This randomized trial of 283 patients with 6 to 12 weeks of severe sciatica compared early microdiskectomy surgery with a strategy of prolonged conservative treatment with eventual surgery if needed. ...Patients who had early surgery reported faster recovery and more rapid improvement in leg pain. After 1 year, the outcomes in the two groups were similar, and 95% of the patients in both groups reported recovery.
Patients who had early microdiskectomy surgery reported faster recovery and more rapid improvement in leg pain. After 1 year, 95% of the patients in both groups reported recovery.
Sciatica is characterized by radiating pain in an area of the leg typically served by one nerve root in the lumbar or sacral spine; it is sometimes also associated with sensory and motor deficits. The most common cause of sciatica is a herniated disk. The estimated annual incidence of sciatica in Western countries is 5 cases per 1000 adults.
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The economic effect of lumbar-spine disorders is great. Lumbar-spine disorders rank fifth among disease categories in the cost of hospital care and account for higher costs resulting from absenteeism from work and disability than any other category.
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The natural history of . . .
Objectives To evaluate the effects of early lumbar disc surgery compared with prolonged conservative care for patients with sciatica over two years of follow-up.Design Randomised controlled ...trial.Setting Nine Dutch hospitals.Participants 283 patients with 6-12 weeks of sciatica.Interventions Early surgery or an intended six months of continued conservative treatment, with delayed surgery if needed.Main outcome measures Scores from Roland disability questionnaire for sciatica, visual analogue scale for leg pain, and Likert self rating scale of global perceived recovery.Results Of the 141 patients assigned to undergo early surgery, 125 (89%) underwent microdiscectomy. Of the 142 patients assigned to conservative treatment, 62 (44%) eventually required surgery, seven doing so in the second year of follow-up. There was no significant overall difference between treatment arms in disability scores during the first two years (P=0.25). Improvement in leg pain was faster for patients randomised to early surgery, with a significant difference between “areas under the curves” over two years (P=0.05). This short term benefit of early surgery was no longer significant by six months and continued to narrow between six months and 24 months. Patient satisfaction decreased slightly between one and two years for both groups. At two years 20% of all patients reported an unsatisfactory outcome.Conclusions Early surgery achieved more rapid relief of sciatica than conservative care, but outcomes were similar by one year and these did not change during the second year.Trial Registry ISRCT No 26872154.
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BFBNIB, CMK, NMLJ, NUK, PNG, SAZU, UL, UM, UPUK
Objective To determine whether the faster recovery after early surgery for sciatica compared with prolonged conservative care is attained at reasonable costs.Design Cost utility analysis alongside a ...randomised controlled trial.Setting Nine Dutch hospitals.Participants 283 patients with sciatica for 6-12 weeks, caused by lumbar disc herniation.Interventions Six months of prolonged conservative care compared with early surgery.Main outcome measures Quality adjusted life years (QALYs) at one year and societal costs, estimated from patient reported utilities (UK and US EuroQol, SF-6D, and visual analogue scale) and diaries on costs (healthcare, patient’s costs, and productivity).Results Compared with prolonged conservative care, early surgery provided faster recovery, with a gain in QALYs according to the UK EuroQol of 0.044 (95% confidence interval 0.005 to 0.083), the US EuroQol of 0.032 (0.005 to 0.059), the SF-6D of 0.024 (0.003 to 0.046), and the visual analogue scale of 0.032 (−0.003 to 0.066). From the healthcare perspective, early surgery resulted in higher costs (difference €1819 (£1449; $2832), 95% confidence interval €842 to €2790), with a cost utility ratio per QALY of €41 000 (€14 000 to €430 000). From the societal perspective, savings on productivity costs led to a negligible total difference in cost (€−12, €−4029 to €4006).Conclusions Faster recovery from sciatica makes early surgery likely to be cost effective compared with prolonged conservative care. The estimated difference in healthcare costs was acceptable and was compensated for by the difference in absenteeism from work. For a willingness to pay of €40 000 or more per QALY, early surgery need not be withheld for economic reasons.Trial registration Current Controlled Trials ISRCTN 26872154.
