Weeks Of Conservative Therapy Research Articles

Customized Reconstruction of Lower Eyelid Defects.

A lower eyelid defect is a loss of skin, muscle, and underlying structures that can occur due to trauma, malignant or benign tumors, burns, or other causes. The conventional surgical treatment of lower lid defects has several limitations, including visible scarring, narrowing of the eye, and ectropion. Here, we combined the use of a customized mid-face lift with a free mucochondral graft to overcome the disadvantages of existing methods. Forty patients underwent reconstructive surgery using a customized mid-face lift with or without a free mucochondral graft for a lower lid defect between April 2013 and October 2020. Patients were discharged shortly after surgery and were expected to visit the outpatient clinic periodically for 12 months. The causes of lower eyelid defects were malignancy, trauma, foreign body granuloma, and other causes. Four patients reported complications, including 2 cases of chemosis, 1 case of a hematoma, and 1 case of corneal abrasion, who reportedly performed well after 2 weeks of conservative therapy. No patient required revision during the average follow-up period. Customized reconstruction demonstrated a better aesthetic reconstruction of the lower eyelid. This method represents a good option for reconstructing lower lid defects.

26 Mandibular Advancement vs Home Treatment for Primary Snoring: A Randomized Trial

OBJECTIVES/GOALS: The primary aim is to evaluate the efficacy of a Mandibular Advancement Device (MAD) vs conservative treatment for adults with non-apneic snoring, as measured by the sleeping partner. The secondary aim is to evaluate the effectiveness of treatment of snoring on the sleeping partner’s sleep quality. METHODS/STUDY POPULATION: We plan to enroll 60 pairs of primary snorers and their sleeping partners in our randomized clinical trial. Snorers will be randomized to either 4 weeks of conservative therapy, consisting of nightly Mometasone nasal rinse, breathe-rite strips, mouth taping, and lateral positional therapy, or 4 weeks of Mandibular Advancement Device therapy (MAD). 30 pairs of snorers and their partners will be in each arm. At follow up the primary outcome measure, the Clinical Global Impression of Improvement Scale (CGI-I), will be assessed by the sleeping partner to evaluate the response to snoring treatment. RESULTS/ANTICIPATED RESULTS: To date, there is no study reporting the rate of response in participants using MAD in Primary Snoring. Due to lack of preliminary data and effect size, we hypothesize that the rate of the responders in the MAD group will be 20% higher than the rate of responders in the active control group based on literature studies and preliminary results. A responder will be classified as someone whose sleeping partner rates on the CGI-I scale that the snoring was much improved or very much improved. MAD has been shown previously to be an effective therapy at treating sleep apnea and reducing snoring, and we anticipate it will continue to be so for patients who do not have sleep apnea. DISCUSSION/SIGNIFICANCE: Snoring is a nearly ubiquitous problem that prevents restful sleep for spouses of snorers, which is known to have detrimental health effects. Yet it does not have scientifically proven treatments. Our study will evaluate these treatments in an effort to improve the health of the sleeping partners.

Atlantoaxial Subluxation Secondary to SARS-CoV-2 Infection: A Rare Orthopedic Complication from COVID-19

Patient: Male, 86-year-old Final Diagnosis: Atlantoaxial subluxation Symptoms: Neck pain Medication:— Clinical Procedure: — Specialty: Rehabilitation Objective: Rare coexistence of disease or pathology Background:There are several reports of atlantoaxial subluxation caused by upper respiratory tract infections. Although, there are many known non-pulmonary complications COVID-19 infection, to date there have been no reported cases of orthopedic complications in the peer-reviewed literature. Diagnosis and management of atlantoaxial subluxation is currently limited. Therefore, it is important to explore other methods of identifying and treating patients suffering from atlantoaxial subluxation.Case Report:Our patient was an 86-year-old man with right-sided neck pain and reduced range of neck motion for the past 6 months, shortly after a mild case of COVID-19. Autoimmune and inflammatory workup was unremarkable. Patient’s symptoms persisted despite 3 weeks of conservative therapy with analgesics, cervical collar, and physical therapy. He received low-frequency kinetically directed impulse wave (al-Kindi wave) treatment administered by the KKT device after 3-dimensional digital X-ray analysis of the atlas. After receiving the treatment over a period of 13 days, patient showed significant improvement in symptoms and follow-up X-rays.Conclusions:For patient’s having neck stiffness or pain with COVID-19, it is important to consider atlantoaxial subluxation as a potential cause, especially if the patient requires intubation, as the technique should be adjusted to reduce spinal injury. Atlas X-ray analysis with Spinalytics provides very precise measurements of the atlas in relation to the skull and cervical spine, and improvement in angles were seen before and after treatment. The al-Kindi wave treatment was also effective in reducing the patient’s symptoms and improving cervical X-ray results, but further studies are required for confirmation.

