The effect of lower extremity nerve decompression on health-related quality of life and perception of pain in patients with painful diabetic polyneuropathy: a prospective randomized trial.

AIMS: The aim of this study was to assess whether surgical decompression of nerves in the lower extremity in people with painful diabetic polyneuropathy would have an effect on health-related quality of life and to determine minimal clinically important differences in pain and quality of life scores. METHODS: The design was a randomized controlled trial in which 42 participants with painful diabetic painful neuroapthy underwent unilateral decompression of nerves in their left or right leg, using the other leg as a control, with 12 months follow-up. Surgical decompression was performed at the tibial, superficial, deep and common peroneal nerves. Preoperatively, and at 6 and 12 months post operatively, a visual analogue scale for pain and the 36 item short-form health survey and EuroQual 5 Dimensions questionnaires were completed. RESULTS: At 12 months follow-up, the visual analogue scale was significantly reduced, but decompression surgery did not significantly alter health-related quality of life scores. The minimal clinically important difference for visual analogue scale reduction was determined at 2.9 points decrease, a threshold reached by 42.5% of the study population. CONCLUSIONS: Although decompression surgery does not influence health-related quality of life, it achieves a clinically relevant reduction of pain in ~42.5% of people with diabetic peripheral neuropathy. It can therefore be considered for patients who do not adequately respond to pain medication.

Sleep disturbances in chronic progressive external ophthalmoplegia.

BACKGROUND: Chronic progressive external ophthalmoplegia (CPEO) is a relatively common mitochondrial disorder. In addition to extraocular muscle weakness, various other organs can typically be affected, including laryngeal and limb muscles, cerebrum, cerebellum, and peripheral nerves. Given this multi-organ involvement, patients are likely to be prone to sleep disturbances. Here, we determined the nature, prevalence, and determinants of sleep disturbances in CPEO. METHODS: We used validated questionnaires for various sleep disorders and possible determinants such as mood and anxiety, and we performed ambulant polysomnography (PSG) in 20 patients with genetically confirmed CPEO. RESULTS: Three quarters of patients reported nocturnal sleep dysfunction. Thirty-five percent of patients fulfilled the criteria for restless legs syndrome, 30% excessive daytime sleepiness, and 70% significant periodic limb movements. PSG recordings revealed several indicators of a disrupted sleep architecture. Obstructive sleep disordered breathing was present in only one patient. However, four patients had an increased central sleep apnea index, all of whom had a polymerase gamma-1 mutation and a SANDO phenotype (sensoric atactic neuropathy, dysarthria, ophthalmoplegia). Physical examination and questionnaire outcomes were poor predictors of PSG results. CONCLUSION: Several specific sleep disturbances are part of the phenotype of CPEO. Given that the disease is otherwise incurable, symptomatic treatment of sleep disturbances may be an important tool to improve quality of life. Therefore, patients with CPEO should be actively screened for sleep disorders, with a low threshold to perform PSG.

The effect of supplementation with an enriched drink on indices of immune function in frail elderly.

Ageing induces a change in immune responses. Besides this, impaired nutritional status is considered to have a critical influence on immune function, which may be reversed by nutritional supplementation. We evaluated the effect of an enriched drink on immune function in the elderly. 33 frail elderly subjects (aged > or = 65 years and body mass index < or = 25) received two 125 ml packages of either an enriched drink (n=20) or placebo (n=13) daily for 6 months. The enriched drink contained macro- and micronutrients. At baseline and after 6 months blood samples were drawn and PBMC's were isolated. ConA stimulated proliferation and IL-2 production of PBMC's were measured. There was a significant difference between groups in proliferation over the study period. The supplement group remained stable whereas the placebo group showed a reduction in proliferation over the 6-month period. There was no significant difference in IL-2 production between groups. Our study adds to the evidence that nutritional supplementation can affect immune function in the elderly.

Hole preparation techniques for transpedicle screws. Effect on pull-out strength from human cadaveric vertebrae.

In each of eight thoracolumbar human cadaveric vertebrae, a hole was made through one pedicle into the vertebral body with a drill bit and through the contralateral pedicle with a probe. Identical metal screws were implanted into the holes to equal depths, and maximum pull-out force was determined for each screw. Using a paired Student t test, no significant difference (P = 0.87) was found in pull-out strength between the screws implanted into drilled holes and those implanted into probed holes. In fact, the average pull-out strengths for the two groups differed by less than 2%. The pedicular cortex was broken through during hole preparation in 5 of the 16 pedicles: 3 as a result of drilling and 2 secondary to probing. The average pull-out strength of the screws in these five pedicles was 11.0% less than the average pull-out strength of the screws implanted into the contralateral intact pedicles. Although this does not represent a statistically significant difference (P = 0.15), it suggests that damaging the pedicular cortex may weaken pedicle screw fixation.

Placement of transpedicular vertebral screws close to anterior vertebral cortex. Description of methods.

Strengthening of the screw-vertebra interface has been shown to occur with implantation of longer transpedicular screws, the tips of which are placed closer to the anterior cortex of the vertebral body. Such implantation probably results in increased risk for anterior cortex penetration and associated vascular or pulmonary damage. Typically recommended lateral and posterior-anterior radiography is shown here to provide potentially misleading visualization during implantation. To reduce the risk of anterior cortical penetration, presented here are 1) a radiographic method ("near approach view") that avoids this problem and allows direct visualization of the relationship between drill bit or screw tip and anterior vertebral cortex, and 2) a surgical technique ("mallet method") that provides both an audible and a palpable change when the drill bit contacts the anterior cortex.

Vasodepressor carotid sinus syncope.

There have been few reports of vasodepressor carotid sinus syncope, as opposed to the cardioinhibitory type, and no definitive treatment has been described. A 58 year old man developed episodes of syncope after surgery and radiotherapy for a laryngeal tumour. The episodes were characterised by hypotension, sharp pain in the right neck, dizziness, and bradycardia. A temporary pacemaker failed to prevent the symptoms, but ephedrine and fludrocortisone produced substantial improvement. Of the four types of treatment used in carotid sinus syncope, irradiation was ruled out because the patient had had irradiation before developing syncope, surgery was inappropriate because of the laryngeal tumour, and pacing failed. Combined drug treatment with a vasoconstrictor and plasma volume expander produced an improvement in symptoms but did not eliminate them.

Stress fractures of the great toe sesamoids.

Stress fractures of the great toe sesamoids have not been previously confirmed as a clinical entity. In this report, we present four such cases, and document the diagnosis by histological sections. All of the patients had experienced the insidious onset of activity-related forefoot pain, and had radiographs that demonstrated a sesamoid fracture. None of the fractures healed with 6 weeks of immobilization and prolonged (4-6 months) inactivity. In all cases, the fractured sesamoid was excised, and the hematoxylin and eosin sections of the fracture segments documented the prefracture stress and incomplete repair characteristic of a stress fracture.