leg pain, Likert scale for functional status, symptom specific well-being score, general well-being score, and ODI score. The outcome measures were recorded pre-operatively and at 6 months and 3 years post-operatively. Successful surgical outcome was defined as an improvement in at least four out of five outcome measures. Results. 108 patients (90%) had a successful surgical outcome. There was a statistically significant improvement in all outcome criteria (p< 0.001) when measured at the 6-month post-operative mark as compared to pre-operatively, with further marginal significant improvement (p< 0.05) at 3 years post-surgery. There was no evidence of progressive lumbar segmental instability at 3 years post-operatively. Conclusion. Decompression of multi-level lumbar spine stenosis using the unilateral approach with the Hinge osteotomy technique is a safe approach for multi-level stenosis, with good outcome and no evidence of significant segmental translational spinal instability

Abstract

Abstract

Objectives. Neurogenic intermittent claudication secondary to lumbar spinal stenosis is a posture dependant complaint typically affecting patients aged 50 years or older. Various treatment options exist for the management of this potentially debilitating condition. Non-surgical treatments: activity modification, exercise, NSAIDs, epidural injections. Surgical treatment options include decompression surgery and interspinous process device surgery. Interspinous process decompression is a relatively new, minimally invasive, stand-alone alternative to conservative and standard surgical decompressive treatments. The aim of this review is to evaluate the use of the X-Stop interspinous implant in all patients with spinal stenosis who were managed using the device in Northern Ireland up to June 2009. Method. We performed a retrospective review of all patients who had the X-Stop device inserted for spinal stenosis by all consultant spinal surgeons in Northern Ireland. Patient demographics, clinical symptomatology, investigative modality, post-operative quality of life, cost effectiveness, complications and long-term outcomes were assessed. Information was collected from patients using a questionnaire which was posted to them, containing the SF-36 generic questionnaire and some additional questions. Results. A total of 23 patients underwent X-stop insertion in Northern Ireland at the time of this review, 19 patients returned their questionnaires and of these 17 were completed in full and therefore included. The mean age of the study population was 60.1 years and all patients included in the study had symptoms of neurogenic claudication secondary to lumbar spinal stenosis confirmed on MRI scan. The average hospital stay was 1.5 days compared to 7.5 days for decompressive laminectomy patients. Also, at a mean follow-up of 17.8 months, 2 patients suffered direct complications of device insertion requiring removal of the implant both of these patients agreed that they would undergo the operation again in the future. SF-36 scores indicate a quality of life improvement which equates to that of other popular orthopaedic operations such as total hip and total knee replacement. X-stop insertion has been shown to be much more cost-effective than decompressive laminectomy in previous studies. Conclusion. Decompression of the lumbar spine with the X-stop interspinous implant device is safe, cost-effective, minimally invasive, and at least as effective at improving symptomatology from lumbar spinal stenosis. It is obviously more invasive than non-surgical techniques, but is less invasive than lumbar decompression procedures, is less destructive to surrounding tissues and if it fails to produce the desired results can be removed easily and the option remains for the patient to under decompression

We undertook this study to investigate the outcomes of surgical treatment for acute carpal tunnel syndrome following our protocol for concurrent nerve decompression and skeletal stabilization for bony wrist trauma to be undertaken within 48-hours.

We identified all patients treated at our trauma centre following this protocol between 1 January 2014 and 31 December 2019. All patients were clinically reviewed at least 12 months following surgery and assessed using the Brief Michigan Hand Outcomes Questionnaire (bMHQ), the Boston Carpal Tunnel Questionnaire (BCTQ) and sensory assessment with Semmes-Weinstein monofilament testing.

The study group was made up of 35 patients. Thirty-three patients were treated within 36-hours. Patients treated with our unit protocol for early surgery comprising nerve decompression and bony stabilization within 36-hours, report excellent outcomes at medium term follow up.

We propose that nerve decompression and bony surgical stabilization should be undertaken as soon as practically possible once the diagnosis is made. This is emergent treatment to protect and preserve nerve function. In our experience, the vast majority of patients were treated within 24-hours.

Spinal tuberculosis is one of the most common presentations of skeletal tuberculosis. It is one of the major health issues of developing countries as it is associated with significant morbidity and mortality. Pott's paraplegia is a dreaded complication which can result in permanent neurological deficit, unless treated by timely intervention. We evaluated the efficacy of transpedicular decompression and functional recovery in patients of spinal tuberculosis with neurological deficit.

A cohort of 23 patients (15 males and 8 female) with diagnosed spinal tuberculosis and having an average age of 37.5±8.4 years, satisfying our inclusion and exclusion criteria's and giving written informed consent were recruited in our study. All patients were managed by transpedicular decompression and fusion with posterior instrumentation. All the patients were followed up clinically, radiologically and hematologically. Patients were followed up at every six weeks for 4 months and thereafter at three monthly intervals to assess the long term outcomes and complications. Neurological evaluation was done by Frankel grading. Functional outcome was assessed by Visual Analog Score (VAS) and Owestry Disability Index score (ODI score).

All the patients were followed for a minimum of 27 months. At the final follow-up, there was a statistically significant improvement in VAS score and ODI score. Out of 23 patients, all except three patients showed neurological recovery.

