Longer Duration Of Preoperative Symptoms Research Articles

A Biomimetic Osteochondral Scaffold Augmented With Filtered Bone Marrow Aspirate for the Treatment of Joint Surface Lesions in the Knee

Background: Multilayered osteochondral scaffolds are becoming increasingly utilized for the repair of knee joint surface lesions (KJSLs). However, the literature on predictive factors is rather limited. Purpose: To (1) evaluate the clinical outcomes and safety of a combined single-step approach using a biomimetic collagen-hydroxyapatite scaffold (CHAS) and filtered bone marrow aspirate (fBMA) for the treatment of KJSLs and (2) identify significant predictors of the treatment outcomes. Study Design: Case series; Level of evidence, 4. Methods: All patients who underwent surgery because of a KJSL (size ≥1.5 cm2; International Cartilage Regeneration & Joint Preservation Society grades 3-4) using the combination above were selected from a hospital registry database (100 patients; minimum 2-year follow-up). Patient characteristics, medical history, knee joint and lesion status, intraoperative details, and cellular parameters of the injected fBMA were collected. The arthroscopic evaluation of chondral and meniscal tissue quality in all knee compartments was performed using the Chondropenia Severity Score. Treatment outcomes were determined clinically using patient-reported outcome measures (Knee Injury and Osteoarthritis Outcome Score, EuroQol–5 Dimensions–3 Levels, EuroQol–Visual Analog Scale, and Tegner Activity Scale) and by assessing the occurrence of serious adverse events and graft failure. Multivariable regression analysis was performed to identify significant predictors of the treatment outcomes. Results: At a mean follow-up of 54.2 ± 19.4 months, 78 (87%) patients completed the questionnaires with significant improvements toward the baseline (P < .00625): KOOS Pain subscale from 62 ± 17 to 79 ± 18, KOOS Total score from 57 ± 16 to 70 ± 20, EuroQol–Visual Analog Scale from 61 ± 21 to 76 ± 16, EuroQol–5 Dimensions–3 Levels from 0.57 ± 0.20 to 0.80 ± 0.21, and Tegner Activity Scale from 2.8 ± 1.5 to 3.9 ± 1.9. The graft failure rate was 4%. A longer duration of preoperative symptoms, previous surgery, larger lesions, older age, and female sex were the main negative predictors for the treatment outcomes. The Chondropenia Severity Score and the number of fibroblast colony-forming units in fBMA positively influenced some of the clinical results and safety. Conclusion: A CHAS augmented with fBMA proved to be an adequate and safe approach for the treatment of KJSLs up to midterm follow-up. Based on the subanalysis of predictive factors, the surgical intervention should be performed in a timely and precise manner to prevent lesion enlargement, deterioration of the general knee cartilage status, and recurrent surgical procedures, especially in older and female patients. When a CHAS is used, the quantity of MSCs seems to play a role in augmentation. Registration: NCT06078072 (ClinicalTrials.gov identifier).

Predicting long-term outcomes after microvascular decompression for hemifacial spasm according to lateral spread response and immediate postoperative outcomes: a cohort study.

Microvascular decompression (MVD) is a well-established and highly effective treatment option for hemifacial spasm (HFS). Lateral spread response (LSR) has been used as an intraoperative indicator of HFS resolution, with controversial reliability. The purpose of this study was to determine long-term outcomes of MVD for HFS and the role of LSR and other preoperative predictors. The authors conducted a cohort study of all patients treated with MVD for HFS at a single institution from January 1, 1998, to December 31, 2019. In addition to a retrospective chart review, all patients were contacted at the time of the study to provide informed consent and responded to a telephone survey to ascertain their current disease and medication status. Patients with at least 12 months of postoperative follow-up were included. Statistical testing included a Student t-test, Fisher's exact test, logistic regression, and Cox proportional hazards analysis. One hundred nineteen patients met study criteria; 41 (34%) had at least 10 years of clinical follow-up. HFS fully resolved in 93 (78%), symptoms subjectively improved in 11 (9%) and were unchanged in 15 (13%). Immediate postoperative HFS status did not correlate with long-term outcome (p = 0.13). Changes in LSR were not associated with outcome. Patients receiving neuromodulating agents had significantly longer preoperative duration of symptoms and were more likely to show persistent LSR intraoperatively. HFS recurrence was associated with younger age at the time of surgery but not with intraoperative LSR resolution. This study demonstrated that MVD for HFS is highly effective for most patients. Neither intraoperative LSR change nor immediate postoperative status was predictive of long-term outcomes.

Flexor tendon degeneration affects short-term outcomes of open trigger digit release.

