Introduction. Ulnar nerve entrapment is the second most common nerve entrapment syndrome of the upper extremity. Despite this, only a few studies have assessed the outcome of ulnar nerve decompression. The objectives of the study were to review the pre-operative symptoms, nerve conduction studies, the co-morbidities, operative procedures undertaken and the post-operative outcomes; and investigate and ascertain prognostic factors particularly in cases of persistence of symptoms after the surgery. Methods. We reviewed the case notes of ulnar nerve decompressions surgery performed over a period of six year period. A structured proforma was created to document the demographics, patient complaints, method of decompression, per-operative findings and symptom status at the last follow up. Outcome grading was recorded as completely relieved, improved, unchanged or worse. Analysis of data was carried out using the SPSS software (Version 16.0; Illinois). The significance level was set at 5%. Results. 136 ulnar nerve decompressions formed the study group. Minimum follow-up was three months. Numbness and paresthesia in ulnar distribution were the two most common presenting symptoms (96%). The cause of compression was identified as idiopathic in 58.2%; flexor carpi ulnaris aponeurosis in 36.7% and Arcade of Stuthers in 5.1% extremities. The outcome was satisfactory in 85.2% of patients. No obvious association was demonstrated between the outcome of surgery and duration of symptoms, presence of co-morbidities or the type of surgery performed. Interestingly out of 12 patients who got worse or had no improvement, nine (75%) had either normal nerve conduction studies or none done pre-operatively. Conclusion. This is the largest review of outcomes after ulnar nerve decompressions at elbow. The study showed that good results (85.2%) of ulnar nerve decompression at elbow in majority of patients regardless of level of surgeon's experience or procedure undertaken

Introduction. Cubital Tunnel syndrome is common affecting 1 in 4000 people. The cubital tunnel serves as major constraint for the ulna nerve. Cubital tunnel decompression is a relatively simple operation to resolve the patients' symptoms. There has been published data on return to work and normal activity after carpal tunnel decompression but not cubital tunnel. Method. All patients who underwent cubital tunnel decompression in Wirral University Teaching Hospital NHS Foundation Trust between September 2006 and September 2010 were identified and sent a questionnaire; enquiring about age, type of job & if it involved heavy lifting, time off work, range of movement at elbow and hand and if their symptoms resolved or if they had any other complications. Results. 106 cubital tunnels were decompressed in the 4 year period. 66 patients returned the questionnaire (62% response). The average age at operation was 59 years (32–86years). The average time to return to work after surgery was 10 days (0–300days). Complications included painful scar, return of symptoms and chronic region pain syndrome, which lead the patient to change jobs (300days). Only one patient was self-employed, they had no time off work. In 24 patients (36%) their symptoms either never resolved or returned, only worsening in 2 patientsstopping them returning to work their heavy manual jobs. The DASH score (work modules) post operatively was 38.3 over all working groups; this was lower in patients who didn't have a manual job. Conclusion. Our patients, returned to work at around 10 days after surgery. People with jobs which involved no heavy lifting returned at 5 days compared to that of 40 days, in patients with manual jobs. Now we can give our patients more accurate information about how long it will take them to return to work, depending on their job type

Introduction. MRI imaging is carried out to identify levels of degenerative disc disease, and in some cases to identify a definite surgical target at which decompression should take place. We wanted to see if repeat MRI scans due to a prolonged time between the initial diagnostic MRI scan of the lumbar sacral spine, and the MRI scan immediately pre-operatively, due for the desire for a ‘fresh’ MRI scan pre-operatively, altered the level or type of procedure that they would have. Methods. This was a retrospective observational cohort study. Inclusion criteria- all patients with more than one MRI scan before their surgical procedure on the lumbar sacral spine, these were limited to patients that had either, discectomy, microdiscectomy, laminotomy decompression, laminectomy decompression and fusion, and posterior lumbar interbody fusion. Exclusion criteria- all patients with anterior approaches, all patients without decompression and all non lumbar sacral patients. Outcome measures were if there was a change between the pre-operative MRI scans, which would have changed the operative level of decompression, added other levels of decompression or type of surgery than primarily decided. Results. 84 patients were identified with our inclusion criteria with two or more pre-operative MRI scans. The repeat MRI did not change the surgical target for all 84 patients. Conclusion. Repeat MRI scanning does not alter the surgical target level, and therefore does not change management. It can delay the initial primary procedure which can lead to progressive neurology, which may be irreversible and should be avoided unless the distribution of neurology has changed