EFFICACY OF UNANI FORMULATION MARHAM-E-EJAZ IN THE MANAGEMENT OF NON-HEALING ULCER: A CASE REPORT

Background and Aim: A Non-healing ulcer is defined as an ulcer that does not heal after 6 weeks of conservative therapy. It is estimated that 1-2% of the people of the world experience a chronic wound during their lifetime. There is direct impact on the physical (amputation), psychological (depression) and social life of individual. Present study was carried out to assess the acclaimed effect of Unani formulation Marham-e-Ejaz in a patient. Material And Method: A female patient of Non-healing ulcer presented in the surgery OPD of our institute. She presented with a chief complaint of wound at the right elbow joint. The diagnosis made was post burn wound. The wound had a history of more than 9 month. The case was treated with Unani Topical formulation, Marham-e-Ejaz for 30 days. The formulation was applied after cleaning it with Normal saline, dressing was changed after every alternate day. The wound was assessed for pain, discharge, size and depth of wound at 0th, 15th, 30th day. Result: On the first day wound size was 2 square cm, depth 0.2 cm, and the floor filled with pale granulation tissue. On 30th day ulcer was completely healed with 100% epithelization. Conclusion: It was observed that there was significant healing of the ulcer. So, Marham-e-Ejaz has potential efficacy in healing Non-healing ulcer.

Evaluation of a Minimally Invasive Bipolar Coagulation System for the Treatment of Grade I and II Internal Hemorrhoids.

