Test-retest reproducibility of the exercise treadmill examination in lumbar spinal stenosis.

OBJECTIVE: To provide further validation of the treadmill test by assessing its "test-retest" reproducibility. PATIENTS AND METHODS: In this prospective study, 28 patients with severe lumbar spinal stenosis underwent exercise treadmill testing, first at a walking speed of 1.2 mph and then at the patient's preferred walking speed. All patients had a second treadmill examination or "retest." No treatment intervention was performed between the initial test and the retest. Time to first symptoms (TFS) and total ambulation time (TAT) were measured. Differences between the baseline examination and the retest examination were assessed by using the concordance correlation coefficient (CCC) as well as graphically. RESULTS: There was good reproducibility between baseline test and retest results for all 4 end points: 1.2 mph, TFS (CCC = 0.90); 1.2 mph, TAT (CCC = 0.89); preferred walking speed, TFS (CCC = 0.98); and preferred walking speed, TAT (CCC = 0.96). The median difference between trials was not significantly different from zero for any of the 4 outcomes. CONCLUSIONS: Exercise treadmill testing has good test-retest reproducibility. There was no learning phenomenon associated with the test procedure. The study further validates the clinical utility of exercise treadmill testing in patients with lumbar spinal stenosis and neurogenic claudication.

Surgical evaluation and management of lumbar synovial cysts: the Mayo Clinic experience.

OBJECT: The authors report a retrospective analysis of 194 patients surgically treated at their institutions for symptomatic lumbar synovial cysts from January 1974 to January 1996. METHODS: Patient characteristics including age, sex, symptoms, signs, and preoperative neuroimaging studies were reviewed. Surgical procedures, complications, results, and pathological findings were correlated with preoperative assessment. One hundred ninety-four patients were surgically treated for symptomatic lumbar synovial cysts. Eighty percent were diagnosed and treated between 1987 and 1996. There were 100 men and 94 women with an average age of 66 years (range 28-94 years). The most common symptoms were painful radiculopathy (85%) and neurogenic single or multiroot claudication (44%). However, sensory loss (43%) and motor weakness (27%) were also presenting symptoms. Eleven percent of patients had undergone previous lumbar surgery prior to being referred to the Mayo Clinic. Preoperative neurological examination demonstrated motor weakness (40%), sensory loss (45%), reflex changes (57%), and variants of cauda equina syndrome (13%). In 19% of patients, normal neurological status was demonstrated. There was equal left/right-sided laterality, and eight patients presented with bilateral synovial cysts. The most commonly affected level was L4-5 (64%). All patients underwent laminectomy and resection of the cyst. Concomitant fusion was performed in 18 patients in whom clinical evidence of instability had been observed. However, subsequent fusion was required in only four patients who developed symptomatic spondylolisthesis. Surgery-related complications included cerebrospinal fluid leak (three patients), discitis (one patient), epidural hematoma (one patient), seroma (one patient), and deep vein thrombosis (one patient). One patient died 3 days after surgery of cardiac dysrhythmia. Follow-up data obtained for at least 6 months postoperatively were available in 147 patients. Of these, 134 (91%) reported good relief of their pain and 82% experienced improvement in their motor deficits. CONCLUSIONS: Lumbar synovial cysts are a more common cause of lumbar radicular pain than previously thought. Surgical removal of the cyst is a safe and effective treatment for symptomatic relief in patients with lumbar synovial cysts. A concomitant fusion procedure may be performed in select cases. In this study, only a few patients developed symptomatic spinal instability requiring a second operation.

Multiple hemangiomas (hemangiomatosis) of the cauda equina and spinal cord. Case report.

A case of multiple hemangiomas of the cauda equina nerve roots, conus medullaris, and lower spinal cord is described. The 74-year-old male patient presented with a 9-month history of progressive bilateral leg weakness. He had a history of lymphoma at the age of 39 years and renal cell carcinoma in his early 40s. Neither disease was evident at the time of this presentation. A magnetic resonance image revealed multiple enhancing nodules in the cauda equina region as well as on the pial surface of the lower thoracic spinal cord and conus medullaris. The patient underwent an L2-3 laminectomy. Cauda equina nerve roots were found to be studded with numerous purple nodules, the largest measuring 6 to 8 mm. The nodules were adherent to nerve roots from which they could not be resected. Two lesions were histologically examined and found to be capillary hemangiomas. Twelve months into an uneventful postoperative course, the patient is neurologically unchanged. This unique case might represent a distinct form of hemangiomatosis confined to the cauda equina nerve roots and spinal cord.