Introduction. Chronic Achilles tendinopathy is a common overuse injury. There are several modalities of treatment, reflecting difficulties in its management. In particular, due to the well-recognised morbidity associated with surgical decompression, treatment has steered towards a less invasive route. Dry needling has been efficacious in managing other tendinopathies. This study therefore assessed dry needling and percutaneous hydrostatic decompression of the Achilles tendon as a novel treatment for this condition. Methods. Twenty-two patients with 27 sonographically-confirmed chronic Achilles tendinopathy were prospectively enrolled. All were symptomatic for >6 months and have failed alternative conservative treatments. Ultrasound-guided dry needling of neovascular areas and paratenon hydrostatic decompression was performed by a dedicated musculoskeletal radiologist on a 6-weekly basis until symptomatic resolution or no improvement was evident. Sonographic assessment of the tendon's thickness and neovascularity was undertaken. Following treatment, a standardized physiotherapy regime was adopted. At baseline and 6 weeks post-final procedure, visual analogue scores (VAS) at rest and during activity were obtained. Telephonic interviews were carried out 12 and 24 months post-treatment. Results. 24 tendons (in 19 patients) were successfully treated - 1 patient had spontaneous symptomatic resolution and 2 progressed to surgical intervention. The mean number of treatment sessions was 2. There was no significant change in neovascularity or tendon thickness after treatment. Therapeutic intervention led to a significant improvement in VAS at rest (42 v 18.4, p=0.0005) and during activity (74 v 33.7, p< 0.0001). At 12 months, 77% of patients were >80% satisfied with their outcome of the procedure, with 85% of patients able to return to their sporting interests. At 24 months, 90% of patients were >80% satisfied with their outcome, with nearly half having complete symptomatic resolution. Conclusion. Dry needling and percutaneous paratenon decompression under ultrasound guidance shows promise as an alternative treatment for this chronic condition

We obtained approval from the local research and ethics committee and prospectively evaluated the incidence of Deep vein thrombosis (DVT) in arthroscopic shoulder sub acromial decompression in 72 patients. All patients were assessed clinically for DVT risks as per the established guidelines. Patients with previous history of DVT, those on anticoagulants and those positive for DVT on pre op scans were excluded from the study. All patients had doppler scans on 4 limbs performed by a single consultant radiologist at an average of 4 weeks pre and post operative period. All operations were performed by a single surgeon under GA in beach chair position with routine precautions for DVT, as a day case procedure. Arthroscopy and additional procedures were performed on standard lines. Postoperatively the shoulder was immobilised in a sling for comfort and physiotherapy was supervised by a qualified therapist. Demographic data, co-morbidities, patient position, ASA risk, nerve blocks, surgery duration, medications, intra operative findings, were documented. No patient received any DVT prophylaxis. All patients were available for followup and clinical and doppler findings were documented at an average 4 week period. 3 patients had bilateral procedures. There were 38 female and 34 male patients with an average age of 54.6 years. 47 were classified as ASA1, 15 as ASA2 and 10 ASA 3. Common co morbidities included hypertension, diabetes, acid peptic disease in 34 patients. 37 patients had additional interscalene nerve blocks for pain relief. The average operating time was 52 mins. Additional procedures included excision of lateral clavicle in 32, glenoid labral and rotator cuff debridement in 12 and 14 patients. There were no DVT's on all doppler scans. Shoulder arthroscopic sub acromial decompression procedures do not carry a risk of DVT and routine thromboprohylaxis is not required even in higher anaesthetic risk patients

