Multilevel Disease Research Articles

Outcome of Multilevel Anterior Cervical Discectomy and Fusion without plating

Background & objectives: The safety and efficacy profile of stand-alone polyetheretherketone cages has been questioned in the management of patients with more than one cervical disc disease. In this article, we evaluated the idea of safety of multilevel anterior cervical discectomy and fusion, without using a plate and the achieved pain relief. Methods: In this study, retrospectively we reviewed 30 patients diagnosed with multilevel cervical disc disease (total 69 segments) due to degenerative changes, disc herniation, and/or osteophyte formation. They complained of axial neck pain and/or radiculopathy not responding to non-surgical measures. All the included subjects treated for more than one-disc disease using stand-alone polyetheretherketone. With minimum 2-years of regular, clinical and radiological follow up. We have assessed the patient for criterions defined for cage subsidence and protrusion, as well as pain assessment pre and postoperatively using the visual analog score. Results: we assessed 22 patients (73.3%) for two level pathology and 8 patients (26.7%) with three level diseases. Mean age was 48.2±8.9 years. Female to male ratio was (1.1:1). The most common segment involved was C5-6 segment in 83.3%. The pre-operative visual Analogue Score for axial neck pain 6.3±3.05 and radiculopathy 6.8±2.2 was decreased post-operatively to 2±1.3 points respectively. Subsidence and protrusion assessed by measurement of serial X rays and one patient 3.3% developed subsidence in 2 adjacent levels which is statistically not significant. No incidence of cage protrusion was detected. Conclusions: Multilevel anterior cervical discectomy and fusion without plating provide good fusion, low subsidence rate, stability provided by the cage with excellent pain improvement.

Peripheral artery disease affects the function of the legs of claudicating patients in a diffuse manner irrespective of the segment of the arterial tree primarily involved.

Different levels of arterial occlusive disease (aortoiliac, femoropopliteal, multi-level disease) can produce claudication symptoms in different leg muscle groups (buttocks, thighs, calves) in patients with peripheral artery disease (PAD). We tested the hypothesis that different locations of occlusive disease uniquely affect the muscles of PAD legs and produce distinctive patterns in the way claudicating patients walk. Ninety-seven PAD patients and 35 healthy controls were recruited. PAD patients were categorized to aortoiliac, femoropopliteal and multi-level disease groups using computerized tomographic angiography. Subjects performed walking trials both pain-free and during claudication pain and joint kinematics, kinetics, and spatiotemporal parameters were calculated to evaluate the net contribution of the calf, thigh and buttock muscles. PAD patients with occlusive disease affecting different segments of the arterial tree (aortoiliac, femoropopliteal, multi-level disease) presented with symptoms affecting different muscle groups of the lower extremity (calves, thighs and buttocks alone or in combination). However, no significant biomechanical differences were found between PAD groups during the pain-free conditions with minimal differences between PAD groups in the claudicating state. All statistical differences in the pain-free condition occurred between healthy controls and one or more PAD groups. A discriminant analysis function was able to adequately predict if a subject was a control with over 70% accuracy, but the function was unable to differentiate between PAD groups. In-depth gait analyses of claudicating PAD patients indicate that different locations of arterial disease produce claudication symptoms that affect different muscle groups across the lower extremity but impact the function of the leg muscles in a diffuse manner generating similar walking impairments.

Inadequate rehabilitation after multi-level revascularization as a risk factor of low quality of life

