A Survey on the Short-term Outcome of Microlumbar Discectomy with General versus Spinal Anesthesia

BACKGROUND: Surgery on the lower thoracic and lumbosacral spine is possible with both general and spinal anesthesia, but most spine surgeons are reluctant to perform the surgery with spinal anesthesia. We aimed to conduct a survey on the short-term outcome of microlumbar discectomy in the patients who had been treated under general or spinal anesthesia. METHODS: In this prospective study, we performed a survey on 72 patients who underwent microlumbar discectomy under general anesthesia (group A) or spinal anesthesia (group B). Demographic characteristics, American Society of Anesthesiologists physical status, duration of operation, blood loss, and complications were all documented. Preoperative and early postoperative (at the time of discharge) disability and pain were assessed by using Japanese Orthopedic Association (JOA) scoring system and a visual analog scale questionnaire. RESULTS: The two groups were homogenous preoperatively. The mean intraoperative blood loss was less and the mean operating time was shorter in group A than in group B, but there was no statistically significant difference between groups. The rate of postoperative improvement in JOA score and improvement in pain were similar between groups. Anesthetic complications were unremarkable. CONCLUSIONS: Simple lumbar disc operations in the otherwise healthy patients can be safely performed under either spinal or general anesthesia. Both anesthetic methods led to comparable outcomes with minimal complications.

A Survey on Low Back Pain Risk Factors in Steel Industry Workers in 2015

STUDY DESIGN: This was a cross-sectional study. PURPOSE: The aim of this study was to determine the prevalence of low back pain (LBP) and its association with individual factors and current job status among steel industry workers in Mashhad, Iran. OVERVIEW OF LITERATURE: Several studies have been conducted on LBP and its related risk factors, some of which emphasized oc-cupational factors as the main etiology of LBP. Meanwhile, individual risk factors have been emphasized in other studies. Despite several published articles, there are still many unresolved, basic issues about developing LBP. METHODS: For this study, 358 male workers were selected by a random sampling method and divided into two groups: production workers (n=201) and administrative personnel (n=157). Data were collected using modified Nordic questionnaire and physical examination. Statistical analysis was performed to identify the correlation between individual factors and current job status with LBP. RESULTS: Despite the young age of participants and their short employment duration, the overall prevalence of LBP was high (32.4%) in this industry. The prevalence of non-specific LBP in production workers and administrative personnel was 26.8% and 21.0%, respectively. Disk herniation was observed in 10.4% of production workers and 6.3% of administrative personnel. Age, employment duration, body mass index and smoking status were similar in the two groups. There was no significant relationship between LBP and current job status; however, a significant relationship was found between prevalence of LBP with age, duration of employment, and leisure time physical activity (p<0.05). CONCLUSIONS: We have not found any relationship between LBP and current occupational status suggesting that the effects of general health-related factors such as weight, age, leisure time physical activity, and duration of employment are more important than occupational factors in developing LBP.

Ten Important Tips in Treating a Patient with Lumbar Disc Herniation

Lumbar disc herniation is a common spinal disorder that usually responds favorably to conservative treatment. In a small percentage of the patients, surgical decompression is necessary. Even though lumbar discectomy constitutes the most common and easiest spine surgery globally, adverse or even catastrophic events can occur. Appropriate patient selection and effective neural decompression constitute the most important points for better surgical outcomes and avoidance of unpleasant complications. Other important tips include timely performance of magnetic resonance imaging, correct interpretation of scan data, preoperative detection of underlying instability, exclusion of non-discogenic sciatica, determination of the main cause of clinical pathology, avoidance of the wrong side or level, and being sure that the more detailed procedure does not necessarily mean the more effective procedure.

Failure Rate of Spine Surgeons in Preoperative Clinical Screening of Severe Psychological Disorders

BACKGROUND: The surgeon's attention to the patient's underlying psychological state is essential to attaining desired outcomes. We aimed to investigate the prevalence and severity of psychological disorders in patients undergoing elective spine surgery. METHODS: In this case-control study, associated psychological disorders were assessed using the Hospital Anxiety and Depression Scale (HADS) questionnaire at a single academic spine surgery center from August 2013 to June 2015. The case group consisted of 68 adult patients (mean age, 38.2 ± 9.6 years; male:female = 41:27) undergoing elective spine surgery and the control group included 69 healthy visitors of the orthopedic patients (mean age, 37.1 ± 6.9 years; male:female = 40:29) who voluntarily participated in the study. The 2 groups were compared for statistical analysis and a p-value < 5% was considered significance. RESULTS: There was no statistically significant intergroup difference with regard to gender and age. The incidences of abnormal anxiety and depression were the same in the case group (14 patients, 20.6%). The values were 3 (4.3%) and 5 (7.2%), respectively, in the control group, showing statistically significant difference. Any association between the severity of depression and age or sex could not be identified. CONCLUSIONS: In spite of spine surgeons' attempts to screen severe psychological disorders preoperatively, up to 21% of which cannot be diagnosed prior to elective spine surgery. Therefore, we believe the use of a questionnaire would be helpful in assessing patients' underlying psychological state before elective spine surgery.