Hemorrhoids are common and affect mainly the young and middle-aged populations. Current guidelines recommend treating grade I and II hemorrhoids with office-based procedures. These therapies usually require multiple applications. Hemorrhoid energy therapy treats the hemorrhoids at 1 treatment session. The purpose of this study was to evaluate the safety and efficacy of hemorrhoid energy therapy. This was a prospective pilot study evaluating patients with symptomatic grade I and II internal hemorrhoids. The study was conducted at a tertiary academic center. Patients over the age of 18 years with chronic, symptomatic grade I and II internal hemorrhoids who failed 2 weeks of conservative therapy were enrolled between July 2015 and January 2019. Exclusion criteria included patients with grade III or IV internal hemorrhoids, external hemorrhoids, nonhemorrhoidal GI bleeding, active proctitis, and IBD. Hemorrhoid energy therapy was administered in clinic, and 2 postprocedure visits were completed. A pretreatment hemorrhoid symptom score was obtained from each patient. A visual analog score was assessed posttreatment. The primary end point was to evaluate the effect of hemorrhoid energy therapy on hemorrhoid symptoms and its safety. The secondary end point was evaluation of postprocedural pain. A total of 35 patients were enrolled. The mean duration of hemorrhoid symptoms was 3.3 ± 6.4 years, and rectal bleeding and hemorrhoidal prolapse were the most common symptoms. After the procedure, patient hemorrhoid symptom scores decreased from mean 5.5 to 1.4. The mean immediate postprocedural visual analog score was 2.4 ± 2.1 and decreased to <1.0 after 14 days. The limitations include lack of comparative groups, single-center design, and small cohort of patients. The application of hemorrhoid energy therapy in the treatment of grade I and II internal hemorrhoids is safe and results in reduction of symptoms, low rate of short-term complications, and minimal pain. See Video Abstract at http://links.lww.com/DCR/B491. EVALUACIÓN DE UN SISTEMA DE COAGULACIÓN BIPOLAR MÍNI-INVASIVA PARA EL TRATAMIENTO DE HEMORROIDES INTERNAS GRADOS I Y II: La enfermedad hemorroidal es muy común y afecta principalmente poblaciones jóvenes y de mediana edad. Las guías actuales recomiendan tratar las hemorroides de grado I y II con procedimientos en el consultorio. Estos tratamientos suelen requerir múltiples aplicaciones. La aplicación de energía para tratar las hemorroides requiere de una sola sesión.Evaluar la seguridad y eficacia del tratamiento hemorroidal con una fuente de energía.Estudio piloto prospectivo que evalúa los pacientes con hemorroides internas de grado I y II sintomáticas.El estudio se realizó en un centro académico terciario.Entre julio de 2015 y enero de 2019 se inscribieron pacientes mayores de 18 años con hemorroides intomáticas internas crónicas grado I y II que fracasaron luego de 2 semanas de tratameinto conservador. Los criterios de exclusión incluyeron pacientes con hemorroides internas de grado III o IV, hemorroides externas, sangrado de orígen gastrointestinal no hemorroidal, proctitis activa y enfermedad inflamatoria intestinal.Se realizó la aplicación de energía sobre las hemorroides en el consultorio y se completó el procedimiento con dos visitas posteriores. Se obtuvo una puntuación analógica de síntomas hemorroidarios en cada paciente antes del tratamiento. Se evaluó la puntuación analógica visual luego del procedimiento.El principal criterio final fué evaluar el efecto de la terapia energética hemorroidaria con relación a los síntomas y la seguridad del dispositivo. El segundo criterio final fué el evaluar el dolor posoperatorio.Se registraron un total de 35 pacientes. La duración media de los síntomas hemorroidarios fué de 3,3 ± 6,4 años, el sangrado rectal y el prolapso hemorroidal fueron los síntomas más frecuentes. Después del procedimiento, las puntuaciones de los síntomas hemorroidarios disminuyeron en una media de 5,5 a 1,4. La puntuación analógica visual media inmediatamente posterior al procedimiento fue de 2,4 ± 2,1 y disminuyó a <1 después de 14 días.Las limitaciones incluyen la falta de grupos comparativos, el diseño de un solo centro y una pequeña cohorte de pacientes.La aplicación de energía como tratamiento de la enfermedad hemorroidal interna grado I y II es segura y da como resultados la reducción de los síntomas, una baja tasa de complicaciones a corto plazo y mínimo dolor. Consulte Video Resumen en http://links.lww.com/DCR/B491. (Traducción-Dr Xavier Delgadillo).

Piezosurgical management of sealer extrusion‐associated mental nerve anaesthesia: A case report

The present report describes a case where sealer extrusion (Sealapex) occurred during root canal obturation of a left lower second premolar tooth, and the patient experienced sudden pain and followed by complete anaesthesia of the lower lip. After 3weeks of conservative therapy and an unaltered anaesthesia period, piezosurgical removal of the extruded sealer and root-end resection was performed despite the direct contact with the mental neurovascular bundle. At suture removal, 1week after surgery, there was no improvement in sensation. Two weeks after the operation, the patient reported some changes, including a short paraesthesia period alternating with anaesthesia. At the fourth post-operative week, neurosensory function recovered completely. This case represents successful use of the piezoelectric technique for mental nerve decompression and periapical surgery of a lower second premolar with close contact of the mental nerve.

46-Year-Old Man With Lower Back Pain

46-Year-Old Man With Lower Back Pain

Surgical Decompression in Pott's Paraplegia Patients by Anterior Approach

Background: Spinal tuberculosis is the most serious form of skeletal tuberculosis. Most of the patients with pott’s spine or grade I and II pott’s paraplegia responds well to chemotherapy alone but patients with grade III and IV paraplegia and those patients with grade I and II paraplegia, who do not responds to conservative treatment need urgent surgical decompression to avoid irreversible damage to spinal cord. Material and method: This study is based on 13 patients with preoperative diagnosis of grade III and grade IV Pott’s paraplegia, who did not respond to three to four weeks of conservative therapy or deteriorated neurologically during treatment and were treated by anterior decompression and fusion, at department of orthopaedics, JN Medical College, AMU Aligarh. Results: Out of 13 patients 10 patients recovered & among these complete recovery was seen in 8 patients while 2 patients had partial recovery. Two patients didn’t show neural recovery until last follow up & one patient deteriorated after anterior decompression. Conclusion: Early decompression of cord by anterior approach in patient with grade III & grade IV paraplegia gives satisfactory results in terms of early recovery, short period of hospitalization, early mobilization & healing of the lesion. With this approach adequate exposure can be obtained and post operative rehabilitation of patients is better.