We aimed to investigate the association between flexor tendon degeneration and outcome of open trigger digit release. We recruited 162 trigger digits (136 patients) who had open trigger digit release from February 2017 to March 2019. Intraoperatively, six features of tendon degenerations were identified: irregular tendon surface, tendon fraying, intertendinous tear, synovial thickening, hyperaemia of sheath and tendon dryness. Longer duration of preoperative symptoms was associated with worsening tendon surface irregularity and fraying; increased number of steroid injections was associated with worsening tendon surface irregularity and dryness; higher DASH score was associated with severe tendon fraying, dryness and intertendinous tear; limited proximal interphalangeal joint (PIPJ) motion was associated with severe tendon dryness. At 1-month post-surgery, DASH score remained high in severe intertendinous tear group while PIPJ motion remained limited in severe tendon dryness group. In conclusion, the severity of various flexor tendon degenerations influenced the outcome of open trigger digit release at 1-month but did not affect the outcome at 3- and 6-months post-surgery.

Paper 03: Suprascapular Neuropathy: Two Distinct Presentations and Outcomes of Decompression

Objectives: Suprascapular neuropathy due to nerve compression or tension at the suprascapular notch is an uncommon source of shoulder pain and rotator cuff weakness with recent increased recognition and treatment. Long considered an elusive diagnosis, work-up can be lengthy and patients may experience treatment delay. We aimed to review presentation patterns and outcomes of arthroscopic suprascapular nerve decompression in a predominantly young and active military population. Methods: The surgical databases of two surgeons were queried for patients treated with arthroscopic suprascapular nerve decompression at the suprascapular notch from 2013 to 2021. Patient data, presentation and workup findings, and outcome measures were collected through review of the electronic medical record. Primary outcome measures were rate of return to active-duty military service, shoulder abduction and external rotation strength, and VAS pain scores. Secondary outcome measures were American Shoulder and Elbow Surgeons (ASES) Shoulder Score, Visual Analogue Scale (VAS), and Single Assessment Numerical Evaluation (SANE) score. Results: Twenty-five patients were identified. Average age was 26.6 years and follow-up 17.9 months (4-62 months). There were two distinct primary presentation types in this cohort: the chief complaint was pain in 13 patients (52%) and weakness in 12 (48%). Supraspinatus and/or infraspinatus atrophy was present on MRI in 10/12 patients with weakness and 0/13 with pain. Electromyography was positive in 9/12 with weakness and negative when obtained in 5 patients with pain. Ultrasound-guided suprascapular nerve injection was performed in 10/13 with pain and provided mean 91% symptom relief. Patients with pain had longer duration of pre-operative symptoms (22.2 [±13.1] vs. 10.3 [±13.6] weeks). Postoperatively, the pain group had significant improvement in VAS scores (6.2 [±1.6] to 1.0 [±0.9]), while the weakness group had significant improvement in abduction and external rotation motor grading (3.7 [±0.7] to 4.7 [±0.4] and 3.3 [±0.8] to 4.4 [±0.6] respectively). Return to duty or sport was 92% at a mean of 14.6 (±9.3) weeks. Conclusions: In this young, active cohort, suprascapular neuropathy presented with one of two distinct primary presenting complaints: pain or weakness. Given different expected work-up findings, categorizing patients into one of these two groups may be beneficial in effectively diagnosing and treating suprascapular neuropathy. Outcomes after arthroscopic suprascapular nerve release at the suprascapular notch predictably led to successful pain relief and strength improvement in patients presenting with pain and weakness respectively. [Table: see text][Table: see text]

Timing of Surgical Intervention for Dysphagia in Patients With Diffuse Idiopathic Skeletal Hyperostosis: A Systematic Review and Meta-Analysis.

This was a systematic review and meta-analysis. The objective was (1) to measure rates of successful resolution of dysphagia in patients after undergoing surgical intervention for diffuse idiopathic skeletal hyperostosis (DISH); and (2) to determine if older age, longer duration of preoperative symptoms, or increased severity of disease was correlated with unsuccessful surgical intervention. DISH, also known as Forestier disease, is an enthesopathy affecting up to 35% of the elderly population. Many patients develop osteophytes of the anterior cervical spine, which contribute to chronic symptoms of dysphagia causing debilitating weight loss and possibly resulting in the placement of a permanent gastrostomy feeding tube. For patients that fail conservative medical management, an increase in surgical interventions have been reported in the literature in the last 2 decades. A systematic search was performed on PubMed, Medline, Cochrane Library, and Embase. Studies measuring outcomes after surgical intervention for patients with dysphagia from DISH were selected for inclusion. Two independent reviewers screened and assessed all literature in accordance with Cochrane systematic reviewing standards. In total, 22 studies reporting 119 patients were selected for inclusion. Successful relief of dysphagia was obtained in 89% of patients after surgical intervention. Failure to relieve dysphagia was associated with increased length of symptoms preoperatively (P<0.01) using logistic regression. Patients with more severe preoperative symptoms also seem to have an increased risk for treatment failure (risk ratio, 2.86; 95% confidence interval, 1.19-6.85; P=0.02). Treatment failure was not associated with patient age, use of intraoperative tracheostomy, implementation of additional fusion procedures, level of involved segments, or number of involved segments. Patients undergoing surgical intervention have a higher likelihood of failing surgery with increasing preoperative symptom length and increased preoperative symptom severity. Level III.