Failure Rate of Spine Surgeons in Preoperative Clinical Screening of Severe Psychological Disorders

BACKGROUND: The surgeon's attention to the patient's underlying psychological state is essential to attaining desired outcomes. We aimed to investigate the prevalence and severity of psychological disorders in patients undergoing elective spine surgery. METHODS: In this case-control study, associated psychological disorders were assessed using the Hospital Anxiety and Depression Scale (HADS) questionnaire at a single academic spine surgery center from August 2013 to June 2015. The case group consisted of 68 adult patients (mean age, 38.2 ± 9.6 years; male:female = 41:27) undergoing elective spine surgery and the control group included 69 healthy visitors of the orthopedic patients (mean age, 37.1 ± 6.9 years; male:female = 40:29) who voluntarily participated in the study. The 2 groups were compared for statistical analysis and a p-value < 5% was considered significance. RESULTS: There was no statistically significant intergroup difference with regard to gender and age. The incidences of abnormal anxiety and depression were the same in the case group (14 patients, 20.6%). The values were 3 (4.3%) and 5 (7.2%), respectively, in the control group, showing statistically significant difference. Any association between the severity of depression and age or sex could not be identified. CONCLUSIONS: In spite of spine surgeons' attempts to screen severe psychological disorders preoperatively, up to 21% of which cannot be diagnosed prior to elective spine surgery. Therefore, we believe the use of a questionnaire would be helpful in assessing patients' underlying psychological state before elective spine surgery.

Surgical outcome of reduction and instrumented fusion in lumbar degenerative spondylolisthesis

Background: Lumbar degenerative spondylolisthesis [LDS] is a degenerative slippage of the lumbar vertebrae. We aimed to evaluate the surgical outcome of degenerative spondylolisthesis with neural decompression, pedicular screw fixation, reduction, and posterolateral fusion

Methods: This before-after study was carried out on 45 patients [37 female and 8 male] with LDS operated from August 2008 to January 2011. The patients' pain and disability were assessed by visual analogue scale [VAS] and Oswestry disability index [ODI] questionnaire. In surgery, we applied distraction force to facilitate slip reduction. All the intra- and postoperative complications were recorded. The paired t-test and Pearson correlation coefficient were used for statistical analysis

Results: The mean age of patients and mean follow-up period were 58.3 +/- 3.5 years and 31.2 +/- 4.8 months, respectively. The mean slip correction rate was 52.2% with a mean correction loss of 4.8%. Preoperative VAS and ODI improved from 8.8 and 71.6 to postoperative 2.1 and 28.7, respectively. Clinical improvement was more prominent in more reduced patients, but Pearson coefficient could not find a significant correlation

Conclusion: Although spinal decompression with fusion and posterior instrumentation in surgical treatment of the patients with LDS result in satisfactory outcome, vertebral reduction cannot significantly enhance the clinical improvement

Radiologic and Clinical Outcomes of Surgery in High Grade Spondylolisthesis Treated with Temporary Distraction Rod

BACKGROUND: Surgical techniques used in the treatment of patients with high grade lumbar spondylolisthesis (> 50% slippage) are usually associated with a great deal of controversies. We aim to evaluate the surgical outcomes of high grade spondylolisthesis treated with an intraoperative temporary distraction rod. METHODS: We retrospectively studied 21 patients (14 females and 7 males), aged 50.4 +/- 9.2 years, who had high grade lumbar spondylolisthesis that was treated with intraoperative temporary distraction rods, neural decompression, pedicular screw fixation, and posterolateral fusion involving one more intact upper vertebra. The mean follow-up period was 39.2 months. Radiologic and clinical outcomes were measured by slip angle, slip percentage, correction rate, Oswestry Disability Index (ODI), visual analogue scale (VAS), patient's satisfaction rate in the pre- and postoperative period. Data were analyzed by SPSS ver. 11.5. RESULTS: Analysis of the preoperative visits and final follow-up visits indicated that surgery could improve ODI, lumbar VAS, and leg VAS from 60.5% to 8.2%, from 6.7 to 2.2, and from 6.9 to 1.3, respectively. Slip angle and slip percentage were also changed from -8degrees to -15degrees and from 59.2% to 21.4%, respectively. Mean correction rate at the final follow-up visit was 64.1%. Loss of correction was insignificant and a neurologic complication occurred in one patient due to misplacement of one screw. Excellent and good levels of satisfaction were observed in 90.5% of the patients. CONCLUSIONS: In the surgical treatment of refractory high grade spondylolisthesis, the use of a temporary distraction rod to reduce the slipped vertebra in combination with neural decompression, posterolateral fusion, and longer instrumentation is associated with satisfactory clinical and radiologic outcomes.