BACKGROUND: Reconstructive surgery of multilevel lesions in peripheral atherosclerosis has been undergoing changes over the past decades. The spectrum of such interventions includes conventional, endovascular and hybrid technologies. Due to the fact that the main goal of treatment is to preserve the limb, the outcome of the surgical intervention directly affects the quality of patients life; however, there is insufficient data in the literature on the tactics of postoperative rehabilitation of patients who underwent surgery for a multilevel lesion. Randomized clinical trials aimed at studying the effectiveness of walk training and rehabilitation measures demonstrate an increase in walking distance in people with peripheral atherosclerosis against the background of controlled physical exertion.
 АIM: To assess the effect of rehabilitation program on the vital activity levels in the patients who suffered from multilevel peripheral arterial disease in a long-term period after revascularization.
 MATERIALS AND METHODS: The study included 216 patients with MPAD who underwent various lower limb revascularization, including 87 patients with hybrid interventions, 81 open surgery and 48 with endovascular interventions. The patients have been examined both in perioperative and postoperative periods as well as in a long-term period (36 months) after reconstruction. Depending on the fulfillment or non-fulfillment of the proposed rehabilitation program, such indicators as limb preservation, walking distance and quality of patients life have been evaluated in accordance with the EQ-5D questionnaire.
 RESULTS: In the early postoperative period, a decrease in the number of thrombosis of the operated segment has been registered in the group of hybrid interventions in comparison with the results in the group with open operations. In the long-term period after the operation, the use of complex rehabilitation measures allowed to reduce the number of amputations and stabilize the maximum walking distance. Walk training provided the necessary level of quality of life, which, in most cases, has been recorded in the patients who underwent hybrid interventions.
 CONCLUSIONS: The composition and fullness of rehabilitation program is a circumstance affecting long-term outcomes after reconstructive vascular interventions. The exclusion of walk training from the rehabilitation program does not allow achieving the maximum frequency of limb preservation, increasing the walking distance and improving the quality of life of patients suffering from multilevel lesion of the arteries of the lower extremities.

TaylorCSROA-based Deep Residual Network: An Optimization driven Deep Network for the multilevel spinal cord disease classification

ABSTRACT Spinal cord is a cylindrical shape located in Central Nervous System (CNS) and extended between the medulla oblongata and lumbar vertebrae. The main task in the classification of multilevel spinal cord disease in Computed Tomography (CT) is the accuracy. In this research, a Taylor Crow Search-Rider Optimization Algorithm (TaylorCSROA) is developed for accurate classification of spinal cord disease. The segmentation is done through the adaptive thresholding method. The Sparse Fuzzy C-Means clustering (Sparse FCM) algorithm is implemented for the localization of disc. The features, like connectivity, Local Optimal-Oriented Pattern (LOOP), statistical, image-level, Grid-based shape features, and tetrolet features are extracted. The spinal cord disease is classified into intervertebral disc (IVD) bulges, the cal sac compressing, bone marrow disease, central or foraminal stenosis, annular tears, scoliosis, end plate degeneration, endplate defects (modic type), facet connection, and ligamentum flavum hypertrophy, and spondylolisthes is by training the Deep Residual Network using the developed TaylorCSROA. The developed TaylorCSROA algorithm derived from the integration of Taylor Series, Crow Search Algorithm (CSA), and the Rider Optimization Algorithm (ROA). When compared with the existing spinal cord disease classification methods, the developed method obtained a maximum accuracy of 0.9102, sensitivity of 0.8945, and specificity of 0.9245.

Concomitant Cervical Spine Stenosis Negatively Affects Subpectoral Biceps Tenodesis Outcomes