The Impact of Modic Changes on Preoperative Symptoms and Clinical Outcomes in Anterior Cervical Discectomy and Fusion Patients.

ObjectiveTo assess the impact of Modic changes (MC) on preoperative symptoms, and postoperative outcomes in anterior cervical discectomy and fusion (ACDF) patients. MethodsWe performed a retrospective study of prospectively collected data of ACDF patients at a single institution. Preoperative magnetic resonance imagings were used to assess the presence of MC. MC were stratified by type and location, and compared to patients without MC. Associations with symptoms, patient-reported measures, and surgical outcomes were assessed. ResultsA total of 861 patients were included, with 356 patients with MC (41.3%). MC more frequently occurred at C5–6 (15.1%), and type II was the most common type (61.2%). MC were associated with advanced age (p < 0.001), more levels fused (p < 0.001), a longer duration of symptoms, but not with specific symptoms. MC at C7–T1 resulted in higher postoperative disability (p < 0.001), but did not increase risk of adjacent segment degeneration or reoperation. ConclusionThis study is the first to systematically examine the impact of cervical MC, stratified by type and location, on outcomes in ACDF patients. Patients with MC were generally older, required larger fusions, and had longer duration of preoperative symptoms. While MC may not affect specific outcomes following ACDF, they may indicate a more debilitating preoperative state for patients.

Surgical results and prognostic factors following percutaneous full endoscopic posterior decompression for thoracic myelopathy caused by ossification of the ligamentum flavum

Minimally invasive surgery (MIS) has shown satisfactory surgical results for the treatment of thoracic myelopathy (TM) caused by ossification of the ligamentum flavum (OLF). This study investigated the prognostic factors following MIS and was based on the retrospective analysis of OLF patients who underwent percutaneous full endoscopic posterior decompression (PEPD). Thirty single-segment OLF patients with an average age of 60.4 years were treated with PEPD under local anaesthesia. Clinical data were collected from the medical and operative records. The surgical results were assessed by the recovery rate (RR) calculated from the modified Japanese Orthopaedic Association (mJOA) score. Correlations between the RR and various factors were analysed. Patients’ neurological status improved from a preoperative mJOA score of 6.0 ± 1.3 to a postoperative mJOA score of 8.5 ± 2.0 (P < 0.001) at an average follow-up of 21.3 months. The average RR was 53.8%. Dural tears in two patients (6.7%, 2/30) were the only observed complications. Multiple linear regression analysis showed that a longer duration of preoperative symptoms and the presence of a high intramedullary signal on T2-weighted MRI (T2HIS) were significantly associated with poor surgical results. PEPD is feasible for the treatment of TM patients with a particular type of OLF. Patients without T2HIS could achieve a good recovery if they received PEPD early.

Longer Preoperative Duration of Symptoms Negatively Affects Health-related Quality of Life After Surgery for Cervical Radiculopathy.

Retrospective cohort. Determine the effect of duration of symptoms (DOS) on health-related quality of life (HRQOL) outcomes for patients with cervical radiculopathy. The effect of DOS has not been extensively evaluated for cervical radiculopathy. A retrospective analysis of patients who underwent an anterior cervical decompression and fusion for radiculopathy was performed. Patients were grouped based on DOS of less than 6 months, 6 months to 2 years, and more than 2 years and HRQOL outcomes were evaluated. A total of 216 patients were included with a mean follow-up of 16.0 months. There were 86, 61, and 69 patients with symptoms for less than 6 months, 6 months to 2 years, and more than 2 years, respectively. No difference in the absolute postoperative score of the patient reported outcomes was identified between the cohorts. However, in the multivariate analysis, radiculopathy for more than 2 years predicted lower postoperative Short Form-12 Physical Component Score (P = 0.037) and Short Form-12 Mental Component Score (P = 0.029), and higher postoperative Neck Disability Index (P = 0.003), neck pain (P = 0.001), and arm pain (P = 0.004) than radiculopathy for less than 6 months. Furthermore, the recovery ratios for patients with symptoms for less than 6 months demonstrated a greater improvement in NDI, neck pain, and arm pain than for 6 months to 2 years (P = 0.041; 0.005; 0.044) and more than 2 years (P = 0.016; 0.014; 0.002), respectively. Patients benefit from spine surgery for cervical radiculopathy at all time points, and the absolute postoperative score for the patient reported outcomes did not vary based on the duration of symptoms; however, the regression analysis clearly identified symptoms for more than 2 years as a predictor of worse outcomes, and the recovery ratio was statistically significantly improved in patients who underwent surgery within 6 months of the onset of symptoms. 3.