Primary epidural varicosis as a rare cause of sciatica: a case report

Non-discogenic sciatica can be caused by any lesion along the course of the lumbosacral nerve roots and sciatic nerve. We aim to present a rare case of refractory sciatica in an otherwise healthy 25-year-old man. He complained of left leg pain without significant back pain. Extensor hallucis longus muscle was weak on the left side with limited straight leg rising. On magnetic resonance imaging, a space-occupying lesion resembling a sequestrated disc was noted that after surgical decompression, epidural varicosis was demonstrated

Sciatica in a Five-Year-Old Boy

The prevalence of back pain during childhood is 50%; in 22% of these cases, a specific diagnosis can be found. Osteoid osteoma is a rare benign tumor that occursonly in 20% of cases and involves the spine. The aim of this report is to explain an atypical case of lumbar osteoid osteoma with significant neurologic deficit at a very young age. A five-year-old boy was presented with refractory pain in the low back and left extremity for approximately one year. Positive clinical findings were antalgic gait, stiff lumbar spine, weak left big toe extension force and a positive straight leg rising test on the left side. Paraclinical studies revealed osteoid osteoma in the left-sided pedicle of the fifth lumbar vertebra. With surgical excision, he recovered immediately. Lumbar osteoid osteoma should be suspected as the cause of low back pain or sciatalgia in any young patient.

Comparison of Functional Outcomes following Surgical Decompression and Posterolateral Instrumented Fusion in Single Level Low Grade Lumbar Degenerative versus Isthmic Spondylolisthesis

BACKGROUND: The two most common types of surgically treated lumbar spondylolisthesis in adults include the degenerative and isthmic types. The aim of this study was to compare the functional outcomes of surgical decompression and posterolateral instrumented fusion in patients with lumbar degenerative and isthmic spondylolisthesis. METHODS: In this retrospective study, we reviewed the clinical outcomes in surgically treated patients with single level, low grade lumbar degenerative, and isthmic spondylolisthesis (groups A and B, respectively) from August 2007 to April 2011. We tried to compare paired settings with similar initial conditions. Group A included 52 patients with a mean age of 49.2 +/- 6.1 years, and group B included 52 patients with a mean age of 47.3 +/- 7.4 years. Minimum follow-up was 24 months. The surgical procedure comprised neural decompression and posterolateral instrumented fusion. Pain and disability were assessed by a visual analog scale (VAS) and the Oswestry Disability Index (ODI), respectively. The Wilcoxon and Mann-Whitney U-tests were used to compare indices. RESULTS: The most common sites for degenerative and isthmic spondylolisthesis were at the L4-L5 (88.5%) and L5-S1 (84.6%) levels, respectively. Surgery in both groups significantly improved VAS and ODI scores. The efficacy of surgery based on subjective satisfaction rate and pain and disability improvement was similar in the degenerative and isthmic groups. Notable complications were also comparable in both groups. CONCLUSIONS: Neural decompression and posterolateral instrumented fusion significantly improved pain and disability in patients with degenerative and isthmic spondylolisthesis. The efficacy of surgery for overall subjective satisfaction rate and pain and disability improvement was similar in both groups.

Lumbar Spinal Stenosis: Who Should Be Fused? An Updated Review

Lumbar spinal stenosis (LSS) is mostly caused by osteoarthritis (spondylosis). Clinically, the symptoms of patients with LSS can be categorized into two groups; regional (low back pain, stiffness, and so on) or radicular (spinal stenosis mainly presenting as neurogenic claudication). Both of these symptoms usually improve with appropriate conservative treatment, but in refractory cases, surgical intervention is occasionally indicated. In the patients who primarily complain of radiculopathy with an underlying biomechanically stable spine, a decompression surgery alone using a less invasive technique may be sufficient. Preoperatively, with the presence of indicators such as failed back surgery syndrome (revision surgery), degenerative instability, considerable essential deformity, symptomatic spondylolysis, refractory degenerative disc disease, and adjacent segment disease, lumbar fusion is probably recommended. Intraoperatively, in cases with extensive decompression associated with a wide disc space or insufficient bone stock, fusion is preferred. Instrumentation improves the fusion rate, but it is not necessarily associated with improved recovery rate and better functional outcome.