PurposeTo determine whether an association exists between the presence of cervical spine pathology and postoperative patient-reported outcomes (PROs) in patients undergoing open subpectoral biceps tenodesis (BT).MethodsA retrospective review of patients undergoing isolated BT from August 2011 to May 2019 was conducted. Cases were defined as patients with concomitant cervical spine disease (disc disease, disc herniations, neuroforaminal/central stenosis). Controls were patients without cervical spine disease. Postoperative PROs were collected from all patients with a minimum of 12-month follow-up. Cases and controls were matched 1:1 using age and body mass index. PROs were compared using the χ2 text, Fisher exact test, or analysis of variance.ResultsA total of 23 cases and 23 controls were identified. Cases and controls had similar distributions of age (42.4 ± 4.4 years, 40.4 ± 4.5, P = .15), sex (83% male, 87% male, P = .68), body mass index (28.0 ± 4.0, 27.6 ± 4.3, P = .78), and percentage of athletes (65% athlete, 61% athlete. P = .76). All cases had evidence of neuroforaminal stenosis and multilevel degenerative disc disease, whereas 19 of 23 (83%) had evidence of central canal stenosis. Cases had a greater visual analog scale (VAS) score during Sport score (3.6 ± 0.7 vs 1.2 ± 0.6, P = .013) and lower Subjective Shoulder Value (69.5 ± 5.8 vs 84.1 ± 5.4, P = .070) and Shoulder Instability-Return to Sport after Injury score (60.4 ± 5.8 vs 77.4 ± 6.0, P = .046). There were no significant differences between groups’ ASES, baseline VAS, overall satisfaction scores, and willingness to undergo the same operation again. No significant differences were found in postoperative rate of return to sport, time to return, and return to preoperative competitiveness.ConclusionsPatients with SLAP tears undergoing isolated BT in the presence of cervical spinal stenosis may have inferior Subjective Shoulder Value, Shoulder Instability-Return to Sport after Injury, and VAS during sport scores as compared with controls, although many PROs were similar at follow-up. Athletes undergoing BT, particularly with concomitant cervical spine pathology, should be counseled appropriately before surgery.Level of EvidenceLevel III, case–control study.

AB034. SOH22ABS041. Outcomes of single stage hybrid revascularization for multilevel peripheral arterial disease

Background: Due to multilevel disease often seen in peripheral arterial disease (PAD), straightforward management options are challenging. Hybrid procedure, combining endovascular and open surgery, is an ideal strategy for managing this cohort of patients. The aims of this study were to investigate the suitability of hybrid surgery in those with multilevel PAD.

Radiological Analysis of Minimally Invasive Microscopic Laminectomy for Lumbar Canal Stenosis with a Focus on Multilevel Stenosis and Spondylolisthesis

We retrospectively compared the radiological and clinical outcomes of two different surgical techniques (lumbar spinous process splitting laminectomy [LSPSL] and unilateral laminotomy for bilateral decompression [ULBD]) to treat lumbar spinal canal stenosis (LCS). We performed a retrospective comparative study of 141 consecutive patients with an average age of 70.8 ± 9.4 years who had undergone LSPSL or ULBD for LCS between April 2015 and April 2019. None of the patients had developed remote fractures of the spinous processes using either technique. These cases were divided into 2 groups: group L, 73 patients who had undergone LSPSL from April 2015 to April 2017; and group U, 68 patients who had undergone ULBD from May 2017 to April 2019. The clinical and radiological outcomes and surgical complications at the 1-year postoperative follow-up period were evaluated. We found no significant differences in the operative time between the 2 groups. However, group U had had significantly less blood loss than group L. The facet joints were significantly well preserved in group U. We examined the multilevel and spondylolisthesis cases separately and found that both surgical procedures were equally effective and that the visual analog scale scores for back or leg pain and Japanese Orthopaedic Association scores had significantly improved postoperatively in each group. Group U showed better outcomes in terms of LCS recurrence, with 3 patients in the group L requiring repeat surgery. We found both ULBD and LSPSL to be safe and effective techniques for LCS, even for patients with spondylolisthesis and multilevel disease. ULBD was superior in terms of recurrence prevention, preservation of the facet joints, and less blood loss.

Challenges in Spinal Endoscopy

The advent of any new technology or technique is fraught with challenges in the early stages of development and adoption. This situation is no different for spinal endoscopy, which has been continuously developing for decades and has only recently gained significant traction in North America. Patient selection can be challenging for even expert endoscopic surgeons, given the limited abilities of current technology for patients with multilevel disease. Anatomic limitations, such as iliac crest location and small foraminal dimensions, can restrict application of the transforaminal approach, considered the "workhorse" of endoscopic techniques. A paucity of dedicated training opportunities has led many to become late adopters or preclude exposure entirely, limiting the next generation of surgeons and expansion of the field. Finally, economic constraints, including capital expenses and issues with insurance reimbursement, have generated difficulties to widespread acquisition. Nonetheless, the future is bright for spinal endoscopy, with potential solutions to these issues already generating progress. In the present report, we have summarized these challenges and discussed some of the current steps underway to help alleviate their impact.