Lumbar spinal stenosis-specific symptom scale: validity and responsiveness.

Cross-sectional study. To test the validity and responsiveness of the lumbar spinal stenosis (LSS)-specific symptom scale (FLS-25 [Fukushima LSS Scale 25]). The FLS-25, a self-administered questionnaire designed to comprehensively cover various symptoms of LSS, has been developed to address the need to measure symptoms specific to this disorder. One hundred sixty-seven patients with confirmed LSS who required conservative therapy were asked to complete a questionnaire including questions regarding walking capacity and the FLS-25. These patients also underwent a lumbar extension test and a walking stress test, which are stress tests designed to objectively evaluate LSS symptoms, to measure standing time, walking distance, and walking time. Relationship between the FLS-25 scores and these external standards was analyzed to evaluate the criterion validity of the FLS-25. The patients underwent the same evaluations after 8 weeks of conservative therapy. The relationship between changes from baseline to week 8 in FLS-25 scores and changes in the 3 external standards was analyzed to evaluate the responsiveness of the FLS-25. The distribution of FLS-25 scores among patients was symmetric, and there were no ceiling or floor effects. FLS-25 scores increased as self-reported walking capacity decreased (P=0.006). The mean standing time in the lumbar extension test was 165 (SD=109) seconds, and FLS-25 scores increased as standing time decreased (P=0.003). In the walking stress test, mean walking distance and mean walking time were 213 (SD=154) m and 236 (SD=114) seconds. FLS-25 scores increased as walking distance (P=0.002) and walking time (P=0.054) decreased. Changes from baseline to week 8 in FLS-25 scores correlated with changes in the stress test standing time (P=0.014), walking distance (P<0.001), and walking time (P<0.001). The criterion validity and responsiveness of the FLS-25 were confirmed. The use of FLS-25 in clinical and investigational settings is warranted to monitor patients and evaluate therapeutic efficacy. 3.

Surgical treatment of anogenital hemangiomas of infancy

Abstract Introduction Infantile hemangiomas (IHs) are the most common benign tumors of the soft tissue in infants and children and they often represent a serious challenge for the treating physician. Hemangiomas located in the anogenital region represent only about 1% of all IHs, but raise special concerns as they have the propensity to ulcerate. This condition may appear spontaneously, or could result from therapeutic procedures. Ulceration is extremely painful and takes many weeks of conservative therapy to heal. Material and Methods. The aim of this study is to present the surgical approach of the IHs located in the anogenital area and the outcomes of this treatment option. Results. During a period of 36 months, 11 children (nine girls, two boys) were referred to our plastic surgery department with hemangiomas involving the anogenital, groin and perineum areas. The average follow-up period was of 8 months, during which 82% of cases experienced complications, especially ulceration. All the target hemangiomas were removed through a lenticular excision and the wound closed with a linear suture. Conclusions. Our study has shown that surgical excision of a complicated anogenital hemangioma or of a “healthy” hemangioma at high risk for ulceration in the anogenital region is an effective treatment, with fast healing and complete resolution of the pathogenic condition. Lenticular excision and linear closure represent a convenient surgical technique that can be performed as early surgery, during the proliferative stage, or at any time later, when the patient needs treatment, in safety conditions and with good results.

Two-year comprehensive medical management of degenerative lumbar spine disease (lumbar spondylolisthesis, stenosis, or disc herniation): a value analysis of cost, pain, disability, and quality of life: clinical article.