Increasing reoperation rates and inferior outcome with prolonged symptom duration in lumbar disc herniation surgery — a prospective cohort study

BACKGROUND CONTEXTLumbar disc herniation (LDH) is associated with great morbidity and significant socioeconomic impact in many parts of the world. Studies have shown that most LDH can be treated effectively with nonoperative management. However, for some patients in whom pain and disability are unacceptable, surgical intervention provides effective clinical relief. Currently, there is little consensus in the medical community on the timing of surgery for patients suffering from radicular pain due to LDH. Multiple studies suggest that prolonged symptom duration adversely affects clinical outcome. PURPOSEThe aim of this study is to evaluate if prolonged symptom duration is correlated with less favorable outcome following surgery for LDH. STUDY DESIGN/SETTINGConsecutive series of patients from a single-center, multisurgeon, tertiary spine practice. PATIENT SAMPLEConsecutive series of patients who underwent surgery for LDH. OUTCOME MEASURESOswestry Disability Index (ODI), EuroQol-5D (EQ-5D), and Visual Analog Scale (VAS) for back and leg pain (0–100). METHODSPatients with a first-episode LDH were included. Data were prospectively collected in DaneSpine, the Danish National Spine Registry. Subjects were divided into three groups based on their preoperative self-reported duration of leg pain: <3 months, 3 to 12 months, and >12 months. Associations between patient-reported outcomes (PROs), perioperative complications and duration of symptoms were evaluated. Statistical significance level was set at p value <.01. RESULTSThere were 2,144 patients included in the study, with complete 1-year follow-up on 1,694 patients (79%) and a reoperation rate of 8.4%. Incidence of surgical complications, specifically dural tears, was higher with increasing duration of leg pain; however, this did not reach statistical significance (p=.039). Prolonged preoperative symptoms adversely influenced all PROs (EQ-5D, ODI, VAS) 1 year after surgery (p=.001). Furthermore, reoperation rates increased with longer duration of preoperative symptoms. A statistically significant trend (p=.008) of increasing incidence of reoperation was found with increasing length of symptom duration. CONCLUSIONSDelayed surgical intervention results in inferior outcomes and increased reoperation rates. Patients who had surgery within the first 3 months of leg pain achieved significantly better outcome 1 year after surgery when compared to the other groups.

Friday, September 28, 2018 3:00 PM–4:00 PM abstracts: optimizing lumbar disc surgery: 217. Increasing reoperation rates and inferior outcome with prolonged symptom duration in lumbar disc herniation surgery

BACKGROUND CONTEXT Lumbar disc herniation (LDH) is associated with great morbidity and significant socio-economic impact in many parts of the world. Studies have shown that most LDH can be treated effectively with nonoperative management. However, for some patients where pain and disability is unacceptable, surgical intervention provides effective clinical relief. Currently there is little consensus in the medical community on the timing of surgery for patients suffering from radicular pain due to LDH. Multiple studies suggest that prolonged symptom duration adversely affects clinical outcome. PURPOSE The aim of this study is to evaluate if patients with prolonged preoperative symptom duration will have less favorable outcome following surgery for LDH. STUDY DESIGN/SETTING Consecutive series of patients from a single-center, multisurgeon, teritiary spine practice. PATIENT SAMPLE Consecutive series of patients scheduled for spine surgery. OUTCOME MEASURES Oswestru Disability Index (ODI), EuroQol-5D (EQ-5D) and Visual Analog Scale (VAS) for back and leg pain (0–100). METHODS Patients with first episode LDH were included in a single-center study. Data were prospectively collected in DaneSpine, the Danish National Spine Registry. Subjects were divided into three groups based on their self-reported duration of leg pain prior to enrollment into the registry: <3-months, 3-12 months and >12-months. Associations between patient-reported outcomes (PROs), perioperative complications and duration of symptoms were evaluated. RESULTS A total of 1,834 patients were included in the study, with complete 1-year follow-up on 1,448 patients (79%) and an overall reoperation rate of 8.4%. Incidence of surgical complications, specifically dural tears, was higher with increasing duration of leg pain, however, this did not reach statistical significance (p=.028). Prolonged preoperative symptoms adversely influenced all PROs (EQ-5D, ODI, VAS) 1 year after surgery (p=.001). Furthermore, reoperation rates increased with longer duration of preoperative symptoms. A statistically significant trend (p=.009) of increasing incidence of reoperation was found with increasing length of symptom duration. CONCLUSIONS Delayed surgical intervention results in inferior clinical outcomes and increased reoperation rates. Patients who had surgery within the first 3 months of leg pain achieved the best outcome 1 year after surgery. Lumbar disc herniation (LDH) is associated with great morbidity and significant socio-economic impact in many parts of the world. Studies have shown that most LDH can be treated effectively with nonoperative management. However, for some patients where pain and disability is unacceptable, surgical intervention provides effective clinical relief. Currently there is little consensus in the medical community on the timing of surgery for patients suffering from radicular pain due to LDH. Multiple studies suggest that prolonged symptom duration adversely affects clinical outcome. The aim of this study is to evaluate if patients with prolonged preoperative symptom duration will have less favorable outcome following surgery for LDH. Consecutive series of patients from a single-center, multisurgeon, teritiary spine practice. Consecutive series of patients scheduled for spine surgery. Oswestru Disability Index (ODI), EuroQol-5D (EQ-5D) and Visual Analog Scale (VAS) for back and leg pain (0–100). Patients with first episode LDH were included in a single-center study. Data were prospectively collected in DaneSpine, the Danish National Spine Registry. Subjects were divided into three groups based on their self-reported duration of leg pain prior to enrollment into the registry: <3-months, 3-12 months and >12-months. Associations between patient-reported outcomes (PROs), perioperative complications and duration of symptoms were evaluated. A total of 1,834 patients were included in the study, with complete 1-year follow-up on 1,448 patients (79%) and an overall reoperation rate of 8.4%. Incidence of surgical complications, specifically dural tears, was higher with increasing duration of leg pain, however, this did not reach statistical significance (p=.028). Prolonged preoperative symptoms adversely influenced all PROs (EQ-5D, ODI, VAS) 1 year after surgery (p=.001). Furthermore, reoperation rates increased with longer duration of preoperative symptoms. A statistically significant trend (p=.009) of increasing incidence of reoperation was found with increasing length of symptom duration. Delayed surgical intervention results in inferior clinical outcomes and increased reoperation rates. Patients who had surgery within the first 3 months of leg pain achieved the best outcome 1 year after surgery.

