Variations in selective nerve root block technique.

INTRODUCTION: Much literature reports on selective nerve root blocks (SNRBs) in cases of lumbosacral radiculopathy. Unfortunately, authors only inconsistently reveal the exact needle tip position relative to the causative pathology at the time of injection. Different injection sites may provide different symptomatic benefits. We investigated the variation in injection techniques of practitioners working in the UK. METHODS: A clinical scenario was devised depicting a patient with radiculopathy secondary to an L4/5 vertebral disc prolapse. Participants were questioned on their chosen management of this patient, focusing particularly on SNRB technique. Questionnaires were sent to spinal surgeons, pain management specialists and musculoskeletal radiologists. RESULTS: A total of 100 responses were detailed enough for inclusion. The majority (83%) of respondents reported they would inject local anaesthetic and steroids, 4% would inject local anaesthetic alone and 13% would inject a different substance. Over half (53%) would target the L5 nerve root, 26% the L4 nerve root, 12% the prolapsed disc itself and 9% two separate vertebral levels. Variation was also noted in needle tip location relative to the neural sheath. CONCLUSIONS: When treating lumbar radiculopathy, there are apparent variations in the use and positioning of SNRBs for a given level of disc pathology. Needle tip position may have a direct influence on clinical outcome following SNRBs. Caution is therefore required when considering the validity of previously published studies investigating SNRBs and different injectates.

Is cauda equina syndrome linked with obesity?

No previous studies have examined the physical characteristics of patients with cauda equina syndrome (CES). We compared the anthropometric features of patients who developed CES after a disc prolapse with those who did not but who had symptoms that required elective surgery. We recorded the age, gender, height, weight and body mass index (BMI) of 92 consecutive patients who underwent elective lumbar discectomy and 40 consecutive patients who underwent discectomy for CES. On univariate analysis, the mean BMI of the elective discectomy cohort (26.5 kg/m2 (16.6 to 41.7) was very similar to that of the age-matched national mean (27.6 kg/m2, p = 1.0). However, the mean BMI of the CES cohort (31.1 kg/m2 (21.0 to 54.9)) was significantly higher than both that of the elective group (p < 0.001) and the age-matched national mean (p < 0.001). A similar pattern was seen with the weight of the groups. Multivariate logistic regression analysis was performed, adjusted for age, gender, height, weight and BMI. Increasing BMI and weight were strongly associated with an increased risk of CES (odds ratio (OR) 1.17, p < 0.001; and OR 1.06, p < 0.001, respectively). However, increasing height was linked with a reduced risk of CES (OR 0.9, p < 0.01). The odds of developing CES were 3.7 times higher (95% confidence interval (CI) 1.2 to 7.8, p = 0.016) in the overweight and obese (as defined by the World Health Organization: BMI ≥ 25 kg/m2) than in those of ideal weight. Those with very large discs (obstructing > 75% of the spinal canal) had a larger BMI than those with small discs (obstructing < 25% of the canal; p < 0.01). We therefore conclude that increasing BMI is associated with CES.

The relationship of pre- and postoperative median and ulnar nerve conduction measures to a self-administered questionnaire in carpal tunnel syndrome.

STUDY AIMS: Following carpal tunnel release (CTR), only very modest correlations have been found between subjective symptoms and function indexes compared to neurophysiological measures. The objective of this study was to evaluate this relationship by comparing the self-administered Boston symptom severity score and function severity score questionnaire against nerve conduction studies (NCS) before and after CTR using two different electrophysiological techniques. PATIENTS AND METHODS: Carpal tunnel release was performed in 51 patients (62 hands). Pre- and postoperative NCS were evaluated using both conventional neurophysiological methods and by means of a new hand-held device. RESULTS: Preoperatively there was almost no correlation between symptom severity and function scores and NCS results. Following surgery however, both symptom severity and function showed a modest, but significant improvement in their correlation to NCS (at highest r=0.405, P<0.01). This improvement in the relation of subjective measures to neurophysiological results was seen in both median nerve sensory and motor conduction as well as in ulnar nerve motor conduction. CONCLUSIONS: In addition to median-nerve dysfunction, it might be suggested that ulnar nerve changes can contribute to symptoms of carpal tunnel syndrome in patients. Several associations were found using a median-ulnar sensory latency difference in the finger-wrist segment and a sensory conduction difference in the palm to wrist segment. Significant correlations were established by both conventional NCS and the new hand-held device.

Reducing the economic impact of carpal tunnel surgery.

A nurse-led carpal tunnel service was started in Leicester in 1999. Many developments in the service have been patient-driven. A large proportion of our patients are not salaried and many had expressed concerns about the amount of time taken off work after surgery. This therefore prompted us to encourage immediate hand function after surgery. Subsequently, in 494 patients studied prospectively, we have seen 93% of patients return to work by 2 weeks and 99% by 4 weeks. This has obvious benefits in terms of reducing loss of income. Furthermore there is potential for considerable economic savings.

The long-term outcome after central cord syndrome: a study of the natural history.

We studied 32 patients with central cord syndrome who were managed conservatively. Six were under 50 years of age (group 1), 16 between 50 and 70 years (group 2) and ten over 70 years (group 3). At the time of discharge all patients in group 1 could walk independently and had good bladder control compared with 11 (69%) and 14 (88%) in group 2 and four (40%) and two (20%) in group 3, respectively. At follow-up after a mean of 8.6 years (4 to 15), ten patients had died leaving 22 in the study. All those in group 1 were alive, could walk independently and had bladder control. In group 2, 13 were alive of whom ten (77%) could walk independently and nine (69%) had bladder control. In group 3 only three were alive of whom only one was independent and none had bladder control. Function at discharge as measured by the ASIA motor scoring system was usually maintained or improved at follow-up, but patients over 70 years of age at injury did poorly.

Delayed focal neurological deficit secondary to a cervico-thoracic spinal cord epidural haematoma.

This is a report of an elderly woman who developed focal neurological deficit in association with a cervico-thoracic spinal epidural haematoma. Symptoms developed several days after the initial injury and subsequently resolved without surgical intervention. The unusual features of this presentation are discussed.

Deep hand infection complicating chickenpox in an otherwise healthy infant.

Chickenpox is a common childhood infection, and complications are rare in the healthy child. This report describes a significant complication of varicella in an otherwise healthy infant.

Pain relief following tennis elbow release.

We studied the outcome of tennis elbow release in 27 patients at an average of 29.6 months after surgery. We found that 44% of patients had obtained complete pain relief, 37% of patients experienced occasional pain and 19% of patients still experienced moderate pain. Pain relief was significantly better in those patients with the shorter duration of preoperative symptoms. We therefore conclude that surgery for tennis elbow should be employed at an earlier stage than is currently practised.

The AO classification of long bone fractures: an early study of its use in clinical practice.

Over a period of 6 months, 543 long bone fractures were classified using the AO classification system. Factors important in determining the management of fractures occurring in three regions; hip, forearm and tibia, were identified. In hip fractures, we found that the anatomical configuration of the fracture, and therefore its classification, generally determined management. However, there were other factors that influenced the more specific form of surgical treatment used. In forearm fractures, the age of the patient was the most important factor determining treatment, while many factors, including consultant preference, determined the treatment of tibial fractures. While we found the system useful for audit purposes, we also found that it was unnecessarily complicated and often fell short of playing a useful role in the planning of management.