Current health care reform calls for a reduction of procedures and treatments that are less effective, more costly, and of little value (high cost/low quality). The authors assessed the 2-year cost and effectiveness of comprehensive medical management for lumbar spondylolisthesis, stenosis, and herniation by utilizing a prospective single-center multidisciplinary spine center registry in a real-world practice setting. Analysis was performed on a prospective longitudinal quality of life spine registry. Patients with lumbar spondylolisthesis (n = 50), stenosis (n = 50), and disc herniation (n = 50) who had symptoms persisting after 6 weeks of medical management and who were eligible for surgical treatment were entered into a prospective registry after deciding on nonsurgical treatment. In all cases, comprehensive medical management included spinal steroid injections, physical therapy, muscle relaxants, antiinflammatory medication, and narcotic oral agents. Two-year patient-reported outcomes, back-related medical resource utilization, and occupational work-day losses were prospectively collected and used to calculate Medicare fee-based direct and indirect costs from the payer and societal perspectives. The maximum health gain associated with medical management was defined as the improvement in pain, disability, and quality of life experienced after 2 years of medical treatment or at the time a patient decided to cross over to surgery. The maximum health gain in back pain, leg pain, disability, quality of life, depression, and general health state did not achieve statistical significance by 2 years of medical management, except for pain and disability in patients with disc herniation and back pain in patients with lumbar stenosis. Eighteen patients (36%) with spondylolisthesis, 11 (22%) with stenosis, and 17 (34%) with disc herniation eventually required surgical management due to lack of improvement. The 2-year improvement did not achieve a minimum clinically important difference in any outcome measure. The mean 2-year total cost (direct plus indirect) of medical management was $6606 for spondylolisthesis, $7747 for stenosis, and $7097 for herniation. In an institution-wide, prospective, longitudinal quality of life registry that measures cost and effectiveness of all spine care provided, comprehensive medical management did not result in sustained improvement in pain, disability, or quality of life for patients with surgically eligible degenerative lumbar spondylolisthesis, stenosis, or disc herniation. From both the societal and payer perspective, continued medical management of patients with these lumbar pathologies in whom 6 weeks of conservative therapy failed was of minimal value given its lack of health utility and effectiveness and its health care costs. The findings from this real-world practice setting may more accurately reflect the true value and effectiveness of nonoperative care in surgically eligible patient populations.

Hip Arthroscopy and Femoroacetabular Impingement in the Pediatric Patient

Femoroacetabular impingement (FAI) is widely understood to be an underlying etiology of injuries to the acetabular labrum and cartilage in the adult hip, although somewhat less attention has previously been spent on its incidence in the pediatric and adolescent populations. Initially recognized as a consequence of periacetabular osteotomies performed for developmental dysplasia of the hip, it can also be because of a number of other disorders or to a developmental process causing irregular bony growth. The adolescent presenting with FAI is athletic, particularly in endeavors placing excessive stress on the hip and surrounding soft tissues. The pain is characterized as sharp, localized around the anatomic femoral head location, and may be associated with catching or popping. Complete physical examination includes full range of motion testing, as a hallmark of FAI is restriction and pain with internal rotation. Special tests include the anterior impingement test, the FABER test, and the dial test. Imaging includes anteroposterior pelvic and cross-table lateral radiographs and magnetic resonance imaging. Treatment in all patients is 6 weeks of conservative therapy. If patients see no improvement with conservative treatment, they may be candidates for hip arthroscopy. Arthroscopic treatment of FAI includes rim trimming for pincer lesions, osteoplasty for cam decompression and labral detachment, and repair or reconstruction for labral tears. Studies have shown improvements in the modified Harris Hip Score and the Hip Outcomes Score postoperatively. As FAI is diagnosed most frequently in athletes, and it is estimated that 30 to 45 million adolescents 6 and 18 years old are involved in sports, it is becoming imperative to identify factors that may predict its development, study treatments, and improve outcomes.

Effect of submucosal alcohol injection on prolonged rectal prolapse in infants and children

Aim:Our aim in this study is to evaluate the effect of ethanol as a sclerosing agent on subset of pediatric patients with prolonged rectal prolapse.Materials and Methods:From 1997 to 2003, 165 cases of primary rectal prolapse were treated by submucosal injection of ethyl alcohol (96%) after 8 weeks of conservative therapy. Around 1.5-2 ml of alcohol was linearly injected in three sites (two laterals and one posterior).Results:Twelve of the 165 cases lost the follow-up and 153 cases were followed from 9 months to 6 years. One hundred and six patients (69.3%) had a duration of prolapse for 3-7 months. Forty patients (26.1%) had prolapse for more than 7 months and seven patients had prolapse for more than 1 year. One hundred and forty-seven out of 153 (96%) patients responded to single injection. Three of the children required a second injection. Three patients with age of more than 13 did not respond to the treatment. Twenty five cases had fecal soilage for few days. No infectious complication and no recurrence were observed.Conclusion:We concluded that 4-6 ml of ethyl alcohol (96%) is effective for the treatment of rectal prolapse. The duration of rectal prolapse had no deleterious effect on treatment; however, patients with age more than 13 years did not respond to sclerosing agent, probably due to different etiology.