Symptoms of 100 patients with electromyographically verified carpal tunnel syndrome.

To determine the symptoms of carpal tunnel syndrome (CTS), screening evaluations were performed in 244 consecutive patients with sensory symptoms in the hand and unequivocal slowing of median nerve conduction at the wrist. This yielded 100 patients thought to have no explanation other than CTS for their upper limb complaints. These patients completed a hand symptom diagram (HSD) and questionnaire (HSQ) about their symptoms. CTS symptoms were most commonly reported in median and ulnar digits, followed by median digits only and a glove distribution. Unusual sensory patterns were reported by some patients. Based on the HSQ, paresthesias or pain proximal to the wrist occurred in 36.5% of hands. The usefulness of the HSD and HSQ for diagnosis was determined by asking three physicians, blinded to the diagnosis, to rate the likelihood of CTS in the patients with CTS and in 50 patients with other causes of upper extremity paresthesia. The sensitivities of the instruments ranged from 54.1% to 85.5%. Combining the HSD and HSQ ratings increased the range of sensitivities to 79.3% to 93.7%.

Vascular pedicle rib graft in anterior transthoracic fusion procedures. Technical note.

A method is described in which anterior fusion of the thoracic vertebral column is performed using a rib strut graft maintained on its vascular pedicle. This straightforward technique is useful in selected patients undergoing anterior thoracic fusion procedures and can be used in conjunction with other anterior spinal implants. By maintaining bone graft blood supply, this technique promotes an optimum fusion environment, which may enhance the speed of graft incorporation and the ultimate strength of the construct.

Use of patient-centered function and symptom rating systems in spinal disorders.

The criteria for assessing patients with disorders of the lumbar spine have historically been subjective and variable. This situation has led to uncertainty about diagnostic criteria, operative indications, and surgical outcome. In an effort to improve the evaluation process, various patient-centered function and symptom rating systems, including questionnaires and functional tests, have recently been developed. This report reviews several of these rating systems and their role in the assessment of patients with back-related symptoms.

From slowly progressive amnesic syndrome to rapidly progressive Alzheimer disease.

A 57-year-old woman had a neuropsychologically documented 5-year history of a slowly progressive amnesic syndrome followed by a 1-year history of rapidly progressive dementia. There was no family history of dementia. Magnetic resonance imaging failed to show a structural basis, electroencephalography failed to show changes of Creutzfeldt-Jakob disease, and cerebrospinal fluid examination was normal. A diagnosis of Alzheimer disease was confirmed by brain biopsy. The abrupt change in disease course was unique but suggested probable overlap between posited subtypes of Alzheimer disease.

Use of the exercise treadmill to measure baseline functional status and surgical outcome in patients with severe lumbar spinal stenosis.

STUDY DESIGN: A prospective study of exercise tolerance on the treadmill before and after decompressive laminectomy in patients with severe lumbar spinal stenosis. OBJECTIVES: To determine whether treadmill testing provides useful information about baseline functional status and surgical outcome. SUMMARY OF BACKGROUND DATA: Historically, criteria for selecting patients for surgery and assessing postoperative outcome have been variable. Functional testing has not been used in a systematic fashion. METHODS: Fifty patients with severe lumbar spinal stenosis underwent decompressive laminectomy. Preoperatively and 3 months postoperatively, functional capacity was assessed on an exercise treadmill. Time to first symptoms and total ambulation time were recorded. The examination was stopped at the onset of severe symptoms or after 15 minutes. RESULTS: In the preoperative trial, mean time to first symptoms (+/- standard deviation) was 1.82 minutes (median, 0.58), and mean total ambulation time was 6.91 minutes (median, 5.22). In the postoperative trial, mean time to first symptoms increased to 11.93 minutes (median, 15) and mean total ambulation time increased to 13.26 minutes (median, 15). There was significant improvement after surgery in both time to first symptoms (P < 0.001) and total ambulation time (P < 0.001). CONCLUSION: Exercise stress testing on a treadmill is a safe, easily administered, and quantifiable means of assessing baseline functional status and surgical outcome in patients with neurogenic claudication due to lumbar spinal stenosis. Treadmill testing provides objective evidence that surgery is beneficial in most cases and is helpful in guiding subsequent management of patients with residual symptoms.