Clinical problems of structural failure after rotator cuff repairs

Arthroscopic rotator cuff repairs are preformed due to growing knowledge of rotator cuff tears among surgeons as well as patients. However, it is unavoidable and may sometimes very common that some patients develop structural failures or retears after surgical repairs because of unique blood supply and healing procedure of the rotator cuff, on which there is still much debate focusing on problems that one needs to deal with in clinical practice. Retears often occur, if without new trauma, during early postoperative period, or more specifically within the first 6 months after repair and are more frequently observed in those with old ages, diabetes or osteoporosis. In addition, risk factors of retears consist of longer preoperative duration of symptoms, larger primitive tear sizes, higher grades of fatty infiltration of muscles on preoperative imaging examinations, excessive tension within reconstructed structures, deteriorated quality of rotator cuff tissues and special shapes of the acromion, etc. Diagnosis is recently based on results of postoperative magnetic resonance imaging or echogram examination. MR/CT arthrography is also used. Each instrument has its advantages and limitations. However, the lack of a golden standard when establishing a diagnosis of rotator cuff retears makes integrating evaluations and comparisons of different methods a difficult question. It has been reported by many that the onset of retear leads to obvious shoulder pain or weakness, whereas more than a few studies demonstrated that very limited influences of retears in spite of generally unaffected shoulder functions, like decreased muscle strength on certain motions. The disagreement is possibly caused by specific methods of diagnosis, function instruments and time point of assessments used by different researchers as studies have displayed that feelings of patients after surgery and results attained by objective examinations are not always parallel. Moreover, some long-time follow-ups studies indicated that the impact posted by retears on shoulder functions evolves over a period of time. Owing to the varied opinions on actual symptoms and final functional outcomes caused by structural failure, the mainstay of treatment for rotator cuff tears are still conservative protocols, including observation and symptoms relief instead of second surgery. Second surgery could be an effective choice for certain patients, especially for those who have apparent symptoms.

Chapter 30 - Spinal cavernous malformations

Spinal cavernous malformations are rare intramedullary vascular lesions of the central nervous system. Most are located in the thoracic spine. Patients present with either acute neurologic deficit or gradual deterioration. Weakness is the most common presenting symptom. The annual hemorrhage risk is 2.1%. Diagnosis is made by magnetic resonance imaging as these lesions are occult on angiography. Surgical removal is indicated in patients with hemorrhage and neurologic deficit. All lesions are approached posteriorly by laminectomy. Dorsal cavernous malformations are exposed by focused laminectomy of the level or levels overlying the lesion with minimally facet violation. Ventral and lateral lesions are approached by laminectomy including a level above and level below as well as unilateral radical facetectomy. After midline dural opening, the dentate ligament is divided and retracted to allow up to 90° of rotation of the spinal cord. Microsurgical treatment is associated with 42% symptom improvement and 50% symptom stabilization. Postoperative worsening is associated with longer preoperative duration of symptoms. Therefore we recommend consideration of early surgery for cavernous malformation removal in patients with symptoms attributable to the lesion.