The surgical outcome of multilevel anterior cervical discectomy and fusion in myelopathic elderly and younger patients

The elderly population has an increased risk of degenerative cervical myelopathy due to multilevel disease, causing motor and sensory dysfunctions and a poor quality of life. Multilevel anterior cervical discectomy and fusion (ACDF) is an alternative surgical treatment option, but has a perceived higher risk of complications. The goal of this study is to report the outcome. We retrospectively reviewed patients from 2006 to 2019 undergoing multilevel ACDF for degenerative cervical myelopathy and compared outcomes and complications between elder patients (aged 70 and above) and younger patients (below 70). The patients’ comorbidities, and postoperative complications, radiographic parameters such as C2–C7 Cobb angle, C2–C7 sagittal vertical axis, inter-body height of surgical levels and fusion rate were recorded. Japanese Orthopaedic Association (JOA) score and modified Odom’s score were collected. Included were 18 elderly (mean age 74, range 70–87) and 45 young patients (mean age 56, range 43–65) with a follow-up of 43.8 and 55.5 months respectively. Three-level ACDF was the most common. The ratios of ASA class III patients were 94.4% and 48.9% (p < 0.001). The Charlson comorbidity indexes were 4.3 ± 1.03 and 2.1 ± 1.11 (p < 0.001). The average lengths of hospital stays were 4.9 and 4.6 days. Eleven patients (61.1%) in the elderly group experienced at least one short-term complication, compared with 16 patients (35.6%) in the younger group (p < 0.05). The middle-term complications were comparable (22.2% and 20.0%). The JOA score, recovery rate and modified Odom score showed comparable result between groups. Despite its extensiveness, multilevel ACDF is feasible for the elder patients with good clinical outcome and fusion rate. When compared to younger cohort, there is a trend of lower preoperative JOA score and recovery rate. The short-term complication rate is higher in the elderly group.

Elevated C-Reactive Protein/Albumin Ratio Is Associated With Lesion Complexity, Multilevel Involvement, and Adverse Outcomes in Patients With Peripheral Artery Disease.

Inflammation plays an important role in the progression of peripheral artery disease (PAD). We investigated the predictive value of the C-reactive protein-to-albumin ratio (CAR) on the severity of PAD and outcomes after endovascular therapy (EVT). Patients (n = 307) with PAD who underwent EVT were retrospectively reviewed and categorized according to CAR tertiles. The groups were compared for the prevalence of complex lesions and multilevel involvement as well as the incidence of major adverse cardiovascular events (MACEs) and major adverse limb events (MALEs). The rates of complex lesions and multilevel involvement increased with increasing CAR tertiles (all P < .001). These associations remained significant even after adjustment for other confounders (complex lesion odds ratio, 1.22 [1.03-1.50]; P = .036; multilevel disease odds ratio, 1.20 [1.01-1.44]; P = .041). The third CAR tertile showed a significantly higher incidence of MACEs and MALEs than the second and first tertiles within a year (log-rank P < .001). A higher CAR as a continuous variable was also independently associated with the 4-year rate of MACE (hazard ratio, 1.20 [1.04-1.38]; P = .015). Elevated CAR was a powerful surrogate marker of severe PAD and worse outcomes. Thus, CAR might become a predictor of poor prognosis in patients with PAD.