Conservative management of acoustic neuroma: an outcome study.

OBJECTIVE: This study analyzed selection criteria, clinical outcome, and tumor growth rates in patients with acoustic neuromas in whom the initial management strategy was observation. METHODS: A retrospective review of patients with conservatively managed unilateral acoustic neuromas was conducted. Minimum follow-up was 6 months. Patients with neurofibromatosis Type II were excluded. Differences in tumor growth rates were analyzed by use of the Wilcoxon rank sum test. RESULTS: Sixty-eight patients (31 men and 37 women) with a mean age of 67.1 years were followed for an average of 3.4 years after diagnosis. The reasons for a trial of observation included advanced age (55%), patient preference (21%), minimal symptoms (9%), poor general medical condition (7%), asymptomatic tumor (4%), and tumor in the only hearing ear (4%). Fifty-eight patients (85%) were successfully managed with observation alone. Ten patients (15%) ultimately required treatment (nine received microsurgical treatment and one patient underwent radiosurgical intervention) at a mean time interval of 4.0 years after diagnosis. Forty-eight tumors (71%) showed no growth and 20 (29%) enlarged during the study period. The mean tumor growth rate at the 1-year follow-up was significantly higher in the group requiring treatment (3.0 mm) than in the group not requiring treatment (0.36 mm) (P < 0.0001). Thus, the tumor growth rate at the 1-year follow-up was a strong predictor of the eventual need for treatment. CONCLUSION: Observation is a reasonable management strategy in carefully selected patients with acoustic neuromas. Diligent follow-up with serial magnetic resonance imaging is recommended, because some tumors will enlarge to the point at which active treatment is required.

Diagnosis and management of lumbar disk disease.

Acute low-back pain is one of the most common problems encountered by primary-care physicians. A few patients have severe neurologic impairment or evidence of cancer or other serious underlying systemic illness. For such patients, a broad differential diagnosis must be considered, and a prompt work-up and specialty consultation may be necessary. For most patients with acute low-back pain, extensive laboratory and imaging tests are unnecessary, and rapid improvement can be expected with only simple treatment measures. Physical therapy is useful in patients with refractory symptoms. Magnetic resonance imaging and other sophisticated spinal imaging should usually be reserved for patients who are being considered for an operation. Surgical referral should be considered for the patient with a documented lumbar disk herniation that correlates precisely with clinical findings. Surgical treatment is usually elective in patients with persistent radicular pain and a mild to moderate neurologic deficit, urgent in patients with severe or progressive monoradiculopathy, and emergent in patients with the cauda equina syndrome. Lumbar diskectomy with magnified vision is the surgical procedure of choice, and success rates of 80 to 90% can be expected in properly selected patients.

"Preplacement" of the back of the halo vest in patients undergoing cervical traction for cervical spine injuries: a technical note.

BACKGROUND: In patients with unstable cervical spine injuries initially managed with in-line traction, there is some risk of loss of cervical alignment and of new neurologic deficit when the halo vest is applied. This report outlines a simple technique which facilitates halo application in these patients. METHODS: The back of the halo vest is "prepositioned" before traction is instituted. Once alignment is optimized, halo vest application is easily completed without lifting the patient or discontinuing cervical traction. RESULTS: The authors have used this technique in four patients without complication. CONCLUSIONS: In patients with unstable cervical spine injuries who require an initial period of in-line traction, halo vest application is made easier and safer by "prepositioning" the back of the vest.

Measurement of exercise tolerance on the treadmill in patients with symptomatic lumbar spinal stenosis: a useful indicator of functional status and surgical outcome.

