Assessing the long-term effect of educational reminder messages on primary care radiology referrals

AIM: To investigate whether the effect of educational reminder messages for knee and lumbar spine radiographs varied over a 12 month period. MATERIALS AND METHODS: In a previous randomized, controlled trial, educational reminder messages attached to x-ray reports were shown to be effective in reducing the number of radiograph requests by general practitioners for knee and lumbar spine radiographs. In this study, all radiology departments from the previous trial were asked for monthly referral records for the 12 month intervention period for knee and lumbar spine radiographs for each general practice. Poisson regression was used to test for a change over time in the number of referrals between control and intervention practices. RESULTS: Data were obtained for 66% of the general practices in the main trial. The number of referrals for both knee and lumbar spine radiographs remained consistently and statistically significantly lower in the educational reminder messages group compared with the control group (relative risk=0.65 and 0.64, respectively). There was no evidence that this difference increased or decreased throughout the 12 month period. CONCLUSIONS: The effect of educational reminder messages was produced as soon as the intervention was delivered and maintained throughout the intervention period. There was no evidence of the effect of the intervention wearing off.     

Clinical analysis of cervical radiculopathy causing deltoid paralysis

In general, deltoid paralysis develops in patients with cervical disc herniation (CDH) or cervical spondylotic radiculopathy (CSR) at the level of C4/5, resulting in compression of the C5 nerve root. Therefore, little attention has been paid to CDH or CSR at other levels as the possible cause of deltoid paralysis. In addition, the surgical outcomes for deltoid paralysis have not been fully described. Fourteen patients with single-level CDH or CSR, who had undergone anterior cervical decompression and fusion for deltoid paralysis, were included in this study. The severity of deltoid paralysis was classified into five grades according to manual motor power test, and the severity of radiculopathy was recorded on a visual analog scale (zero to ten points). The degree of improvement in both the severity of deltoid paralysis and radiculopathy following surgery was evaluated. Of 14 patients, one had C3/4 CDH, four had C4/5 CDH, three had C4/5 CSR, one had C5/6 CDH, and five had C5/6 CSR. Both deltoid paralysis and radiculopathy improved significantly with surgery (2.57+/-0.51 grades vs 4.14+/-0.66, P=0.001, and 7.64+/-1.65 points vs 3.21+/-0.58, P=0.001, respectively). In conclusion, the current study demonstrates that deltoid paralysis can develop due to CDH or CSR not only C4/5, but also at the levels of C3/4 and C5/6, and that surgical decompression significantly improves the degree of deltoid paralysis due to cervical radiculopathy.     

Recurrence of sciatica following hemilaminectomy for disc herniation

This retrospective study investigated the causes of ipsilateral sciatica following formal hemilaminectomy and discectomy for disc herniation and analyzed the factors that influence the outcome of revision surgery for recurrence. From a series of 1,016 patients who were operated upon for primary lumbar disc herniation, 64 patients were revised because of persistent or recurrent sciatica and back pain. Successful outcome was achieved in 81% of the patients with pain recurrence within 6 months following unilateral disc herniation at another level, residual disc herniation, recurrence of disc herniation, pseudomeningocele, and epidural hematoma. In contrast, not successful results were noted in the other 19% of reoperated patients later than 6 moths following primary operation for epidural fibrosis, lateral spinal stenosis, or combined. In this series, the outcome following revision surgery was not related to any specific clinical symptoms and physical examination findings, but mainly to the operative findings during revision surgery and the time lapsed between primary and revision surgery. Computed tomography (CT) was less reliable than magnetic resonance imaging (MRI) in detecting pathology prior to revision surgery, particularly in distinguishing between disc prolapse and fibrosis. Operative findings and pain-free interval between primary discectomy and revision surgery determined the outcome of revision surgery for recurrent ipsilateral sciatica, while MRI seems to be the imaging method of choice. Revision surgery for ipsilateral radicular pain following discectomy in this series showed satisfactory results that were comparable with those of primary discectomy.     

The role of cumulative physical work load in lumbar spine disease: risk factors for lumbar osteochondrosis and spondylosis associated with chronic complaints