Purpose of study. This RCT is to determine whether or not there is a clinical benefit from inserting a dynamic stabilising implant such as the Wallis ligament on the functional recovery of patients who have undergone lumbar decompression surgery. This Interspinous implant was developed as an anatomically conserving procedure without recourse to lumbar spinal fusion surgery. The biomechanical studies have shown that unloading the disc and facet joints reduces intradiscal pressures at same and adjacent levels. The aim of this study was to identify a patential Wallis affect. Methods. Ethicallly approved. Patients were randomized into 2 groups, decompression alone or decompression with wallis interspinous ligament stabilisation. Patients were assessed pre operatively and post operatively every 6 months by VAS pain score and Oswestry Disability Index. Summary of findings. A total of 60 patients were recriuted the study from October 2005. Equal number had been randomized into two groups. The mean age of 54 (24–85) and the average follow is 36 months (6–48). The results were significantly better in decompression plus Wallis group compared to decompression alone, showing a minimal clinical difference compared to the control group. Relationship between findings and existing knowledge: Our results deomonstrate that clincial outcomes are significantly better when a Wallis implant was used in lumbar deompression. Patients experienced less back pain. Overall significance of findings: The Wallis implant represents a successful non fusion stabilisation device in the treatment of degenerative lumbar spine disease with canal stenosis. Minimal soft tissue dissection, quick rehabilitation, low morbidity. The Wallis ligament sucessfully treats spinal stenosis by reducing pain score, preserving mobility, and function

Background. Foraminal stenosis is often encountered in patients undergoing decompression for spinal stenosis. Given the increased resection of facets and the presence of the more sensitive dorsal root ganglion, it is hypothesized that patients with foraminal stenosis have poorer postoperative outcomes. Methods. Thirty-one patients undergoing decompression without fusion for lumbar spinal stenosis were evaluated. The degree of foraminal stenosis was determined by 2 independent reviewers for absence of fat around the nerve roots. ImageJ digital imaging software was also used to evaluate the foraminal area. Patients with foraminal stenosis were compared with those without using the Oswestry Disability Index (ODI) and a numerical pain scale for back and leg pain at a minimum of 1 year follow-up. Results. Twenty patients in the foraminal stenosis group were compared with 11 without foraminal stenosis. There were no significant differences between the 2 groups regarding age, sex, comorbidities, number of levels operated on, preoperative ODI, back pain or leg pain scores. The foraminal area was significantly smaller in the foraminal stenosis group. Patients without foraminal stenosis reported significant improvements in ODI (mean 26.0), back pain (mean 3.1) and leg pain scores (mean 5.5). Patients with foraminal stenosis reported significant improvements in ODI (mean 18.8) and leg pain (mean 2.5) but not in back pain (mean 0.3). Comparing the 2 groups, the patients with foraminal stenosis had significantly less improvement in back pain (p = 0.02) and leg pain (p = 0.02). Conclusion. The results of this study suggest that presence of foraminal stenosis is a negative predictor for successful outcome following decompression surgery. This may be related to the increased instability that occurs when a foraminotomy is required. Spinal fusion may reduce this effect, and further study is required. NO DISCLOSURES

Background. Several orthopaedic studies have found significant correlation between pre-operative psychological status and post-operative outcomes. The majority of research has focused on patients requiring lower limb and spine surgery. Few studies have investigated the effect of psychological status on the outcome of upper limb operations. We prospectively investigated the association between pre-operative psychological status and early postoperative shoulder pain and function in patients requiring arthroscopic subacromial decompression (ASAD) for impingement syndrome. Methods. A consecutive series of patients in 2009/10 completed questionnaires 2 weeks pre-operatively and 3 and 6 weeks post-operatively that assessed psychological state, shoulder function and pain. The hospital anxiety and depression scale, the Oxford shoulder score and a pain visual analogue scale assessed psychological status, shoulder function and shoulder pain, respectively. Data was analysed using non-parametric statistical methods. Results. Thirty-one patients participated (21 women; 10 men; mean age 54.6 years; age range 21–89 years). Preoperative anxiety was significantly associated with pre-operative shoulder pain (P < 0.05). Pre-operative psychological status did not correlate with post-operative shoulder pain or function. Greater pre-operative anxiety and depression were significantly associated with post-operative psychological distress (P < 0.05). Overall shoulder pain, function and psychological state improved significantly during the study (P < 0.05) regardless of pre-operative psychological status. Conclusion. Despite pre-operative associations between anxiety and shoulder pain, there were no associations between pre-operative psychological status and post-operative outcomes. Our results from a total of 31 patients suggest there is no justification for routinely assessing psychological status in patients with ‘uncomplicated’ impingement syndromes that require ASAD. The majority of patients benefit from ASAD both physically and psychologically regardless of psychological state. Therefore abnormal pre-operative psychological status should not be a justifiable reason for delaying or denying this effective operation