A Minimally Invasive Transmuscular Approach to Far-lateral L5-S1 Level Disc Herniations

Among all lumbar disc herniations, L5-S1 far-lateral disc herniations are rare entities. Besides, surgical approach may be difficult because of the very narrow passage at this level. For these 2 reasons, most spine surgeons are not experienced in herniations at this level. According to new microanatomic studies, previous lateral approaches at this level often do not allow access to the neuroforamen without partial or total destruction of the L5-S1 facet joint. To preserve the facet joint, an approach was developed. To assess the efficacy of a surgical technique that is a minimally invasive intermuscular approach (MIIMA) for decompression of L5-S1 far-lateral level disc herniation (FLLDH). We present a prospective clinical study analysis of 14 patients with L5-S1 far-lateral disc herniations in a period between 2000 and 2004, treated with microsurgical technique. An imaging study revealed consistency with the patient's clinical presentation. In our department, a total of 580 patients underwent discectomy between 2000 and 2004 for lumbar disc herniation. Twenty-eight patients had foraminal or extraforaminal herniations (4.8%). Fourteen patients had FLLDH at the L4-L5 level (2.4%), whereas the other 14 were cases of FLLDH at the L5-S1 level (2.4%). One patient had FLLDH at both L5-S1 and L4-L5 levels (7.1%). The mean age of patients was 53.6 years, and the male:female ratio was approximately 5:9. All patients failed to recover after at least 6 weeks of conservative therapy. The mean duration of symptoms until the time of surgery was 7.2 months. Using this MIIMA technique, the authors removed the herniated discs compressing the (L5) nerve roots. Clinical outcome was measured using the visual analog scale. Every patient was discharged within 24 hours. Satisfactory (excellent or good) results were demonstrated in 13 patients (92.9%), because, except for 1 (7.1) permanent dysesthesia case, 4 cases (21.3%) were temporary dysesthesia. Postoperatively all patients reported excellent relief of their sciatic pains, and there were no technique-associated complications. No recurrence was observed during the follow-up period ranging from 10 to 60 months (mean, 29 mo). This is one of the major complications of any approach to a far-lateral disc. The authors describe a MIIMA for excising herniated discs that is applicable to all types of far-lateral lumbar herniations. Postoperative dysesthesia is the most important complication and may persist as it did in our cases. Consequently, manipulation of the ganglion should be avoided at all costs, if possible. The MIIMA procedure provides a simple alternative for treating lumbar foraminal or lateral exit zone herniated discs in selected cases. This approach is effective, allowing the preservation of the L5-S1 facet joint, saving the facet joint, preventing postoperative instability, and offering a direct view of the L5-S1 neuroforamen.

Prolonged diplopia following sinus vein thrombosis mimicking Gradenigo's syndrome

We report about a boy with the symptoms of Gradenigo's syndrome (abducens nerve palsy, acute otitis media, unilateral headache). The MR imaging showed a sinus vein thrombosis instead of the expected petroapicitis. After 2 weeks of conservative therapy with antibiotics and anticoagulation, without any clinical effort the boy underwent a mastoidectomy. Headache and otitis media recovered quickly but the diplopia still remained after 25 months.