Midterm Results of Endovascular Management of Multilevel Arterial Disease in Lower Limb in Diabetic Patients

Midterm Results of Endovascular Management of Multilevel Arterial Disease in Lower Limb in Diabetic Patients

Distal Endarterectomy Combined With Endovascular Proximal Treatment: The Hybrid DEEP Retrograde Technique for High-Complexity Infrainguinal Disease

Purpose: We present a hybrid technique for the treatment of chronic limb-threatening ischemia (CLTI) due to complex, multilevel infrainguinal disease. It consists of an open distal endarterectomy combined with endovascular proximal treatment (the DEEP technique). Materials and Methods: This was a prospective cohort study. Thirty-three limbs (30 patients) were treated. Main inclusion criteria were absence of significant disease in femoral bifurcation associated with a complex infrainguinal pattern. This approach was specially considered in absence of suitable vein for bypass, obesity, hostile groin, and overall high surgical risk. Results: Mean age was 72.8 ± 10 years (ranging 50–93). Most cases presented with severe limb threatening onset (90.9% Rutherford >4 and 81.8% WIfi >3) due to high-complexity infrainguinal disease pattern (Global Limb Anatomic Staging System [GLASS] stage III) in 31/33 (93.9%), chronic total occlusions (CTOs) in 24/33 (72.7%), and severe calcification (Peripheral Arterial Calcium Scoring System [PACSS] grade 4) in 22/33 (66.6%). Mean lesion length was 228.2 mm ± 83 (ranging 40–340 mm). In all procedures, a covered-stent (25 cm length Viabahn) was implanted in a retrograde fashion as the endovascular component. Effective revascularization was achieved in all cases, showing significant clinical and hemodynamic improvement (median pre- and postprocedure ankle-brachial index [ABI]: 0.3 and 0.9, respectively). Results at 12 months follow-up were as follows: 93.9% limb salvage ratio, 75.7% primary patency, 84.6% assisted primary patency, and 90.9% secondary patency. Major adverse limb events (MALE) and cardiovascular events (MACE) occurred in 8/33 (24.2%) and 2/33 (6%), respectively. Mean length of postoperative stay was 7.5 ± 6.92 days (3–27). Conclusion: This less invasive hybrid technique has promising short-term results for limb salvage and it is worth to be included in vascular armamentarium for CLTI revascularization in selected patients.

Anterior cervical corpectomy and fusion with stand-alone cages in patients with multilevel degenerative cervical spine disease is safe

BackgroundIn case of spinal cord compression behind the vertebral body, anterior cervical corpectomy and fusion (ACCF) proves to be a more feasible approach than cervical discectomy. The next step was the placement of an expandable titanium interbody in order to restore the vertebral height. The need for additional anterior plating with ACCF has been debatable and such technique has been evaluated by very few studies. The objective of the study is to evaluate radiographic and clinical outcomes in patients with multilevel degenerative cervical spine disease treated by stand-alone cages for anterior cervical corpectomy and fusion (ACCF).MethodsThirty-one patients (66.5 ± 9.75 years, range 53–85 years) were analyzed. Visual Analog Scale (VAS) and the 10-item Neck Disability Index (NDI) were assessed preoperatively and during follow-up on a regular basis after surgery and after one year at least. Assessment of radiographic fusion, subsidence, and lordosis measurement of Global cervical lordosis (GCL); fusion site lordosis (FSL); the anterior interbody space height (ant. DSH); the posterior interbody space height (post. DSH); the distance of the cage to the posterior wall of the vertebral body (CD) were done retrospectively. Mean clinical and radiographic follow-up was 20.0 ± 4.39 months.ResultsVAS-neck (p = 0.001) and VAS-arm (p < 0.001) improved from preoperatively to postoperatively. The NDI improved at the final follow-up (p < 0.001). Neither significant subsidence of the cages nor significant loss of lordotic correction were seen. All patients showed a radiographic union of the surgically addressed segments at the last follow up.ConclusionsApplication of a stand-alone expandable cage in the cervical spine after one or two-level ACCF without additional posterior fixation or anterior plating is a safe procedure that results in fusion. Neither significant subsidence of the cages nor significant loss of lordotic correction were seen.Trial registrationRetrospectively registered. According to the Decision of the ethics committee, Jena on 25th of July 2018, that this study doesn’t need any registration. https://www.laek-thueringen.de/aerzte/ethikkommission/registrierung/.