Introduction

Health Economists in Denmark have recently reported low and delayed return to work for patients treated for Sub-Acromial Impingement syndrome (SAIS) by Arthroscopic Sub-Acromial Decompression (ASAD). Surgeons however are reporting that patients achieve good pain relief and a high standard of activities of daily living (ADL) after surgery.

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

Abstract. Background. Elderly patients with degenerative lumbar disease are increasingly undergoing posterior lumbar decompression without instrumented stabilisation. There is a paucity of studies examining clinical outcomes, morbidity & mortality associated with this procedure in this population. Methods. A retrospective analysis of aged 80–100 years who underwent posterior lumbar decompression without instrumented stabilisation at University Hospitals of Derby &Burton between 2016–2020. Results. Total 167 eligible patients, 163 octogenarians & 4 nonagenarians. Mean age was 82.78 ± 3.07 years. Mean length of hospital stay 4.79 ± 10.92 days. 76% were pain free at 3months following decompression. The average Charleston co-morbidity index (CCI) was 4.87. No association found with CCI in predicting mortality (ODD ratio 0.916, CI95%). 17patients suffered complications; dural tear (0.017%), post-op paralysis (0.017%), SSI(0.01%), and 0.001% of hospital acquired pneumonia, delirium, TIA, urinary retention, ileus, anaemia. High BMI (35+) was associated with increased incidence of complication (CI 95%, p<0.002). There was significant social drift following discharge as 147 patients went home and 4 patients to rehabilitation facility (p<0.001FE test). The mean operative time was 91.408±41.17 mins and mean anaesthetic time was 36.8±16.06 mins. Prolonged operative time was not associated with increased mortality.2year revision decompression rate was 0.011%. Conclusion. Posterior lumbar decompression without instrumented stablisation in elderly is safe & associated with low mortality with 99.5%survival at 1 year. It significantly improves PROMs & has extremely low revision rate. Incidence of post-op complication is <0.05% and 54% of patients get discharged within 72hours of surgery. Careful selection & optimising patients with high BMI would reduced perioperative morbidity and mortality

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

Sacral fractures are often underdiagnosed, but are frequent in the setting of pelvic ring injuries. They are mostly caused by high velocity injuries or they can be pathological in aetiology. We sought to assess the clinical outcomes of the surgically treated unstable sacral fractures, with or without neurological deficits. unstable sacral fractures were included in the study. Single centre, prospectively collected data, retrospective review of patients who sustained vertically unstable fractures of the sacrum who underwent surgical fixation. out of a total of 432 patients with pelvis and acetabulum injuries. fifty six patients met the inclusion criteria. 18 patients had sustained zone one injuries. 14 patients had zone 2 injuries and 10 patients had zone 3 injurie. Operative fixation was performed percutaneously using cannulated screws in 18 patients.. Open fixation of the sacrum using the anterior approach in 6 patients. Posterior approach was indicates in all 10 of the zone 3 injuries of the sacrum. While in 4 patients, combined approaches were used. 3 patients had decompression and spinopelvic fixation. Neurological deficits were present in 16% of the patients. 2 patients presented with neurgenic bladder. Of the 4 patients who had neurological fall out, 3 resolved with posterior decompression and posterior fixation. All 4 neurological deficits were due to taction or compression of the nerve roots. No hardware failures or non unions observed. The rate of neurological deficit was related more to the degree of pelvic ring instability than to a particular fracture pattern. Low rates of complications and successful surgical treatment of sacral fractures is achiavable. Timeous accurate diagnosis mandatory