Povidone iodine and dextrose solution combination sclerotherapy in chyluria

Objectives To evaluate the effectiveness of combination (povidone iodine and 50% dextrose) renal pelvic instillation sclerotherapy (RPIS) as a minimally invasive therapy for chyluria resistant to conservative treatment. Methods A total of 50 patients with chyluria and hematochyluria (28 men and 22 women) were included in the study. Initially, all were offered conservative antifilarial drug therapy and dietary fat restriction. Intravenous urography was done in all cases to document normal renal functional status. In the patients in whom chyluria persisted after 3 weeks of conservative therapy, cystoscopic lateralization was done and a 5F open-ended ureteral catheter was positioned under local anesthesia. The same was left attached to a 16F Foley catheter for 3 days of RPIS. A solution of 5 mL of 5% povidone iodine and 5 mL of 50% dextrose was instilled twice a day with the patient in the Trendelenburg position for 3 days. In cases of bilateral efflux, the dominant side was treated first. The opposite side was subjected to a similar instillation sclerotherapy schedule after 6 weeks if chyluria persisted. Results Of the 50 patients, only 4 responded to conservative therapy. The remaining 46 patients underwent combination RPIS. The mean follow-up was 24 months. Complete remission of chyluria or hematochyluria occurred in 40 (87%) and persisted in 6 patients (13%). Of the 6 patients in whom symptoms persisted, 2 developed chyluria on the side opposite the one treated with RPIS. Another 2 patients developed recurrence on the same side after remaining asymptomatic for 6 months after RPIS. All four of these patients subsequently underwent chylolymphatic disconnection and nephropexy (two open and two laparoscopic) with a successful outcome. The final 2 patients with persistent symptoms were lost to follow-up. Conclusions Combination sclerotherapy using a 5% povidone iodine and 50% dextrose solution is a safe and cost-effective minimally invasive therapy for chyluria refractory to conservative treatment.

Management of biliary and duodenal complications of chronic pancreatitis.

Biliary stricture and duodenal obstruction have been increasingly recognized as complications of chronic pancreatitis. The anatomical relationship of the distal common bile duct and the duodenum with the head of the pancreas is the main factor for their involvement in chronic pancreatitis. In hospitalized patients with pancreatitis, the incidence of biliary stricture and duodenal obstruction is reported to be about 6% and 1.2%, respectively. For patients requiring an operation for chronic pancreatitis the incidence increases to 35% for biliary stricture and 12% for duodenal obstruction. Fibrosis around the distal common bile duct can cause stenosis with obstruction of bile flow. Clinically, the presentation of these patients ranges from being asymptomatic with elevated alkaline phosphatase or bilirubin, or both, to being septic with cholangitis. Jaundice, cholangitis, hyperbilirubinemia, and persistent elevation of serum alkaline phosphatase occur more frequently in patients with pancreatitis with a biliary stricture. A twofold elevation of alkaline phosphatase is a marker of possible common duct stenosis in patients with chronic pancreatitis. The incidence of both biliary cirrhosis and cholangitis in these patients is about 10%. ERCP reveals a characteristic long, smoothly tapered stricture of the intrapancreatic common bile duct. In duodenal obstruction, the factors that convert self-limiting edema to chronic fibrosis and stricture formation are unknown, but ischemia superimposed on inflammation may be the major cause. These patients present with a prolonged history of nausea and vomiting. Barium studies typically show a long constricting lesion of the duodenum, and endoscopy reveals reactive inflammatory changes in a narrowed duodenum. Operation is indicated in patients with common bile duct strictures secondary to chronic pancreatitis when there is evidence of cholangitis, biliary cirrhosis, common duct stones, progression of stricture, elevation of alkaline phophatase and/or bilirubin for over a month, and an inability to rule out cancer. The operation of choice is either choledochoduodenostomy or choledochojejunostomy. A cholecystoenterostomy is less favored because of its higher failure rate (23%). Endoscopic stenting plays a role in patients who are unfit for surgery, but it is not recommended as definitive therapy. For duodenal obstruction, failure to resolve the obstruction with 1-2 weeks of conservative therapy is an indication for bypass. The operation of choice is a gastrojejunostomy. Not uncommonly, combined obstruction of the pancreatic duct, common bile duct, and duodenum will develop. Combined drainage procedures or resection are used to manage these problems.

