Preoperative predictors for good postoperative satisfaction and functional outcome in lumbar spinal stenosis surgery--a prospective observational study with a two-year follow-up.

BACKGROUND AND AIMS: Lumbar spinal stenosis (LSS) is the most frequent indication for back surgery in adults aged over 65 years, but about one-third of operated patients have less than good/excellent results from the operation. Awareness of outcome predictors and their predictive values may help clinicians in their assessment of the prognosis of patients when considering surgical treatment. Our aim was to study the preoperative predictors in LSS for a good postoperative outcome (satisfaction with surgery and functional improvement) with a two-year follow-up. MATERIAL AND METHODS: LSS patients (n = 102) completed a questionnaire preoperatively and on two-year follow-up. Preoperative patient-related predictors, self-rated health, comorbidities and preoperative treatment were assessed. Satisfaction with the surgical outcome was assessed with a seven-category scale; satisfaction was determined to be good if the patient response was "condition has considerably improved" or "totally cured". Other responses ("condition has slightly improved" or worse) represented poorer satisfaction. A good functional outcome was determined as >30% relative improvement compared to the presurgery score in the Oswestry Disability Index (ODI). RESULTS: The predictors for good satisfaction were age < 75 years at operation (OR 4.03; 95% CI 1.35-12.02; p = 0.012) and no previous lumbar operation (OR 3.65; 95% CI 1.13-11.79; p = 0.031). Predictors for a good improvement in the ODI score were regular preoperative analgesic use < 12 months (OR 3.40; 95% CI 1.21-9.53; p = 0.020), non-smoking (OR 3.47; 95% CI 1.09-11.03; p = 0.035) and good (above average) self-rated health (OR 3.27; 95% CI 1.06-10.12; p = 0.039). CONCLUSIONS: In LSS, regular analgesic treatment preoperatively for 12 months or less, self-rated health above average and non-smoking predicted a good postoperative functional improvement. An age under 75 years and no previous lumbar operation predicted good post-operative satisfaction with the surgery.

Percutaneous bone grafting in the treatment of the delayed union and non-union of tibial fractures.

The classic method of open bone grafting in the treatment of un-united tibial fractures has been associated with some complications. A novel, minimally invasive, percutaneous technique of bone grafting is described. Forty-one consecutive patients with delayed union or non-union of a tibial fracture was treated with percutaneous bone grafting from 1993 to 1999. The mean age of the patients was 41 (15-86) years. Twenty-seven patients had grade I-III open fractures. The fractures had initially been treated in a cast (n=26), external fixator (n=14) or intramedullary nail (n=1). Two patients had an earlier unsuccessful Phemister-Charnley-type bone-grafting procedure for delayed union. The mean interval from injury to percutaneous bone grafting was 21 (13-66) weeks. Thirty-seven of the 41 un-united fractures healed in 13 (10-48) weeks after the percutaneous bone grafting. The mean hospital stay was 1 day. No infections, bleeding or neural complications existed. Percutaneous bone grafting appeared to be as effective as open techniques, and possessed considerable advantages. It is safe, time saving and economical, it involves minimal trauma at the fracture site and it avoids major donor site problems.

Long-term clinical and magnetic resonance imaging follow-up assessment of patients with lumbar spinal stenosis after laminectomy.

STUDY DESIGN: A cross-sectional retrospective study to observe the correlation between postoperation findings shown on magnetic resonance imaging and clinical observations of 56 patients 10 years after laminectomy for lumbar spinal stenosis. OBJECTIVE: To evaluate the relation between postoperation findings on magnetic resonance imaging and surgical outcome in patients surgically treated for lumbar spinal stenosis. SUMMARY OF BACKGROUND DATA: Surgical management of lumbar spinal stenosis is based on the compression seen in radiologic imaging of neurovascular structures in the vertebral canal, but the success of surgical decompression and its correlation with clinical observations very seldom have been monitored by postoperation radiologic imaging. METHODS: In this study, 56 patients surgically treated for lumbar spinal stenosis were re-examined clinically by use of the Oswestry disability questionnaire. Their walking capacity was evaluated by the treadmill test. Severity of pain before and after the treadmill test was investigated using a visual analog scale. Patients' perception of improvement measured as the change in their condition during the preceding 5 years was elicited by a questionnaire. On the basis of the stenotic findings on magnetic resonance imaging, the patients were classified into no stenosis (NoSten, n = 15) and stenosis (Sten, n = 41) groups, and a summative degenerative scale also was constructed with the findings categorized as follows: disc degeneration, disc herniation, facet joint arthrosis, and degenerative spondylolisthesis. RESULTS: Whereas the patients' perception of improvement correlated very strongly with the Oswestry score and walking capacity, there was no statistical difference between the NoSten and Sten groups in the Oswestry score, walking capacity, perception of improvement, or severity of pain. The effect of the summative degenerative scale on the patients' walking capacity was 13 times greater than the effect of the minimum area of the dural sac. CONCLUSIONS: Patients' perception of improvement had a much stronger correlation with long-term surgical outcome than structural findings seen on postoperation magnetic resonance imaging. Moreover, degenerative findings had a greater effect on patients' walking capacity than stenotic findings.