Abstract. Introduction. There is paucity of evidence in predicting outcomes following cervical decompression in patients in octogenerians with cervical myelopathy. Our aim is to analyse the predictive value of Charlson comorbidity index (CCI) on clinical outcomes in this group. Methods. All patients age >80 years who underwent cervical decompression+/−stabilisation between January 2006-December 2021 at University Hospitals of Derby & Burton were included. Logistic regression analysis was performed using JASP. Results. Total 72 patients (n=32 male, n=28 female). Mean age 83.44 ± 3.21 years. 67 patients underwent posterior decompression+ stabilisation & 5 patients had posterior decompression alone. Mean CCI was 5; graded moderate in 32 (44%, CCI=<4) and severe in 40 (55.5%, CCI>4). Mean age and preoperative Nurick grade was similar between moderate and severe groups. Postoperative Nurick grade improved equally in both groups by 0.67 and 0.68 respectively (p=0.403). Mean LOS 16±16.12 days. 5 complications in the moderate group (21.8%) and 8 complications in severe group (21.6%); wound infection (n=7), other infection (n=2), electrolyte derangement (n=2), AKI (n=1), blood transfusion (n=1) and early death (n=3) (p=0.752). 1 early postoperative death <30 days occurred in the moderate group (4.3%) whereas 2 occurred in the severe group (5.3%) (p=0.984). No patients with moderate CCI required nursing home discharge whereas 7.9% of severe patients required this. Conclusion. Both groups benefitted from neurological improvement postoperatively, low 1 year mortality. No difference in hospital stay, complication rate and early mortality between both groups. More patients with severe CCI require nursing care after discharge than those with moderate CCI

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. Methods. Data were obtained from electronic searches of five online databases. Included studies were limited to randomised-controlled trials (RCTs) which compared DA with DF or IPD using patient-reported outcomes such as the Oswestry Disability Index (ODI) and Zurich Claudication Questionnaire (ZCQ), or perioperative data. Patient-reported data were reported as part of the systematic review, while meta-analyses were conducted for perioperative outcomes in MATLAB using the DerSimonian and Laird random-effects model. Forest plots were generated for visual interpretation, while heterogeneity was assessed using the I. 2. -statistic. Results. A total of 13 articles met the eligibility criteria. Of these, eight compared DA with DF and six studies compared DA with IPD. Patient-rated outcomes reported included the ODI and ZCQ, with mixed results for both types of comparisons. Overall, there were few statistically significant and no clinically significant differences in patient-rated outcomes. Study quality varied greatly across the included articles. Meta-analysis of perioperative outcomes revealed DF to result in greater blood loss than DA (MD = 406.74 ml); longer operation duration (MD = 108.91 min); and longer postoperative stay in hospital (MD = 2.84 days). Use of IPD in comparison to DA led to slightly reduced operation times (MD = –25.18 min), but a greater risk of reoperation compared to DA (RR = 2.70). Conclusion. Currently there is no evidence for the use of DF or IPD over DA in both patient-rated and perioperative outcomes. Indeed, both procedures can potentially lead to greater cost and risk of complications, and therefore, a stronger evidence base for their use should be established before they are promoted as routine options in patients with degenerative spondylolisthesis