Lumbar Spinal Stenosis: Who Should Be Fused? An Updated Review

Lumbar spinal stenosis (LSS) is mostly caused by osteoarthritis (spondylosis). Clinically, the symptoms of patients with LSS can be categorized into two groups; regional (low back pain, stiffness, and so on) or radicular (spinal stenosis mainly presenting as neurogenic claudication). Both of these symptoms usually improve with appropriate conservative treatment, but in refractory cases, surgical intervention is occasionally indicated. In the patients who primarily complain of radiculopathy with an underlying biomechanically stable spine, a decompression surgery alone using a less invasive technique may be sufficient. Preoperatively, with the presence of indicators such as failed back surgery syndrome (revision surgery), degenerative instability, considerable essential deformity, symptomatic spondylolysis, refractory degenerative disc disease, and adjacent segment disease, lumbar fusion is probably recommended. Intraoperatively, in cases with extensive decompression associated with a wide disc space or insufficient bone stock, fusion is preferred. Instrumentation improves the fusion rate, but it is not necessarily associated with improved recovery rate and better functional outcome.

Lumbar Spondylolysis and Spondylolytic Spondylolisthesis: Who Should Be Have Surgery? An Algorithmic Approach

Lumbar spondylolysis and spondylolisthesis are common spinal disorders that most of the times are incidental findings or respond favorably to conservative treatment. In a small percentage of the patients, surgical intervention becomes necessary. Because too much attention has been paid to novel surgical techniques and new modern spinal implants, some of fundamental concepts have been forgotten. Identifying that small but important number of patients with lumbar spondylolysis or spondylolisthesis who would really benefit from lumbar surgery is one of those forgotten concepts. In this paper, we have developed an algorithmic approach to determine who is a good candidate for surgery due to lumbar spondylolysis or spondylolisthesis.

Comment on: Sciatica in the Young

No abstract available.

Posterior Surgery Alone in the Treatment of Post-traumatic Kyphosis by Posterior Column Osteotomy, Spondylodesis, Instrumentation, and Vertebroplasty

STUDY DESIGN: Retrospective study. PURPOSE: To determine if posterior surgery alone can satisfactorily treat post-traumatic kyphosis (PTK). OVERVIEW OF LITERATURE: One of the worst complications of vertebral fractures is PTK. The type of surgery and approach to treat a symptomatic and refractory PTK is a challenging issue in spinal surgery, and yet, there is no specific treatment algorithm. METHODS: From August 2003 to September 2010, we collected 26 cases (male to female ratio, 2.25; mean age, 31.9+/-9.7 years and follow-up period of 42.4+/-8.1 months) with PTK treated by posterior column osteotomy, spondylodesis, instrumentation and cement vertebroplasty in one stage posterior surgery. PTK angle, Oswestry Disability Index (ODI), visual analogue scale (VAS), and subjective satisfaction from surgery were used to determine the results. We used a student t test for analyzing the data before and after surgery. RESULTS: In our patients, T11 and L1 had the highest incidence of vertebral fractures. The results indicated that in PTK, ODI, and VAS were significantly improved this surgery. Solid fusion occurred in 96.2% of patients with 3.2degrees+/-2.1degrees loss of correction. A total of 84.6% of patients have satisfaction level of excellent and good. CONCLUSIONS: Posterior surgery alone with posterior column osteotomy, vertebroplasty, posterior spinal fusion and instrumentation can effectively treat symptomatic PTK.