A prospective study of patients with neurogenic claudication and lumbar spinal stenosis was undertaken to determine whether measurement of exercise tolerance on the treadmill would be useful in defining baseline functional status and response to surgical treatment. Twenty patients with an average age of 73 years, all of whom had intractable neurogenic claudication and radiographically confirmed severe lumbar spinal stenosis, were studied. Lumbar decompressive laminectomy was performed in all patients. Preoperatively and 2 months postoperatively, quantitative assessment of ambulation was conducted on a treadmill at 0 degree ramp incline at two different speeds: 1.2 mph and the patient's preferred walking speed. The following information was recorded: time to first symptoms, time to severe symptoms, and nature of symptoms (leg pain, back pain, or generalized fatigue). The examination was stopped after 15 minutes or at the onset of severe symptoms. In the preoperative 1.2-mph trial, the mean time to first symptoms was 2.68 minutes (median 1.31) and the mean time to severe symptoms was 5.47 minutes (median 3.42). In the postoperative trial at the same speed, 13 patients (65%) were able to walk symptom free for 15 minutes. The mean time to first symptoms was 11.12 minutes (median 15) and the mean time to severe symptoms was 11.81 minutes (median 15). Similar findings were recorded in the preferred walking-speed trials. There were no complications from the treadmill testing procedure. These findings indicate that exercise stress testing on a treadmill is a safe, easily administered, and quantifiable means of assessing baseline functional status and outcome following laminectomy in patients with symptomatic lumbar spinal stenosis.

Analysis of early failures after lumbar decompressive laminectomy for spinal stenosis.

OBJECTIVE: To determine why some patients have no improvement after surgical treatment of lumbar spinal stenosis. DESIGN: We conducted a retrospective study of patients who were referred to our institution between 1990 and 1993 because their symptoms were unchanged or worsened after lumbar decompressive laminectomy. MATERIAL AND METHODS: For the 45 study patients (25 women and 20 men; mean age, 70.8 years), preoperative and postoperative clinical status, preoperative and postoperative imaging studies, and operative reports were analyzed. RESULTS: Preoperatively, only 23 patients (51%) had the clinical syndrome of neurogenic claudication, and 15 (33%) had midline low-back pain without a radicular component. Three other patients had peripheral neuropathy, and three had atypical leg pain. Only 10 patients had radiographic evidence of severe lumbar canal stenosis; the others had moderate, mild, or no stenosis. In 10 patients, surgical decompression was inadequate. Only three patients had the triad of neurogenic claudication, radiographically confirmed severe lumbar stenosis, and adequate decompression of the lumbar canal and lateral recesses. CONCLUSION: The most common pattern in patients with early failure after lumbar laminectomy was the absence of actual neurogenic claudication coupled with the absence of severe stenosis on preoperative imaging studies. The most common technical error was inadequate neural decompression. These data suggest that the outcome may be improved by more careful selection of patients and by performance of an adequate surgical decompression.

Assessment of bladder function after lumbar decompressive laminectomy for spinal stenosis: a prospective study.

Lumbar spinal stenosis is a common problem in elderly patients. In its more advanced forms, it typically causes intractable leg pain, but many patients also manifest varying degrees of bladder dysfunction. The goal of lumbar decompressive laminectomy is relief of leg pain and paresthesias, yet some patients also achieve improvement in bladder function. This study prospectively investigated patients with lumbar spinal stenosis to determine whether laminectomy had any effect on urological function. Of the 20 patients in the study, 10 were men and 10 women (average age 70.9 years). All patients had severe lumbar stenosis affecting between two and four spinal segments, and all reported some degree of bladder dysfunction. Cystoscopy and urodynamic testing were completed preoperatively. A standard decompressive laminectomy was performed over the appropriate number of spinal segments. Urodynamic studies were repeated at 2 and 6 months postoperatively. At the 6-month follow-up review, bladder function was subjectively improved in 12 patients (60%) and unchanged in eight (40%). Postvoiding residual urine volume was the urodynamic factor most likely to be improved by laminectomy. In nine patients (45%), baseline postvoiding residual urine volume was elevated and all nine had improvement postoperatively. In the remaining 11 patients (55%), this urine volume was normal before and after surgery. Maximum urine flow rates also improved, but the results of cytometrography and electromyography, urine flow pattern, and bladder capacity were unchanged postoperatively. Cystoscopy detected previously undiagnosed malignancy of the lower urinary tract in two patients (10%). It is concluded that lumbar decompressive laminectomy can have a beneficial effect on bladder function in a significant number of patients with advanced lumbar spinal stenosis.

Lumbar disk disease in active duty military personnel.

We studied a group of active duty military personnel with well-defined, lumbar discogenic, radicular pain syndromes. Our study group included 29 patients, 12 of whom required surgery during the study period. Three of the 29 patients had to be medically retired from active military service. Two patients required permanent limited-duty assignment and 10 others required prolonged (6 months or more) periods of limited duty. These findings highlight the significant adverse impact of lumbar disk disease on fitness for full active duty in military personnel.