Complex multilevel and multivessel endovascular revascularization through an occluded femoral-popliteal bypass in a patient with chronic limb threatening ischemia.

Chronic limb-threatening ischemia (CLTI) represents the end stage of peripheral artery disease, a problem of growing prevalence and increased health care costs around the globe. CLTI is a highly morbid disease, incurring significant mortality, limb loss, pain, and diminished health-related quality of life. The major cause of non-traumatic lower extremity amputation are related to diabetes and CLTI. Between 2% to 3% of patients with peripheral artery disease present with a severe case of CLTI, a condition that is correlated with multilevel and multivessel arterial disease, calcification, and chronic total occlusions. Multiple technical strategies to successfully cross long occlusions in arterial segments have been described. Recanalization can be performed using endoluminal, subintimal, and retrograde techniques. We report a case of complex multilevel and multivessel endovascular revascularization through an occluded femoro-popliteal bypass in a patient with CLTI.

Clinical adjacent segment pathology after anterior cervical discectomy, with and without fusion, for cervical degenerative disc disease: A single center retrospective cohort study with long-term follow-up

IntroductionClinical adjacent segment pathology (CASP) continues to be a cause of concern after anterior surgical treatment for single- or multilevel cervical degenerative disc disease (CDDD). The current literature reports inconsistent incidence rates and contended risk factors in the development of CASP. Research questionThe aim is to determine the incidence of additional CASP-related surgeries after anterior cervical discectomy with fusion (ACDF) or without fusion (ACD) for CDDD. Secondary outcomes include risk factors for the development of CASP and long-term clinical outcomes. Materials & methodsThis is a single-center, retrospective cohort study with a long-term follow up. Patients undergoing ACD(F) for CDDD between January 2012 and December 2019 were included. ResultsA total of 601 patients were included, with an average follow-up period of 5.0 years. Most patients underwent ACDF with stand-alone cages (87.7%). CASP developed in 58 (9.7%) patients, 41 (70.7%) of which required additional adjacent level surgery. ACD significantly accelerated the development of CASP. The C2–C7 Cobb angle appeared less lordotic upon early post-operative imaging in ACDF patients that later-on developed CASP. Baseline degeneration at the index level and adjacent levels was not significantly different between patients with and without CASP. Discussion & conclusionIn this retrospective cohort, we observe a relatively low rate of additional surgery for CASP in ACDF with stand-alone cages. We suggest that surgical technique, fusion, segmental kyphosis and natural degeneration play a multifactorial role in the development of CASP. Complication rates were low and clinical outcomes were similar for all techniques used.

The Role of Minimally Invasive Percutaneous Pedicle Screw Fixation for the Management of Spinal Metastatic Disease

Optimal surgical management of spinal metastatic disease remains controversial. Skip and diffuse spinal lesions, patient frailty, and the need for timely adjuvant chemoradiation complicate surgical decision-making. Minimally invasive percutaneous pedicle screw fixation (MIPSF) is an attractive concept that can confer stability and allow early postoperative mobilization. To date, outcomes of the MIPSF technique remain under-investigated. A single-center retrospective review of patients undergoing percutaneous instrumentation for multilevel spinal metastatic disease between January 2012 and October 2020 was performed. Twenty-four patients were identified, and their primary tumor diagnoses, modified Tokuhashi scores, Spine Instability Neoplastic Scores, neurologic functions, pain scores, and procedure types were noted. Of these patients, 17 underwent fixation of 6 or more levels (L-MIPSF), whereas 7 underwent fixation of <6 levels (S-MIPSF). All patients had screw-and-rod constructs placed percutaneously using bi-planar fluoroscopy guidance. Patients undergoing corpectomy, multilevel laminectomies, or open posterior instrumentation were excluded. Improvement in pain and neurological function was noted in nearly all patients who underwent MIPSF. Average skin incision-to-closing time was 130 minutes, and standard deviation of 55 minutes. Likewise, the average estimated operative blood loss was 402 mL, and standard deviation of 388 mL. Only one patient required hardware revision due to proximal loss of fixation. Two patients required mini-open decompression procedures due to tumor recurrence at different levels than the index pathology. Multilevel minimally invasive spinal fixation is feasible in patients with diffuse spinal metastasis. The percutaneous nature of the technique minimizes dissection, blood loss, and operative times. Early outcomes of MIPSF are promising and demonstrate utility in avoiding multiple subsequent procedures in a cohort of deconditioned patients.