Treatment Outcomes of Open Pelvic Fractures Associated with Extensive Perineal Injuries

BACKGROUND: The main causes of death in patients with open pelviperineal injuries are uncontrollable bleeding and pelvic sepsis. The aim of this study was to evaluate the management outcomes of open pelvic fractures associated with extensive perineal injuries. METHODS: We retrospectively studied 15 cases with open pelvic fractures associated with extensive perineal injuries (urethral and anal canal laceration) admitted between August 2006 and September 2010. Mechanism of injury, Injury Severity Score, associated injuries, hemodynamic status on arrival, resuscitation and transfusion requirements, operative techniques, intra- and postoperative complications, length of intensive care unit and hospital stay, and mortality were recorded in a computerised database for further evaluation and analysis. RESULTS: The male to female ratio was 12:3 with an average age of 38.6 years (ranged, 11 to 65 years). The average packed red blood cell units used were 8 units (ranged, 4 to 21 units). All patients were initially transferred to the operating room for colostomy, radical debridement and fixation of the pelvic fracture by an external fixator. One patient had acute renal failure, which improved with medical treatment and 2 patients (13.3%) died, one with type III anteroposterior compression fracture due to hemorrhagic shock and the other due to septicemia. CONCLUSIONS: Open pelvic fractures with extensive perineal injuries are associated with high mortality rates. Early diagnosis and appropriate treatment, including reanimation, colostomy, cystostomy, vigorous and repeated irrigation and debridement, and fixation by an external fixator can improve the outcomes and reduce the mortality rate.

Anterior spinal surgery alone in the surgical treatment of thoracolumbar spinal tuberculosis: a prospective study

One of the important sites for extrapulmonary TB involvement is the skeleton. Tuberculous spondylitis [Pott's disease] comprises 50-70% of the skeletal tuberculosis. In this case series study, we prospectively investigated the result of anterior surgery alone [anterior debridement, fusion and instrumentation] in the patients with spinal tuberculosis. The patients with immature skeleton, long segment disease or kyphosis more than 50° were excluded. All the cases were followed for at least 2 years [mean 31.4 +/- 6.4 months]. This study comprised of 23 [13 male and 10 female] cases with a mean age of 35.8 [SD=7.8] years old. Segmental kyphosis was corrected from +11.9° [SD=13.8°] preoperatively to -3.8° [SD=8.9°] after surgery that was mainly maintained at the last follow up visit. Bony union was achieved in all cases but one. Our results showed that in selected cases of tuberculous spondylitis, anterior surgery alone could be encouraging

Is Bristow-Latarjet operation effective for every recurrent anterior shoulder dislocation?

The treatment of recurrent anterior shoulder dislocation in patients who failed a supervised rehabilitation program is operative stabilization. Anatomical repair addressing the underlying pathology is the preferred method. We hypothesize that Bristow-Latarjet procedure is effective in all types of traumatic recurrent anterior shoulder dislocations, although in cases with Bankart lesion, Bankart operation is certainly preferred. Thirty-five shoulders on which a Bristow-Latarjet operation had been performed on account of traumatic recurrent anterior shoulder instability were followed up for an average of 24.6 months [range: 18 - 51]. The clinical outcome was measured according to Walch-Duplay Rating Sheet for Anterior Instability of the Shoulder at the latest follow-up. The clinical outcome was excellent in 11 [31%] patients and good in 24 [69%] patients. Two patients had redislocation that were treated nonoperatively and remained symptom-free at the latest follow-up. Radial nerve palsy occurred in one patient that spontaneously recovered after nine weeks. Although the treatment of anterior shoulder instability in patients with Bankart lesion and intact capsular material [without excessive laxity] is certainly Bankart operation, we claim that in almost all types of anterior shoulder instability, especially in patients with large Hill-Sachs lesions, glenoid bone loss, or excessive capsular laxity, the Bristow-Latarjet operation is associated with good or excellent results and can make the patient satisfied

Fixation of tibial avulsion fractures of the posterior cruciate ligament using pull through suture and malleolar screw

Tibial avulsion fractures of the posterior cruciate ligament are not infrequent. However, controversies exist between the fixation of the fragments and their reconstruction in the cases with small bony fragments. This prospective study was undertaken to study the results after fixation of the fragments by the malleolar screw and the pull through suture techniques. From June 2003 to March 2005, 26 patients with acute isolated posterior cruciate ligament avulsion fracture of the tibial attachment were treated surgically at Qhaem and Emam Reza hospitals at Mashhad University of Medical Sciences. The screw fixation was used in 18 cases with large bony fragments and the suturing method for other cases who had small or comminuted fragments. The patients were followed for an average of 14 months; and according to The International Knee Documentation Committee the results were evaluated. All our patients were men and all the avulsion fractures achieved union at an average of 4.8 months [range, 3-8 months]. All the patients had sever posterior instability [>10mm] pre-operatively. However, when the union of the fracture was achieved, no one suffered severe instability. Both of these two techniques [especially screw fixation] had satisfactory results. Although the number of our cases was not high enough, it can be claimed that when the bony fragment is small and the screw fixation increases the risk of fragment breakage, the double bundles pull-through suture technique is an effective alternative choice