Patient perspective: diagnosis and prognosis of acute spinal cord injuries.

STUDY DESIGN: Qualitative study. OBJECTIVES: The purpose of this study is to understand the patient perspective after diagnosis of an acute traumatic spinal cord injury (tSCI). Discussing the diagnosis and prognosis of a tSCI with a patient can be a challenging experience for both the patient and the physician. As such, this paper attempts to better understand the patient experience to improve communication when discussing this life-altering injury. SETTING: Vancouver General Hospital, Vancouver, British Columbia, Canada. METHODS: This study is a qualitative study utilizing grounded theory and semi-structured interviews. The interview transcripts were manually coded using manifest and latent content analysis. Major and minor codes were identified and discussed. RESULTS: In total, 17 interviews were conducted, fifteen individuals with tSCI who received acute care at Vancouver General Hospital (VGH) and eleven family members were interviewed. Patient participants were interviewed individually or in a paired interview with a participating family member. Patient participants had varying spinal cord injuries from AIS A-D. Two major themes were identified from the interviews. The first major theme was physician demeanor (general approach and attitude towards patients) and the second major theme was delivery of information (content, timing, and source). CONCLUSIONS: This study summarizes the preferences of patients who sustained a tSCI discussions regarding their diagnosis and prognosis in the acute care setting. The goal of this study is to help guide physician interactions at this difficult and vulnerable time for patients with hopes to improve patient care through effective communication.

Orthosis versus no orthosis for the treatment of thoracolumbar burst fractures without neurologic injury: a multicenter prospective randomized equivalence trial.

BACKGROUND CONTEXT: Thoracolumbar burst fractures have good outcomes when treated with early ambulation and orthosis (TLSO). If equally good outcomes could be achieved with early ambulation and no brace, resource utilization would be decreased, especially in developing countries where prolonged bed rest is the default option because bracing is not available or affordable. PURPOSE: To determine whether TLSO is equivalent to no orthosis (NO) in the treatment of acute AO Type A3 thoracolumbar burst fractures with respect to their functional outcome at 3 months. STUDY DESIGN: A multicentre, randomized, nonblinded equivalence trial involving three Canadian tertiary spine centers. Enrollment began in 2002 and 2-year follow-up was completed in 2011. PATIENT SAMPLE: Inclusion criteria included AO-A3 burst fractures between T11 and L3, skeletally mature and older than 60 years, 72 hours from their injury, kyphotic deformity lower than 35°, no neurologic deficit. One hundred ten patients were assessed for eligibility for the study; 14 patients were not recruited because they resided outside the country (3), refused participation (8), or were not consented before independent ambulation (3). OUTCOME MEASURES: Roland Morris Disability Questionnaire score (RMDQ) assessed at 3 months postinjury. The equivalence margin was set at δ=5 points. METHODS: The NO group was encouraged to ambulate immediately with bending restrictions for 8 weeks. The TLSO group ambulated when the brace was available and weaned from the brace after 8 to 10 weeks. The following competitive grants supported this work: VHHSC Interdisciplinary Research Grant, Zimmer/University of British Columbia Research Fund, and Hip Hip Hooray Research Grant. Aspen Medical provided the TLSOs used in this study. The authors have no financial or personal relationships that could inappropriately influence this work. RESULTS: Forty-seven patients were enrolled into the TLSO group and 49 patients into the NO group. Forty-six participants per group were available for the primary outcome. The RMDQ score at 3 months postinjury was 6.8 ± 5.4 (standard deviation [SD]) for the TLSO group and 7.7 ± 6.0 (SD) in the NO group. The 95% confidence interval (-1.5 to 3.2) was within the predetermined margin of equivalence. Six patients required surgical stabilization, five of them before initial discharge. CONCLUSIONS: Treating these fractures using early ambulation without a brace avoids the cost and patient deconditioning associated with a brace and complications and costs associated with long-term bed rest if a TLSO or body cast is not available.

The reliability of differentiating neurogenic claudication from vascular claudication based on symptomatic presentation.

BACKGROUND: Intermittent claudication can be neurogenic or vascular. Physicians use a profile based on symptom attributes to differentiate the 2 types of claudication, and this guides their investigations for diagnosis of the underlying pathology. We evaluated the validity of these symptom attributes in differentiating neurogenic from vascular claudication. METHODS: Patients with a diagnosis of lumbar spinal stenosis (LSS) or peripheral vascular disease (PVD) who reported claudication answered 14 questions characterizing their symptoms. We determined the sensitivity, specificity and positive and negative likelihood ratios (PLR and NLR) for neurogenic and vascular claudication for each symptom attribute. RESULTS: We studied 53 patients. The most sensitive symptom attribute to rule out LSS was the absence of "triggering of pain with standing alone" (sensitivity 0.97, NLR 0.050). Pain alleviators and symptom location data showed a weak clinical significance for LSS and PVD. Constellation of symptoms yielded the strongest associations: patients with a positive shopping cart sign whose symptoms were located above the knees, triggered with standing alone and relieved with sitting had a strong likelihood of neurogenic claudication (PLR 13). Patients with symptoms in the calf that were relieved with standing alone had a strong likelihood of vascular claudication (PLR 20.0). CONCLUSION: The classic symptom attributes used to differentiate neurogenic from vascular claudication are at best weakly valid independently. However, certain constellation of symptoms are much more indicative of etiology. These results can guide general practitioners in their evaluation of and investigation for claudication.