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BFBNIB, CMK, NMLJ, NUK, PNG, SAZU, UL, UM, UPUK
Obstetric brachial plexus palsy (OBPP) is caused by traction to the brachial plexus during labour. In the majority of cases delivery of the upper shoulder is blocked by the mother's pubic symphysis ...(shoulder dystocia). If additional traction is applied to the child's head, the angle between the neck and the shoulder is forcefully widened, overstretching the ipsilateral brachial plexus. The resulting traction injury may vary from neurapraxia or axonotmesis to neurotmesis and avulsion of rootlets from the spinal cord. Recently, the exact origin of OBPP was again a matter of debate. It was suggested that intrauterine maladaptation, not nerve traction, causes the plexopathy. The incidence of OBPP varies from 1.6 to 2.9 per 1000 births in prospective studies. The upper brachial plexus is most commonly affected, resulting in paresis of the shoulder and biceps muscles, as first described by Erb and Duchenne. Hand function is additionally impaired in approximately 15% of patients; isolated injury to the lower plexus (Déjèrine-Klumpke's type) is rare.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Sciatica caused by a lumbar disk herniation is a frequently diagnosed disorder with a favorable natural course. While most prognostic studies focus on good outcome, patients might experience ...unsatisfactory results. Female gender has been found to be associated with chronic pain in other musculoskeletal disorders. Our aim is to quantify the relationship between gender and (1) rate of recovery and (2) outcome at one year. Recovery was registered on a 7-point Likert scale for 283 patients with 6–12 weeks of persistent sciatica who participated in a randomized trial to investigate timing of surgery. Complete and near complete recovery were considered good outcomes. Function and pain were registered by the Roland Disability Questionnaire (RDQ) and a visual analogue scale (VAS). A univariate Cox model was used to study the influence of variables on rate of recovery while a univariate and multivariate logistic regression analysis evaluated variables predicting unsatisfactory outcome at 12 months. At one year unsatisfactory outcome was registered for 17% of patients, 11% of all males and 28% of all females (
p
<
0.001). Patients with an unsatisfactory outcome had worse RDQ and VAS scores compared to those who recovered satisfactorily (
p
<
0.001). Women had a slower rate of recovery: HR 0.76 (95% CI 0.59–0.99) and xbfnkbsdkvbated with an unsatisfactory outcome represented by an unadjusted odds ratio of 3.3 (95% CI 1.7–6.3) compared to males. Besides a slower recovery rate, female gender was a strong predictor of unsatisfactory outcome at one year for patients with sciatica.
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GEOZS, IJS, IMTLJ, KILJ, OILJ, SBCE, SBJE, UL, UPUK
The aim of this retrospective study was to evaluate the restoration of shoulder function by means of suprascapular nerve neurotization in adult patients with proximal C-5 and C-6 lesions due to a ...severe brachial plexus traction injury. The primary goal of brachial plexus reconstructive surgery was to restore biceps muscle function and, secondarily, to reanimate shoulder function.
Suprascapular nerve neurotization was performed by grafting the C-5 nerve in 24 patients and by accessory or hypoglossal nerve transfer in 29 patients. Additional neurotization involving the axillary nerve was performed in 18 patients. Postoperative needle electromyography studies of the supraspinatus, infraspinatus, and deltoid muscles showed signs of reinnervation in most patients; however, active glenohumeral shoulder function recovery was poor. In nine (17%) of 53 patients supraspinatus muscle strength was Medical Research Council (MRC) Grade 3 or 4 and in four patients (8%) infraspinatus muscle power was MRC Grade 3 or 4. In 18 patients in whom deltoid muscle reinnervation was attempted, MRC Grade 3 or 4 function was demonstrated in two (11%). In the overall group, eight patients (15%) exhibited glenohumeral abduction with a mean of 44 +/- 17 degrees (standard deviation SD; median 45 degrees) and four patients (8%) exhibited glenohumeral exorotation with a mean of 48 +/- 24 degrees (SD; median 53 degrees). In only three patients (6%) were both functions regained.
The reanimation of shoulder function in patients with proximal C-5 and C-6 brachial plexus traction injuries following suprascapular nerve neurotization is disappointingly low.
Recent progress in the understanding of cerebral plastic changes that occur after an intercostal nerve (ICN)-musculocutaneous nerve (MCN) transfer motivated a study with functional magnetic resonance ...(fMR) imaging to map reorganization in the primary motor cortex.
Eleven patients with traumatic root avulsions of the brachial plexus were studied. Nine patients underwent ICN-MCN transfer to restore biceps function and two patients were studied prior to surgery. The biceps muscle recovered well in seven patients who had undergone surgery and remained paralytic in the other two patients. Maps of neural activity within the motor cortex were generated for both arms in each patient by using fMR imaging, and the active pixels were counted. The motor task consisted of biceps muscle contraction. Patients with a paralytic biceps were asked to contract this muscle virtually. The location and intensity of motor activation of the seven surgically treated arms that required good biceps muscle function were compared with those of the four arms with a paralytic biceps and with activity obtained in the contralateral hemisphere regulating the control arms. Activity could be induced in the seven surgically treated patients whose biceps muscles had regained function and was localized within the primary motor area. In contrast, activity could not be induced in the four patients whose biceps muscles were paralytic. Neither the number of active pixels nor the mean value of their activations differed between the seven arms with good biceps function and control arms. The weighted center of gravity of the distribution of activity also did not appear to differ.