Timing of surgical treatment for idiopathic normal pressure hydrocephalus: association between treatment delay and reduced short-term benefit.

OBJECTIVE A growing body of evidence suggests that longer durations of preoperative symptoms may correlate with worse postoperative outcomes following cerebrospinal fluid (CSF) diversion for treatment of idiopathic normal pressure hydrocephalus (iNPH). The aim of this study is to determine whether the duration of preoperative symptoms alters postoperative outcomes in patients treated for iNPH. METHODS The authors conducted a retrospective review of 393 cases of iNPH involving patients treated with ventriculoperitoneal (VP) shunting. The duration of symptoms prior to the operative intervention was recorded. The following outcome variables were assessed at baseline, 6 months postoperatively, and at last follow-up: gait performance, urinary continence, and cognition. RESULTS The patients' median age at shunt placement was 74 years. Increased symptom duration was significantly associated with worse gait outcomes (relative risk (RR) 1.055 per year of symptoms, p = 0.037), and an overall absence of improvement in any of the classic triad symptomology (RR 1.053 per year of symptoms, p = 0.033) at 6 months postoperatively. Additionally, there were trends toward significance for symptom duration increasing the risk of having no 6-month postoperative improvement in urinary incontinence (RR 1.049 per year of symptoms, p = 0.069) or cognitive symptoms (RR 1.051 per year of symptoms, p = 0.069). However, no statistically significant differences were noted in these outcomes at last follow-up (median 31 months). Age stratification by decade revealed that prolonging symptom duration was significantly associated with lower Mini-Mental Status Examination scores in patients aged 60-70 years, and lack of cognitive improvement in patients aged 70-80 years. CONCLUSIONS Patients with iNPH with longer duration of preoperative symptoms may not receive the same short-term benefits of surgical intervention as patients with shorter duration of preoperative symptoms. However, with longer follow-up, the patients generally reached the same end point. Therefore, when managing patients with iNPH, it may take longer to see the benefits of CSF shunting when patients present with a longer duration of preoperative symptoms.

Can Preoperative Psychological Assessment Predict Outcomes After Temporomandibular Joint Arthroscopy?

Psychological assessment has been used successfully to predict patient outcomes after cardiothoracic and bariatric surgery. The purpose of this study was to determine whether preoperative psychological assessment could be used to predict patient outcomes after temporomandibular joint arthroscopy. Consecutive patients with temporomandibular dysfunction (TMD) who could benefit from arthroscopy were enrolled in a prospective cohort study. All patients completed the Millon Behavior Medicine Diagnostic survey before surgery. The primary predictor variable was the preoperative psychological scores. The primary outcome variable was the difference in pain between the pre- and postoperative periods. The Spearman rank correlation coefficient and the Pearson product-moment correlation were used to determine the association between psychological factors and change in pain. Univariable and multivariable analyses were performed using a mixed-effects linear model and multiple linear regression. A P value of .05 was considered significant. Eighty-six patients were enrolled in the study. Seventy-five patients completed the study and were included in the final analyses. The mean change in visual analog scale (VAS) pain score 1month after arthroscopy was -15.4 points (95% confidence interval, -6.0 to -24.7; P < .001). Jaw function also improved after surgery (P < .001). No association between change in VAS pain score and each of the 5 preoperative psychological factors was identified with univariable correlation analyses. Multivariable analyses identified that a greater pain decrease was associated with a longer duration of preoperative symptoms (P= .054) and lower chronic anxiety (P= .064). This study has identified a weak association between chronic anxiety and the magnitude of pain decrease after arthroscopy for TMD. Further studies are needed to clarify the role of chronic anxiety in the outcome after surgical procedures for the treatment of TMD.

Surgical results and prognostic factors for thoracic myelopathy caused by ossification of ligamentum flavum: posterior surgery by laminectomy

Thoracic ossification of ligamentum flavum (TOLF) of the spine is characterized by a heterotopic bone formation in the thoracic ligamentum flavum, which causes slowly progressing spinal cord injury. Surgical decompression is the most common treatment of choice for patients with compressive myelopathy due to TOLF. However, the surgical outcome is not always satisfactory. To identify the predictors of surgical outcome, we retrospectively studied the associations between various clinical and radiological parameters and postoperative recovery in 78 patients who underwent decompressive laminectomy for thoracic myelopathy due to TOLF between October 1998 and June 2011. Surgical outcomes were assessed using modified Japanese Orthopedic Association (mJOA) recovery rate (RR)/outcome scores. At a minimum of 1 year after surgery for TOLF treatment, the postoperative clinical scores showed statistically significant changes with improvement in the JOA scores. The results indicated that a longer duration of preoperative symptoms, fused-type TOLF, and the degree of compression of the anteroposterior diameter and ossified region (middle thoracic OLF) was related to poor prognosis. Early diagnosis and sufficient surgical decompression improved the functional outcomes of TOLF patients. The surgical risk is relatively higher due to the tenuous blood supply of the spinal cord and the limited spinal canal volume of the middle thoracic spine extending from T4 to T9.