CONTEXTE: La claudication intermittente peut avoir une étiologie neurogène ou vasculaire. Les médecins utilisent un profil fondé sur les particularités des symptômes pour distinguer l'une de l'autre et ceci oriente leur choix des méthodes de diagnostic de la pathologie sous-jacente. Nous avons évalué la validité de ces particularités des symptômes utilisées pour distinguer la claudication d'origine neurogène de la claudication d'origine vasculaire. MÉTHODES: Des patients atteints d'une sténose spinale lombaire (SSL) ou d'une maladie vasculaire périphérique (MVP) avérées qui se plaignaient de claudication ont réponduà 14 questions afin de caractériser leurs symptômes. Nous avons déterminé la sensibilité, la spécificité et les rapports de probabilité positifs et négatifs (RPP et RPN) à l'égard de la claudication neurogène ou vasculaire pour chacune des particularités des symptômes. RÉSULTATS: Notre étude a regroupé 53 patients. La particularité des symptômes dotée de la sensibilité la plus élevée pour ce qui est d'écarter le diagnostic de SSL a été l'absence de « déclenchement de la douleur à la simple station debout ¼ (sensibilité 0,97; RPN 0,050). Les données sur ce qui soulageait la douleur et sur la localisation des symptômes ont eu une faible portée clinique en ce qui a trait à la SSL et à la MVP. La présence d'une constellation de symptômes a donné lieu aux associations les plus solides : les patients qui manifestaient un signe du « panier d'épicerie ¼ positif et dont les symptômes étaient localisés au-dessus du genou, déclenchés par la station debout seule et soulagés en position assise présentaient une forte probabilité de claudication d'origine neurogène (RPP 13). Chez les patients dont les symptômes étaient localisés au mollet et qui étaient soulagés par la station debout, on notait une forte probabilité de claudication d'origine vasculaire (RPP 20,0). CONCLUSION: Considérés individuellement, les attributs classiques des symptômes utilisés pour distinguer la claudication d'origine neurogène de la claudication d'origine vasculaire sont au mieux faiblement valides. Toutefois, certaines constellations de symptômes éclairent bien davantage l'étiologie. Ces résultats peuvent guider l'omnipraticien dans son examen et dans son diagnostic de la claudication.

A biomechanical assessment of soft-tissue damage in the cervical spine following a unilateral facet injury.

BACKGROUND: Unilateral cervical spine facet injuries encompass a wide spectrum, including subluxations, dislocations, and fractures, and the instability produced varies greatly. The extent of anatomical disruption secondary to a unilateral facet injury is poorly understood, and few biomechanical studies have quantified the associated kinematics. The purpose of this study was to develop an experimental method that reliably produces an impending unilateral facet dislocation (perched facet) in cadaveric cervical spines and to identify the soft-tissue damage and resulting changes in cervical spine range of motion and neutral zone associated with this injury. METHODS: Nine fresh-frozen cadaveric human spinal motion segments (C4-C5 or C6-C7) were mounted in a spinal loading simulator to induce a perched unilateral facet injury based on a previously described mechanism of flexion and bending with increasing rotation. Loads were applied to simulate and measure flexion-extension, lateral bending, and axial rotation motions before and after achieving a perched facet. Preinjury and postinjury range of motion and neutral zone were analyzed with use of paired t tests for each movement. Systematic qualitative inspection and gross dissection were then performed to define the soft-tissue injury pattern. RESULTS: Range of motion and neutral zone increased following the reduction of this injury; the largest increase (294%) occurred in contralateral axial rotation (i.e., right axial rotation after a perched left facet). Postinjury dissections revealed bilateral capsular tears, 50% disc disruption, and 50% tearing of the ligamentum flavum in most specimens. The interspinous and supraspinous ligaments were stretched in less than half of the specimens and were never completely disrupted. The longitudinal ligaments were occasionally torn as extensions of anulus fibrosus disruptions. CONCLUSIONS: This study indicates that the anulus fibrosus, nucleus pulposus, and ligamentum flavum are important cervical spine stabilizers. Facet capsules were often torn bilaterally, implying a more advanced injury than a unilateral facet injury. These discoligamentous injuries result in increases in range of motion and neutral zone. CLINICAL RELEVANCE: The results from this work provide further insight into the expected injury and associated instability present in a traumatic unilateral facet injury in the cervical spine.

Short term clinical outcome of a porous tantalum implant for the treatment of advanced osteonecrosis of the femoral head.

PURPOSE OF THE STUDY: Osteonecrosis of the hip mostly affects young individuals and often progresses to a debilitating disease. Several treatment modalities exist, but none are completely satisfactory. This study evaluates the clinical outcome of patients treated with core decompression and insertion of a porous tantalum implant in the femoral head. This procedure is similar to commonly performed procedures, but has the additional advantages of providing structural support to the necrotic femoral head while having no donor-site morbidity. METHODS: We evaluated 15 patients with 18 osteonecrotic hips with Steinberg stage III (3 hips) and IV (15 hips) disease. The mean age of the patients was 42 years-old (eldest 66), and the mean time for follow-up was 23 months. The outcome measure was hip function, evaluated with the Harris hip score, and the end point was total hip arthroplasty, or referral for this procedure. RESULTS: The success rate at twelve months postoperatively was 77.8%, and the overall success rate was 44.5%. Failures occurred at a mean time of 11.7 months, and one complication, a periprosthetic fracture, occurred 4 months postoperatively. On average, patients who did well improved their Harris hip scores by 21.7 points, and patients who eventually required arthroplasty decreased their scores by 14 points. CONCLUSIONS: Core decompression with porous tantalum implants showed encouraging success rates and early clinical results in patients with advanced stage osteonecrosis, but further larger scale studies are required to identify the population best suited for this procedure.