Reactivation of the neural input activity for volitional biceps control after ICN-MCN transfer, as reflected on fMR images, is induced by successful biceps muscle reinnervation. In addition, the restored input activity does not differ from the normal activity regulating biceps contraction and, therefore, has MCN acceptor qualities. After ICN-MCN transfer, cerebral activity cannot reach the biceps muscle following the normal nervous system pathway. The presence of a common input response between corticospinal neurons of the ICN donor and the MCN acceptor seems crucial to obtain a functional result after transfer. It may even be the case that a common input response between donor and acceptor needs to be present in all types of nerve transfer to become functionally effective.
Patients harboring colloid cysts of the third ventricle can present with acute neurological deterioration, or the first indication of the lesion may appear when the patient suddenly dies. The risk of ...such an occurrence in a patient already identified as harboring a colloid cyst is unknown. The goal of this study was to estimate the risk of acute deterioration in patients with colloid cysts.
A retrospective study was made of a cohort of patients with newly diagnosed colloid cysts who were recruited in The Netherlands between January 1, 1993, and December 31, 1997. Seventy-eight patients were identified, all of whom displayed symptoms. Twenty-five patients (32%) presented with symptoms of acute deterioration; four patients died suddenly and the cysts were discovered at autopsy. The overall mortality rate was 12%. Results of a multivariate logistic regression analysis demonstrated that no subgroup of patients presenting without acute deterioration could be identified on the basis of patient age, duration of symptoms, cyst size, or the presence of hydrocephalus. The national incidence of colloid cysts in The Netherlands is 1/10(6) person-years; the prevalence was estimated to be 1800 asymptomatic colloid cysts.
Acute deterioration was a frequent presentation among a national cohort of Dutch patients harboring symptomatic colloid cysts. The risk of acute deterioration in a symptomatic patient with a colloid cyst in The Netherlands is estimated to be 34%. The estimated risk for an asymptomatic patient with an incidental colloid cyst is significantly lower. These results strongly advocate the selection of surgical treatment for patients with symptomatic colloid cysts.
Attachment to and proliferation on the substrate are deemed important considerations when Schwann cells (SCs) are to be seeded in synthetic nerve grafts. Attachment is a prerequisite for the SCs to ...survive and fast proliferation will yield large numbers of SCs in a short time, which appears promising for stimulation of peripheral nerve regeneration. The aim of the present study was to compare the adhesion and proliferation of human Schwann cells (HSCs) on different substrates. The following were selected for their suitability as an internal coating of synthetic nerve grafts; the extracellular matrix proteins fibronectin, laminin and collagen type I and the poly-electrolytes poly(
d-lysine) (PDL) and poly(ethylene-imine) (PEI). On all coatings, attachment of HSCs was satisfactory and comparable, indicating that this factor is not a major consideration in choosing a suitable coating.
Proliferation was best on fibronectin, laminin and PDL, and worst on collagen type I and PEI. Since nerve regeneration is enhanced by laminin and/or fibronectin, these are preferred as coatings for synthetic nerve grafts seeded with SCs.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Although clinical guidelines for sciatica have been developed, various aspects of lumbar disc herniation remain unclear, and daily clinical practice may vary. The authors conducted a descriptive ...survey among spine surgeons in the Netherlands to obtain an overview of routine management of lumbar disc herniation.
One hundred thirty-one spine surgeons were sent a questionnaire regarding various aspects of different surgical procedures. Eighty-six (70%) of the 122 who performed lumbar disc surgery provided usable questionnaires.
Unilateral transflaval discectomy was the most frequently performed procedure and was expected to be the most effective, whereas percutaneous laser disc decompression was expected to be the least effective. Bilateral discectomy was expected to be associated with the most postoperative low-back pain. Recurrent disc herniation was expected to be lowest after bilateral discectomy and highest after percutaneous laser disc decompression. Complications were expected to be highest after bilateral discectomy and lowest after unilateral transflaval discectomy. Nearly half of the surgeons preferentially treated patients with 8-12 weeks of disabling leg pain. Some consensus was shown on acute surgery in patients with short-lasting drop foot and those with a cauda equina syndrome, and nonsurgical treatment in patients with long-lasting, painless drop foot. Most respondents allowed postoperative mobilization within 24 hours but advised their patients not to resume work until 8-12 weeks postoperatively.
Unilateral transflaval discectomy was the most frequently performed procedure. Minimally invasive techniques were expected to be less effective, with higher recurrence rates but less postoperative low-back pain. Variety was shown between surgeons in the management of patients with neurological deficit. Most responding surgeons allowed early mobilization but appeared to give conservative advice in resumption of work.
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