Case Report on Nursing Management of a Client with Peripheral Arterial Disease

Peripheral artery disease is a frequent cardiovascular ailment in which constricted arteries restrict blood flow to our limbs. When we have Peripheral Artery Disease in our limbs, our legs haven't had enough flow of blood to increase production. The capillaries that nourish the lower legs narrow and stiffen in peripheral vascular disease, making walking harder. Reduced blood flow can cause cartilage and necrosis in the limbs. Peripheral arterial disease (PAD) is usually caused by multilevel atherosclerotic disease, typically in patients with a history of cigarette smoking, diabetes mellitus, or both. Intermittent claudication (IC), an early manifestation of PAD, commonly leads to reduced quality of life for patients who are limited in their ambulation. Percutaneous intervention for peripheral artery disease has evolved from balloon angioplasty for single lesions. To achieve good long-term efficacy, a close follow-up including objective tests of both the arterial lesion and hemodynamic status, surveillance of secondary preventive measures, and risk factor control.&#x0D; A 65-year-old man was admitted to the hospital with the following symptoms: worsening left severe calf pain, fatigue, cramping, aching, pain in the legs or arms that worsens when walking or using the arms, tightness in the muscles of the legs that worsens with exercise and improves with rest. He has a diabetes mellitus history. The lower extremity pulse was diminished or absent on physical examination, but all other vital signs were typical. Pulses in the left dorsalispedis and posterior tibialis could not be felt. The results of the cardiac examination were average. The patient has numbness in one leg, pain in both legs, decreased energy in both upper and lower limbs, ulceration, gangrene in the lower extremities, Hair loss, weakness, and dependent rubor (redness caused by swelling) present. He had audible bruits, a nonhealing lower extremity wound, and a delayed capillary refill, so he started treatment as soon as possible.&#x0D; The primary focus of this study is on professional management and outstanding nursing care, which may provide the holistic care that peripheral arterial disease necessitates while also effectively managing the challenging case.

Long-Term Clinical Results with Radiological Correlations After Posterior Foraminotomy for Unilateral Cervical Discopathy

In lateral cervical disc herniations, posterior foraminotomy (PF) provides direct nerve root decompression and maintains segmental mobility. However, partial facetectomy can cause instability. This study evaluated long-term clinical outcomes related to cervical sagittal alignment after PF. The study included 48 consecutive patients with lateral cervical disc herniations who underwent PF. Pain and mobility were evaluated using the Numeric Rating Scale and Neck Disability Index (NDI), respectively. Sagittal alignment was evaluated using the modified Toyama method. Median Numeric Rating Scale arm, Numeric Rating Scale neck, and NDI scores improved by 7, 4.5, and 24 points, respectively. Corresponding mean minimal clinically important differences were achieved in 94%, 77%, and 98% of patients at a mean follow-up of 8.4 years. Of patients, 82% showed favorable radiological results (i.e., retained or developed lordosis or had straight spine), while 18% showed unfavorable radiological results (i.e., retained or changed toward kyphosis). The latter group had multilevel cervical degenerative disc disease (mcDDD) before PF. Nevertheless, the risk of developing kyphosis was only 2.6%, and the potential for improving sagittal balance was 43%. Follow-up median NDI scores, but not minimal clinically important differences, were significantly worse in patients with preoperative kyphosis (21 vs. 8; P= 0.03) or mcDDD (20 vs. 8; P= 0.024) compared with other patients. Patients with preoperative kyphosis or mcDDD had worse NDI outcomes but also benefited from PF. Sagittal alignment improved in >40% of patients, but coexisting mcDDD was a main risk factor for kyphosis persistence.