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

Spine surgery is common and costly. Researchers and policy makers believe that utilization of spine surgery in the US is significantly higher than in other industrialized countries. Although within-country variation in spine surgery utilization is well studied, there has been little exploration of variation in spine surgery between countries. We used population level administrative data from Ontario (years 2011–2015) and New York (2011–2014) to identify all adults who underwent inpatient spinal decompression or fusion surgery. We compared Ontario and New York with respect to patient demographics and the percentage of hospitals performing spine surgery. We compared rates of decompression and fusion surgery (procedures per-10,000 population per-year) in Ontario and New York for all procedures, emergent procedures alone, and elective procedures and after stratifying by patient age. Patients in Ontario were older than patients in New York for decompression (mean age 58.8 vs. 51.3 years, P<.001) and fusion (58.1 vs. 54.9, P<.001). A smaller percentage of hospitals in Ontario performed decompression or fusion compared to New York (decompression, 26.1% in Ontario vs 54.9% in New York: fusion 15.2% vs 56.7%, both P<.001). Overall, utilization of spine surgery in Ontario was 6.6 procedures per-10,000 population per-year and in New York was 18 per-10,000 per-year (P<.001). Ontario-New York differences in utilization were small for emergent cases (2 per-10,000 in Ontario vs. 2.8 in New York, P<.001), but large for elective cases (4.6 vs 15.2, P<.001). In analyses stratified by surgical subtype, differences in utilization of decompression in New York and Ontario were relatively modest (2.4 vs 3.1, P<.001), while utilization of fusion was approximately 400% higher in New York than Ontario (15.7 vs 3.5, P<.001). Further analysis demonstrated that the New York-Ontario difference in utilization was substantially larger among younger patients and smaller for older patients. For example, utilization of spine procedures in New York was 340% greater than Ontario for patients less-than 50 years of age (11.7 vs 3.4), but only 25% greater in patients age 80 and above (10 vs 12.6). After adjusting for patient demographics, hospital LOS and surgical urgency, differences in mortality in Ontario and New York were not significant for either decompression or fusion. In adjusted analyses differences in hospital LOS were slightly greater for decompression in Ontario, but similar for fusion and readmission rates in Ontario were significantly lower than in New York. In conclusion, we found significantly lower utilization of spine surgery in Ontario when compared to New York. The difference in utilization was attributable to less elective fusion surgery, primarily in younger (i.e. non-Medicare) patients. These findings can serve inform broader spine surgery policy reforms in both jurisdictions

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. For any reader queries, please contact . virgo_r24@hotmail.com

Abstract. Objective. Radial to axillary nerve and spinal accessory (XI) to suprascapular nerve (SSN) transfers are standard procedures to restore function after C5 brachial plexus dysfunction. The anterior approach to the SSN may miss concomitant pathology at the suprascapular notch and sacrifices lateral trapezius function, resulting in poor restoration of shoulder external rotation. A posterior approach allows decompression and visualisation of the SSN at the notch and distal coaptation of the medial XI branch. The medial triceps has a double fascicle structure that may be coapted to both the anterior and posterior division of the axillary nerve, whilst preserving the stabilising effect of the long head of triceps at the glenohumeral joint. Reinnervation of two shoulder abductors and two external rotators may confer advantages over previous approaches with improved external rotation range of motion and strength. Methods. Review of the clinical outcomes of 22 patients who underwent a double nerve transfer from XI and radial nerves. Motor strength was evaluated using the MRC scale and grade 4 was defined as the threshold for success. Results. 18/22 patients had adequate follow-up (Mean: 29.5 months). Of these, 72.2% achieved ≥grade 4 power of shoulder abduction and a mean range of motion of 103°. 64.7% achieved ≥grade 4 external rotation with a mean range of motion of 99.6°. Conclusions. The results suggest the use of the combined nerve transfer for restoration of shoulder function via a posterior approach, involving the medial head branch of triceps to the axillary nerve and the XI to SSN

The primary objective is to compare revision rates for lumbar disc replacement (LDR) and fusion at the same or adjacent levels in Ontario, Canada. The secondary objectives include acute complications during hospitalization and in 30 days, and length of hospital stay. A population-based cohort study was conducted using health administrative databases including patients undergoing LDR or single level fusion between October 2005 to March 2018. Patients receiving LDR or fusion were identified using physician claims recorded in the Ontario Health Insurance Program database. Additional details of surgical procedure were obtained from the Canadian Institute for Health Information hospital discharge abstract. Primary outcome measured was presence of revision surgery in the lumbar spine defined as operation greater than 30 days from index procedure. Secondary outcomes were immediate/ acute complications within the first 30 days of index operation. A total of 42,024 patients were included. Mean follow up in the LDR and fusion groups were 2943 and 2301 days, respectively. The rates of revision surgery at the same or adjacent levels were 4.7% in the LDR group and 11.1% in the fusion group (P=.003). Multivariate analysis identified risk factors for revision surgery as being female, hypertension, and lower surgeon volume. More patients in the fusion group had dural tears (p<.001), while the LDR group had more “other” complications (p=.037). The LDR group had a longer mean hospital stay (p=.018). In this study population, the LDR group had lower rates of revision compared to the fusion group. Caution is needed in concluding its significance due to lack of clinical variables and possible differences in indications between LDR and posterior decompression and fusion