Does Arthroscopic FAI Correction Improve Function with Radiographic Arthritis?

Previous studies reporting the impact of osteoarthritis (OA) on pain and function after hip arthroscopy largely predate resection of femoroacetabular impingement (FAI). We determined (1) functional improvement after resection of FAI impingement lesions in patients with preoperative radiographic joint space narrowing, and (2) identified preoperative predictors of pain, function, and failure rates in these patients. Between September 2004 and April 2008, we treated 210 patients (227 hips) with FAI and a minimum 12-month followup (mean, 27 months). Group FAI consisted of 154 patients (169 hips) without radiographic joint space narrowing, whereas Group FAI-OA consisted of 56 patients (58 hips) with preoperative radiographic joint space narrowing. We collected Harris hip scores (HHS), Short Form-12 (SF-12), and pain scores on a visual analog scale (VAS) preoperatively and postoperatively. Score improvements were better for Group FAI compared with Group FAI-OA. The overall failure rate was greater for Group FAI-OA (52%) than for Group FAI (12%). Although patients with less than 50% joint space narrowing or greater than 2 mm joint space remaining on preoperative radiographs had improved scores throughout the study, we observed no score improvements at any time with advanced preoperative joint space narrowing. Greater joint space narrowing, advanced MRI chondral grade, and longer duration of preoperative symptoms predicted lower scores. FAI correction with milder degrees of preoperative radiographic joint space narrowing resulted in improvements in pain and function at short-term followup. Patients with advanced radiographic joint space narrowing do not improve and we believe should not be considered for arthroscopic FAI correction.

Primary Optic Nerve Sheath Meningiomas: A Follow-up Study

The management of optic nerve sheath meningiomas (ONSM) remains controversial, but includes surgery, radiotherapy and plain observation. We present a follow-up study and treatment modalities based on our classification system. A retrospective analysis was performed of 90 patients with optic nerve sheath meningiomas who were treated between 1991 and 2008 (n=65 surgery only, n=5 radiation only, n=18 surgery and postoperative radiation, n=2 observation). Follow-up data was available, ranging from 6 to 220 months with a median of 45.8 months. Our classification system differentiates between intraorbital (type 1), intracanalicular or intrafissural (type 2), and intraorbital and intracranial (type 3) ONSMs. Thirty-seven tumors demonstrated extension through the optic canal (type 2a). 41 further tumors reached the chiasm (type 3a) or contralateral side (type 3b). Visual acuity was not significantly influenced by surgery but did become worse with a longer duration of preoperative symptoms and a longer follow-up period. Radiotherapy improved vision in 4 and preserved vision in 16 out of 23 cases. Loss of vision in optic nerve sheath meningiomas is a question of time. Radiotherapy should be offered for intraorbital ONSM. Surgery with decompression of the optic canal and intracranial tumor resection is still favored for tumors with intracanalicular and intracranial extension.

Anterior cervical corpectomy for cervical spondylotic myelopathy: Experience and surgical results in a series of 70 consecutive patients

Recently the debate over the management of cervical spondylotic myelopathy (CSM) has regained interest; more specifically whether treatment should be operative versus non-operative, raising the question about the real effectiveness of surgery in influencing the natural history of this pathology and about the choice of the most appropriate approach (anterior vs. posterior). The authors report a retrospective review of 70 consecutive patients who underwent elective anterior cervical corpectomy and fusion with iliac crest autograft or titanium mesh and placement of an anterior cervical plate for the treatment of CSM. The patients underwent pre-and postoperative evaluation, including history, and physical and neurological examination. Patients were also evaluated pre-and postoperatively using a modified version of the Japanese Orthopedics Association Scale (mJOA), which provides a fine semi-quantitative graded evaluation of overall function. Upon discharge home, patients were followed for an average of 42 months (range, 12–63 months). Following an anterior cervical decompression of the spinal cord, 94.2% of patients improved their functional status and 5.8% were unchanged; the mean preoperative mJOA score of all patients was 12.2, the postoperative was 15.4 and the amelioration was also documented by neurophysiological studies which showed an increase in amplitude and decrease in latency of somatosensory evoked potentials and motor evoked potential in 47 patients (67%). Older age and longer duration of preoperative symptoms both were not associated with a lower postoperative mJOA score ( p < 0.47, p < 0.29, respectively). Single versus multiple level decompression was not predictive of a lower postoperative mJOA score ( p < 0.18). Preoperative spinal cord low signal intensity changes on T1-weighted MRI were related to a lower postoperative mJOA score ( p < 0.05), whereas spinal cord high-signal intensity changes on T2-weighted MRI were related to a higher postoperative mJOA score ( p < 0.01); finally a lower preoperative mJOA score was highly predictive of a lower postoperative mJOA score ( p < 0.0005). Anterior cervical corpectomy and fusion for CSM appears to be an effective procedure with a more favorable neurological improvement when compared to posterior decompressive laminectomy, minimally invasive procedures or non-surgical treatment. It is also a safe procedure even in the elderly population, with low morbidity and the potential for permanent spinal cord decompression and excellent bone stability.