Speculum lumbar extraforaminal microdiscectomy

Background context: Public interest, monetary pressures and improving diagnostic techniques have placed an increasing emphasis on minimalism in lumbar disc excision. Current techniques include microlumbar discectomy and minimally invasive spinal surgery. Both are good techniques but may be painful, require a hospital stay and/or are not widely used because of difficulty acquiring the necessary skills. The author therefore developed a less invasive microscopic technique that may be performed on a consistent outpatient basis with easily acquired skills.Purpose: The purpose of this study was to describe a variant of minimally invasive lumbar disc excision, while assessing the effects on a small group of patients.Study design: The treatment protocol was a prospective community hospital–based case study designed to evaluate a less invasive method of excising herniated lumbar discs residing in the canal, foraminal or far lateral space.Patient sample: This study is comprised of 50 patients with all anatomic forms of lumbar disc herniations, inside or outside the canal, at all levels except the lumbosacral joint.Outcome measures: Clinical results were measured by return to work time, the criteria of MacNab and by Prolo et al.'s economic and functional criteria.Methods: Selection criteria included adult patients with intractable low back and leg pain, plus an imaging study revealing a lumbar disc herniation consistent with the patient's clinical presentation. Mean patient age was 48 years. The male:female ratio was approximately 2:1. All patients failed at least 3 weeks of conservative therapy. Herniations occurred from the L2–3 space through L4–5, with 30 herniations being within and 20 outside the spinal canal. Both contained and extruded/sequestered herniations were treated. Excluded from the study were patients with herniations inside the spinal canal at the L5–S1 level. Surgical approach was by microscopic speculum transforaminal route for discs residing both within and outside the lumbar canal.Results: The initial 50 consecutive patients had successful technical operations performed on an outpatient basis by this less invasive technique. By the criteria of MacNab (Table 3)Table 3MacNab criteria*Excellent: No pain, no restriction of activity.Good: Occasional back or leg pain of sufficient severity to interfere with the patients' ability to do their normal work or their capacity to enjoy themselves in their leisure hours.Fair: Improved functional capacity, but handicapped by intermittent pain of sufficient severity to curtail or modify work or leisure activities.Poor: No or insufficient improvement to enable increase in activities; further operative intervention required.Data from [3]., 84% (42 of 50) had an excellent or good result, returning to work at a mean time of 3.5 weeks. Per Prolo et al.'s economic scale, 72% were disabled at levels I and II before surgery. Postoperatively, 92% had improved to levels IV and V. Similarly, on his functional scale, 94% functioned at levels I and II before surgery, whereas 88% achieved levels IV and V after surgery. Eighty percent required no pain medications 1 week after surgery. The only complication was an L3 minor nerve root injury as it exited the L3–4 foramen.Conclusion: The author has described a minimally invasive technique for excising herniated discs that is applicable to all types of lumbar herniations, except for those residing in the canal at L5–S1. Clinical outcomes are comparable to those of other forms of discectomy.

Bilateral os peroneum fractures: Comparison of conservative and surgical treatment and outcomes

Acute fracture of the os peroneum without concurrent rupture of the peroneus longus is a rarely cited injury. Sudden violent contraction of the peroneus longus muscle and direct trauma are documented mechanisms of injury. This injury can easily be overlooked due to its infrequency, and it may lead to chronic pain and impairment of function. Presented is a case of acute fracture of the os peroneum bilaterally. The fractures occurred approximately 21 months apart. Treatment varied with the right foot responding to 4 months of conservative therapy, and the left foot undergoing surgical excision of the fractured ossicle following 5 weeks of failed conservative therapy. This case is unique as it presents bilateral os peroneum fractures. This unique situation allows for a comparison of the two distinct treatment options. A fractured os peroneum without peroneus longus tendon rupture may be treated conservatively, however, surgical excision of the ossicle following 4 weeks of conservative therapy may expedite the recovery period and avoid chronic pain.

A clinician's approach to acute low back pain

Two important goals in treating acute low back pain are to return the patient to regular activity as quickly as possible and to do so in a manner that is cost-effective. By following a logical treatment protocol, the clinician is often able to provide the treatment necessary to provide the patient with relief. Referral to an orthopedist or neurosurgeon may be appropriate in only a minority of cases. Thus, after the initial history and physical examination, ruling out (or in) conditions that require urgent or emergent care is essential. These conditions include cauda equina syndrome, circulatory collapse due to expanding abdominal aortic aneurysm, and tumor, infection, and other underlying disorders as a cause of low back pain. Patients without these conditions can be started on conservative therapy-without radiographic or laboratory tests-regardless of the specific diagnosis. Conservative therapy consists of passage of time, controlled physical activity, physical modalities (e.g., cryotherapy or thermotherapy), local injections, nonsteroidal anti-inflammatory drugs, and muscle relaxants. Because low back pain is so common, even the small proportion of patients who do not improve after 6 weeks of conservative therapy represents a sizable number. The location and radiation of pain are used as initial guides to classifying these patients into four groups: those with localized pain, sciatica, anterior thigh pain, or posterior thigh pain. Each follows a different diagnostic path, which will be described herein.