Provocative discography screening improves surgical outcome.

OBJECTIVE: The objective of this study was to compare the surgical outcomes of patients operated on, with or without discography prior to operation. METHODS: The study was designed as a randomized controlled trial, using power analysis with McNemar's test on two correlated proportions. The study comprised of 310 patients divided into trial (207) and control (103) groups. Inclusion criteria were low back pain resistant to nonsurgical treatment for more than 6 months and conventional radiological findings showing degenerative changes without a clear generator of pain. Exclusion criteria were red flags (tumor, trauma, and infection). After standard radiological diagnostic imaging (X-ray, CT, and MR), patients filled in the Oswestry Disability Index (ODI), SF-36, Zung, and MSP questionnaires. Depending on their radiological findings, patients were included and randomly placed in the trial or control group. At the 1-year follow-up examination, patients filled in the ODI, SF-36, and Likert scale questionnaires. RESULTS: The difference between preoperative and postoperative ODI in the control group degenerative disc disease (DDD) subgroup was 22.07 %. The difference between preoperative and postoperative ODI in the trial group DDD subgroup was 35.04 %. Differences between preoperative and postoperative ODI in the control group other indications subgroup was 26.13 %. Differences between preoperative and postoperative ODI in the trial group other indications subgroup was 28.42 %. CONCLUSIONS: DDD treated surgically without discography did not reach the clinically significant improvement of 15 ODI points for the patients treated with fusion. Provocative discography screening with psychological testing in the trial group made improvement following fusion clinically significant.

Brachial plexus injuries complicating video-assisted thoracic surgery.

OBJECTIVE: Video-assisted thoracic surgery (VATS) is a less-invasive alternative to open thoracotomy. According to evidence-based medicine methodology, VATS is associated with better outcomes and the same complication rate as open thoracotomy. CASE DESCRIPTION: Two women (19 and 21 years old) underwent VATS for treatment of pneumothorax. In an attempt to perform hemostasis, the subclavian arteries had to be occluded. Total sensorimotor deficit in both patients on the side where surgery was performed was noticed postoperatively. After 3½ months in patient 1, nerve roots C5 and C6 were neurolyzed. Neuromas of middle and lower trunks and posterior and medial cords were resected and graft repair with sural nerves was performed. In the second patient, 1 month after VATS the entire plexus was neurolyzed because of severe fibrosis. Following neurolysis, positive nerve action potentials (NAPs) were recorded. Patient 1 after the 6-year follow-up has full range of motion of the shoulder and elbow. Extension and flexion in the wrist and fingers recovered to M4/5. Pain sensation and two-point discrimination recovered. Patient 2 after 2½-year follow-up recovered full range of motion of the shoulder, elbow, and forearm. Pain sensation recovered in dermatomes C5 and C6. CONCLUSIONS: The two presented cases show that VATS is not without severe complications, as evidence-based medicine methodology suggests. Surgical findings in our patients imply that if this type of complication happens, early surgical exploration could be the best option for the patients.

Influence of depression on patients satisfaction with the outcome of microsurgical "key-hole" vs classical discectomy: prospective matched-cohort study.

AIM: To assess the influence of depression on patients' satisfaction with lumbar discectomy performed by two different surgical techniques. METHODS: A prospective matched-cohort analysis of classical lumbar discectomy following static imaging (n = 45) and microlumbar "key-hole" discectomy after dynamic CT/myelography (n = 55) was performed. The outcome was independently assessed using Prolo economic/activity (E) and functional/pain (F) scale, and depressiveness according to Hamilton rating scale. Patients without improvement on the Prolo scale were classified as failed back surgery syndrome, and with a Hamilton score 17 as depressive. RESULTS: The groups were well matched by age, sex, clinical presentation and incidence of depression. In the "key-hole" group, both activity and pain outcome were better than in the classical technique group (median E score (range) = 4 (2-5) vs 3 (2-4), p = 0.002, median F score (range) = 4 (2-5) vs 4 (1-5), p = 0.008). Eighteen patients were classified as failed back syndrome, 6 in the "key-hole" group, and 12 in the classical group (z = 3.16, p = 0.075). The incidence of failed back syndrome among non-depressive patients was significantly lower in "key-hole" group (2/55 patients vs 8/45, z = 2.345, p = 0.009). Occurrence of unsatisfactory results among depressive patients was very similar in both groups (4/55 patients vs 4/45, z = 0.296, p = 0.384). CONCLUSION: Introduction of functional imaging and "key-hole" technique decreased incidence of failed back syndrome among non-depressive patients. Unsatisfactory outcome among depressive patients was unrelated to the imaging and surgical technique. Connection between depression and failed back syndrome, although detected, remains unclear and must be further investigated.

Carpal tunnel release by limited palmar incision vs traditional open technique: randomized controlled trial.

AIM: To compare a limited palmar incision for carpal tunnel release (CTR) with a traditional open technique, which is still considered the gold standard. METHODS: Seventy-two patients with a carpal tunnel syndrome were individually randomized into the trial (limited incision CTR) (n=36) and control group (traditional technique CTR) (n=36). In the trial group, skin incision parallel to the thenar crease was made up to 2.5 cm in length, under an operating microscope and endoscopic transillumination. Skin incision in the control group began at the distal border of the carpal ligament, followed the longitudinal crease of the palm, and crossed the base of the palm in a zigzag fashion. Three months after surgery, the patients were asked about symptomatic relief and intervals between the operation and return to their daily activities and work, and examined for scar tenderness and esthetic outcome. Distal motor latency, conduction velocity, scar length, scar width, and operation time were measured. RESULTS: There were no differences between the two groups in symptomatic relief and electrophysiological parameters. Intervals between the operation and return to daily activities (median 5 days, range 2-15) were shorter in the trial group than in the control group (median 10 days, range 2-21; p<0.001), as well as the intervals between the operation and return to work (median 15 days, range 5-45 vs median 30 days, range 10-60; p<0.001). Scar/pillar tenderness, scar length and width, esthetic outcome, and operation time were significantly better in the trial group. CONCLUSION: Limited palmar incision CTR is as effective and safe as traditional CTR technique, but with better postoperative recovery and cosmetic results.