Surgical management of meningiomas involving the optic nerve sheath

The management of optic nerve sheath meningiomas (ONSMs) remains controversial but includes surgery, radiotherapy, and plain observation. Surgery is often thought to result in postoperative blindness. The authors report on a large series of patients surgically treated for ONSM, with an emphasis on the visual outcome. Seventy-three patients with ONSMs who had undergone surgery between 1991 and 2002 were retrospectively analyzed. The standard surgical approach consisted of pterional craniotomy, intradural (54 patients) or extradural (10 patients) unroofing of the optic canal, or a combined procedure (seven patients). Thirty-two tumors demonstrated extension through the optic canal. Twenty-nine tumors reached the chiasm or contralateral side. Patients with intraorbital flat tumors should undergo radiotherapy instead of surgery. Those with a large intraorbital mass and no useful vision should undergo surgery. Tumors extending intracranially through the optic canal are amenable to decompression of the optic canal and resection of the intracranial portion. The follow-up period was a mean 45.4 months (range 6-144 months). Ten patients underwent postoperative radiotherapy. Visual acuity was not significantly influenced by surgery but did become worse with a longer duration of preoperative symptoms and a longer follow-up period. A tumor location in the optic canal was another negative factor. Radiotherapy preserved vision in five of 10 cases. The loss of vision in patients with ONSM is only a matter of time. In patients with good vision the role of radiotherapy becomes more important. Surgery is recommended for intracranial tumors to prevent contralateral extension.

A prospective and consecutive study of surgically treated lumbar spinal stenosis. Part I: Clinical features related to radiographic findings.

A prospective study of consecutive patients undergoing surgery for central lumbar spinal stenosis. To evaluate symptoms and signs in patients undergoing surgery for central spinal stenosis and to correlate the findings to age, preoperative duration of symptoms, and radiographically detected constriction. The degree of constriction of the spinal canal considered to be symptomatic of lumbar canal stenosis is not clear, nor is the relation between the clinical appearance of the disease and the degree of radiographically verified constriction. One hundred five consecutive patients scheduled for decompression surgery were included in a prospective study. The day before surgery, all patients were interviewed and examined, using a defined protocol that included data on age, gender, preoperative duration of symptoms, walking ability, and occurrence of pain at rest and at night. Included were data recording straight leg raising test results, reflex disturbance, and extensor hallucis longus muscle weakness. All radiographs were examined by a neuroradiologist. The anteroposterior diameters at each site from L1-L2 to L5-S1 were recorded. For the computer analysis, the site of and width at the narrowest site was registered, as well as the number of sites with an anteroposterior diameter of less than 10 mm. A statistical analysis was performed using chi-square analysis, nonparametric tests, analysis of variance, and logistic regression. Pain at rest and at night was reported by 68 and 60 patients, respectively, and was more common in younger patients (P = 0.065 and 0.015, respectively). A severe reduction of walking ability (< 0.5 km) was reported by 70 patients. The straight leg raising test results were negative in 70 patients, positive > 60 degrees in 16, positive 30-60 degrees in 14, and positive < 30 degrees in 5. Younger patients had a positive straight leg raising result (P = 0.028, analysis of variance) more often. Reflex disturbances correlated to patient age: Older patients had reflex disturbances more often. There was no correlation between preoperative duration and pain or neurologic disturbances: Patients with longer preoperative duration of symptoms did not demonstrate more severe symptoms. There was a total myelographic block of the spinal canal in 13 patients. The mean value of the antero-posterior diameter in the other patients was 6.8 mm (range, 4-11 mm). In patients younger than 70 years L4-L5 was the site for the most pronounced constriction, whereas L3-L4 was the narrowest site in the older patients. Degenerative spondylolisthesis was found in 32 patients, and they had a more pronounced constriction of the spinal canal (5.6 mm compared with 6.7 mm in those without displacement, P = 0.02). There was a (nonsignificant) tendency toward more walking disturbances in patients with a more pronounced constriction of the spine. There was no correlation between reflex disturbances or extensor hallucis longus weakness and radiographically detected constriction. Pain was more intense and positive straight leg raising test results were more common in younger patients, whereas reflex disturbances were more common in the elderly. The vertebral site for the lowest anteroposterior value was higher with higher age. Preoperative duration did not affect the severity of symptoms or signs. Patients with more pronounced stenosis tended to have a more severe reduction of walking ability. There was no correlation between symptoms and signs and radiographically detected constriction.