We observed that transpedicular decompression is safe and effective approach for management of spinal tuberculosis as it allows adequate decompression of spinal cord while pedicular instrumentation provides stable spinal fixation and helps in early rehabilitation.

Introduction

Aim was to compare the functional outcome of anterior cervical decompression and fusion (ACDF) with stand-alone tricotical iliac crest auto graft verses stand-alone PEEK cage.

Introduction

Aim was to compare the functional outcome of anterior cervical decompression and fusion (ACDF) with stand-alone tricotical iliac crest auto graft verses stand-alone PEEK cage.

To compare the efficacy of local steroid injection with surgical decompression in treatment of carpal tunnel syndrome (CTS) in terms of frequency of pain.

This randomized controlled study was conducted at the Department of Orthopaedics for a duration of 01 year, i.e. from 20th April 2016 to 19th April 2017. 130 patients with carpal tunnel syndrome with moderate (Grade 2) and severe (Grade 3) pain were included. Lottery method was used to allocate the patients randomly into two groups. Group A contained 65 patients who were subjected to surgical decompression and 65 patients were in Group B who were injected with local steroid injection. Complete history was obtained from all patients. All the surgical decompressions through mini incision technique and injections procedures were performed. Information were recorded in a pre designed Performa.

Efficacy was observed significantly high in group B as compared to group A (87.7% vs. 72.3%, p=0.028).

Carpal Tunnel syndrome symptoms were alleviated with surgical decompression as well as local steroid injection at a follow up done after 1 month. However the steroid injections seem to have greater efficacy than surgical decompression, hence we suggest it for routine treatment of all patients with CTS.

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Background

Core decompression (CD) is effective to relieve pain and delay the advent of total hip arthroplasty (THA) for osteonecrosis of the femoral head (ONFH). However, the influence of CD on the subsequent THA has not been determined yet.

Introduction

The purpose of this study was to assess the rate of revision subacromial decompression and identify different pathologies.

Introduction

Only a few studies have assessed the outcome of ulnar nerve decompression, most comparing various forms of decompression. A review of the case notes of patients undergone ulnar nerve decompressions was undertaken looking at the pre-op symptoms, nerve conduction studies, the co-morbidities, operative procedures and the post-operative outcomes.

Aim

To evaluate efficacy of a one stage posterior approach in decompression and eradication of infection in TB spine.

Introduction

Anterior reconstruction has the advantage of conferring immediate stability to the cervico-thoracic junction

Introduction

Anterior cervical decompression and fusion (ACDF) is considered a standard surgical treatment to degenerative discogenic diseases. Lately, the question arises whether or not ACDF significantly influences the progression of adjacent disc degeneration (ADD). The etiology of ADD is obscure and it has not been fully understood whether ADD is a consequence of fusion or it represents the aging pathway of the degenerative cervical process, thus making it a controversial topic [1-3]. There have been several discussions about the possibility of ACDF altering biomechanical conditions at adjacent segments, therefore resulting in increased load and excessive motion [3,4]. The purpose of this study was to compare the cervical segmental motion pre- and post-ACDF using novel 3D analytical techniques.

Although patient-reported outcomes (PROs) have become increasingly important in the evaluation of spine surgery patients, interpretability may be limited by a patient's ability to recall pre-intervention impairment. The accuracy of patient recall of preoperative back pain, leg pain, and disability after spine surgery remains unknown. We sought to characterise the accuracy of patient recall of preoperative symptoms in a cohort of lumbar spine surgery patients.

We analysed consecutive patients undergoing lumbar decompression or decompression and fusion for lumbar radiculopathy by a single surgeon over a four-year period. Using standardised questionnaires, we recorded back and leg numeric pain scores (NPS) and Oswestry Disability Indices (ODI) preoperatively and asked patients to recall their preoperative status at a minimum of one-year following surgery. We then statistically compared and characterised patient recall of their pre-operative status and their actual pre-operative status. Patients with incomplete follow up or diagnoses other than degenerative lumbar stenosis were excluded.

Sixty-seven patients with a mean age of 66.1 years (55% female) were included in the final analysis. All cases were either posterior or combined anterior/ posterior procedures. Mean levels of surgery was 1.7 and 93.8% of all cases were instrumented. Mean duration of preoperative symptoms was 44.5 months (3.7 years). Preoperative vs postoperative PROs improved with regards to NPS back (5.2 vs 2.2, p= to 2 point difference), exceeding the minimal clinical important difference (MCID) for NPS. This pattern was maintained across age, gender, and duration of preoperative symptoms. We also observed cases of symptom minimisation recall bias, and cases in which back and leg pain predominance were switched in severity during recall bias.

Significant recall bias of preoperative symptoms exists in patients undergoing spine surgery, potentially limiting accurate assessment and interpretation of PROs. An understanding of PROs and their limitations is essential to assess treatment efficacy of spinal procedures.

Introduction

Whiplash injury following rear shunt Road traffic accident (RTA) has been associated with impingement syndrome of shoulder. However, the results of arthroscopic subacromial decompression (ASAD) for this group of patients have never been compared to the non accident group. In our study we aim to compare the results of ASAD in these patients to a group who did not sustain whiplash injury.