General and Disease-Specific Factors Associated with Health Related Quality of Life Among Patients With Peripheral Artery Disease to Inform Treatment Selection in the Era of Patient-Reported Outcomes

<h3>Introduction and Objective</h3> Patient-reported outcomes (PRO) have been championed for assessment of peripheral artery disease (PAD) severity and treatment outcomes. Limited evidence exists regarding factors associated with PRO that may affect their sensitivity to change with PAD interventions. We performed a prospective, cross-sectional study to evaluate how patient-level factors are associated with a validated PAD-specific health related quality of life (QOL) instrument, the VascuQol-6. <h3>Methods</h3> Patients were recruited from a diagnostic vascular unit based on referral for ankle brachial index (ABI) testing. All participants were assessed for PAD symptoms using the San Diego Claudication Questionnaire and tested for neuropathy using the Michigan Neuropathy Screening Instrument (MNSI). PAD-specific QOL was assessed using the VascuQol-6. Clinical data was collected from the medical record and patient-self report. Factors associated with QOL were evaluated using ANOVA, confidence intervals, and linear models. <h3>Results</h3> 70 patients were recruited and participated. Mean age was 67.8±11.7 years (Figure 1Figure 1Plot of age versus VascuQOI-6 summary score (P=0.011).Figure 1); 41% of participants were women and 87.1% were white, and 29% were current smokers. Comorbid conditions included diabetes (23.2%) and peripheral neuropathy (44.3%). Mean ABI was 0.77±0.29 and mean TBI was 0.48±0.23. PAD symptoms were classified as claudication in 48.6%, CLTI in 31.4%, and asymptomatic in 20%. Among symptomatic patients, 21 had multi-level symptoms, 13 had calf symptoms only, 4 had buttock symptoms only, and 3 had thigh symptoms (Figure 2Figure 2Distribution of Vascuqol-6 summary scores by anatomic symptom distribution (P=0.025).Figure 2). Symptoms were bilateral in 55 patients (78.6%). Patients with multi-level disease had lower QOL scores (13.8±4.0; 90% CI 12.3-15.3) versus those with no symptoms (17.6±4.8; 90% CI 16.1-19.2), calf symptoms (17.8±3.1; 90% CI 16.2-19.3) (P=0.024). In multivariable models QOL was associated with minimum ABI (P=0.020), symptom anatomic level (P=0.002) and age (P=0.001); a trend was also observed for symptom category (P=0.121). No associations between QOL and smoking status, diabetes, neuropathy, or bilateral versus unilateral symptoms were observed. <h3>Conclusions</h3> PAD-specific QOL assessments are associated with factors related and unrelated to PAD. Higher QOL scores among older participants was unanticipated and may impart ceiling effects that limit potential for improvement through PAD interventions in this subgroup, while patients with multi-level symptoms may have greater potential gains from PAD treatment. Future work following this cohort will explore changes in QOL over time and associations with treatment interventions, adverse events, and patient-level factors.

Revascularization Strategies for Acute and Chronic Limb Ischemia.

Chronic limb-threatening ischemia requires aggressive risk factor management and a thoughtful approach to the complex decision of best strategy for revascularization. Patients often have multilevel disease amenable to endovascular, open surgical, or hybrid approaches. Limited high-quality evidence is available to support a specific strategy; randomized trials are ongoing. Acute limb ischemia is associated with a high risk of limb loss and mortality. Catheter-directed thrombolysis is mainstay of therapy in patients with marginally threatened limbs, whereas those immediately threatened with motor deficits require more rapid restoration of flow with open or endovascular techniques that can establish flow in single setting.