Comparative immunohistochemical study of group II (synovial-type) and group IV (cytosolic) phospholipases A2 in disc prolapse tissue.

Phospholipase A2 (PLA2) has been suggested to be present in herniated disc tissue and it could possibly be involved in sciatica/ discogenic back pain mechanisms. In the present study the occurrence of two different phospholipase A2 enzymes, (1) low molecular weight (14 kDa) group II synovial-type (sPLA2) and (2) high molecular weight (85 kDa) group IV cytosolic (cPLA2), were compared. Fifty-three disc prolapses obtained at disc operations were analyzed by immunohistochemistry, using anti-human monoclonal antibodies to sPLA2 and cPLA2, respectively. Only cell-associated (disc cells, hyaline cartilage chondrocytes) sPLA2 and cPLA2 immunoreactivity could be observed. The results showed that sPLA2 was more common (25/53, 47%) than cPLA2 (13/53, 25%). sPLA2 and cPLA2 were simultaneously present in 13 of 53 samples (25%). However, both PLA2 enzymes were predominantly present in hyaline cartilage cells (sPLA2: 16/53, cPLA2: 5/53), being less commonly observed in disc cells (sPLA2: 6/53, cPLA2: 3/53). In addition, three samples for sPLA2 and two samples for cPLA2 exhibited immunoreactivity in cartilage and disc cells simultaneously. sPLA2 was observed in no other locations, but in 3 of 53 samples cPLA2 was observed more diffusely in areas of granulation tissue, possibly in macrophages. No gender- or age-related dependence for either type of PLA2 enzyme immunoreactivity could be observed. Neither did their occurrence relate to clinical data such as straight leg raising or neurological deficit. The results do not support a major role for either of the two disc-cell-associated PLA2s in disc pathophysiology. For both enzymes, the major pool appears to reside in cartilage tissue cells, presumably in dislodged end-plate fragments. Disc cells are apparently unlikely candidates for major PLA2 storage.

Surgical outcome of 438 patients treated surgically for lumbar spinal stenosis.

STUDY DESIGN: A retrospective, follow-up study. OBJECTIVES: To investigate the overall outcome of surgery for lumbar spinal stenosis and to investigate the preoperative factors affecting outcome. SUMMARY OF BACKGROUND DATA: The success rates of surgical intervention for lumbar spinal stenosis vary, and few preoperative factors have been found to be significantly correlated to surgical outcome. METHODS: A total of 438 patients (183 women, 255 men) who underwent decompressive surgery for lumbar spinal stenosis were re-examined and evaluated for outcome 4.3 years after surgery. Outcome was based on subjective disability, which was assessed using the Oswestry low back pain questionnaire. The preoperative data (clinical documentation, length of laminectomy, and radiographs) were collected from patient records that had been stored in the hospital. Preoperative factors affecting outcome were reported. RESULTS: The mean value of the Oswestry disability score of these 438 patients was 34 +/- 18 (women, 36.3 +/- 17; men, 32.3 +/- 18; P < 0.05). Age did not influence general outcome. The proportion of good to excellent outcomes of all 438 patients was 62% (women, 57%; men, 65%). Diabetes, hip joint arthrosis, and preoperative fracture of the lumbar spine seemed to be associated with poor outcome. The ability to work before or after surgery and a history of no prior back surgery were predictive of good outcome. CONCLUSION: The results suggest that clear myelographic stenosis and no prior surgical intervention, no comorbidity of diabetes, no hip joint arthrosis, and no preoperative fracture of the lumbar spine are factors associated with a good outcome in surgical management of lumbar spinal stenosis.

Foot and ankle fusions in Charcot-Marie-Tooth disease.

We reviewed 15 patients with Charcot-Marie-Tooth disease who were treated with foot or ankle fusions. Altogether, 26 feet were treated with fusions and the average follow-up time was 14 years. In half of the patients the principal symptom leading to fusion operation was instability of the ankle. In four patients, in two of them bilaterally, soft tissue corrections were performed before the fusion. In 21 cases, a subtalar triple arthrodesis was performed and each time correction to neutral position was the aim. In six feet, the triple arthrodesis was complemented by soft tissue plasties, e.g., plantar release, Achilles elongation, or transposition of tibial or peroneal tendons in order to achieve proper balance. Other primary fusions were a Grice-type fusion in one case, pantalar arthrodesis in one case, talocrural fusion in one case, and interphalangeal fusions in both feet in one patient with extreme claw foot. In four cases the triple arthrodesis failed to fuse (three nonunions and one delayed union), and new fusions were successful in three of them. The one pantalar fusion in the series was done for a 58-year-old man with late onset of the disease who had a very severe cavovarus deformity at the time of the operation, and this fusion failed to unite. In 17 of 26 feet, other operations than the primary fusion were performed, and five feet were operated on three or four times. In four feet the result was judged as excellent, in 15 good, in four fair, and in three poor.(ABSTRACT TRUNCATED AT 250 WORDS)