OBJECTIVES—To investigate the relation with a case-control study between symptomatic osteochondrosis or spondylosis of the lumbar spine and cumulative occupational exposure to lifting or carrying and to working postures with extreme forward bending.
METHODS—From two practices and four clinics were recruited 229 male patients with radiographically confirmed osteochondrosis or spondylosis of the lumbar spine associated with chronic complaints. Of these 135 had additionally had acute lumbar disc herniation. A total of 197 control subjects was recruited: 107 subjects with anamnestic exclusion of lumbar spine disease were drawn as a random population control group and 90 patients admitted to hospital for urolithiasis who had no osteochondrosis or spondylosis of the lumbar spine radiographically were recruited as a hospital based control group. Data were gathered in a structured personal interview and analysed using logistic regression to control for age, region, nationality, and other diseases affecting the lumbar spine. To calculate cumulative forces to the lumbar spine over the entire working life, the Mainz-Dortmund dose model (MDD), which is based on an overproportional weighting of the lumbar disc compression force relative to the respective duration of the lifting process was applied with modifications: any objects weighing 5 kg were included in the calculation and no minimum daily exposure limits were established. Calculation of forces to the lumbar spine was based on self reported estimates of occupational lifting, trunk flexion, and duration.
RESULTS—For a lumbar spine dose >9×10⁶ Nh (Newton×hours), the risk of having radiographically confirmed osteochondrosis or spondylosis of the lumbar spine as measured by the odds ratio (OR) was 8.5 (95% confidence interval (95% CI) 4.1 to 17.5) compared with subjects with a load of 0 Nh. To avoid differential bias, forces to the lumbar spine were also calculated on the basis of an internal job exposure matrix based on the control subjects' exposure assessments for their respective job groups. Although ORs were lower with this approach, they remained significant.
CONCLUSIONS—The calculation of the sum of forces to the lumbar spine is a useful tool for risk assessment for symptomatic osteochondrosis or spondylosis of the lumbar spine. The results suggest that cumulative occupational exposure to lifting or carrying and extreme forward bending increases the risk for developing symptomatic osteochondrosis or spondylosis of the lumbar spine.


Keywords: case-control study; physical work load; lumbar osteochondrosis; lumbar spondylosis     

后路椎体间或横突间融合治疗椎间盘源性下腰痛

目的 观察椎体间或横突间融合治疗椎间盘源性下腰痛的手术疗效。方法 经椎间盘造影检查,有32例患者被确诊为椎间盘源性下腰痛。其中17例行后路椎间盘切除椎体间cage植骨,15例行后路椎间盘切除横突间植骨RF内固定。术后随访2－4年,观察患者腰痛改善和腰推融合情况。结果 术后1年患者腰痛较术前平均改善者在椎间融合组为87％,横突融合组为76%。术后2年腰痛较术前平均改善者在椎间融合组为89％,横突融合组为81％。术后1年腰椎融合率在椎间融合组为88％,横突融合组均为87％。术后2年腰椎融合率在椎间盘融合组为92％,横突融合组均为90％。结论 后路椎体间cage植骨融合术治疗椎间盘源性下腰痛,术后近中期腰痛改善率优于经椎弓根固定横突间融合术。椎间融合治疗是治疗椎间盘源性下腰痛的首选术式。     

Complications after LP related to needle type: pencil-point versus Quincke

OBJECTIVES: We studied the incidence of complications after diagnostic lumbar puncture (LP) related to needle type. MATERIAL AND METHODS: A 5 months' observational study of routine diagnostic LP in 83 patients was conducted. RESULTS: Significantly more headache was observed after LP using thicker cutting needles (20G Quincke) compared with thinner cutting or non-cutting needles (22G Quincke or pencil-point). No significant difference in complications after LP was found between the 22G Quincke and pencil-point needles. CONCLUSION: The size of the needle and not the needle shape seems to be the main determinant for post-dural puncture headache (PDPH).     

Three-dimensional evaluation of lumbar disc hernia and prediction of absorption by enhanced MRI

Both the spontaneous shrinkage and the disappearance of disc hernia have been confirmed through the use of computed tomography (CT) and magnetic resonance imaging (MRI). There is, however, no practical method to predict the likely absorption of the herniated mass. The objective of this study was to predict the spontaneous absorption of disc hernia by MRI, and to select the optimum treatment. The study involved 65 patients with lumbar disc hernias. Conservative treatment was carried out in 21 patients, while 44 patients underwent herniotomy. In the nonoperated patients, an MRI was taken both during the painful period, and shortly after pain remission. Hernial shrinkage was evaluated according to the decrease in the calculated volume, in addition to the decrease in hernial area, calculated by MRI. In the operated group, preoperative MRI enhancement, type of hernia, and invasion of granulation tissue in the histological specimens were studied. In the 21 nonoperated patients, the volume (mean ± SD) was 0.488 ± 208 cm³ (range, 0.197–0.931 cm³) in the painful period and 0.214 ± 0.181 cm³ (range, 0.0–0.744 cm³) in the remission period. This decrease in volume was statistically significant. There was also a greater decrease in hernias exhibiting positive enhancement by MRI. In the operated patients, hernias that penetrated the posterior longitudinal ligament (PLL) had high rates of preoperative enhancement, and these hernias showed invasion of granulation tissue with marked neovascularization. Positive enhancement by MRI confirms an ongoing absorption process. Enhanced MRI can be a good method for the prediction of spontaneous absorption of lumbar disc hernias. Received: September 20, 2000 / Accepted: July 17, 2001     

腰椎间盘突出症微创手术

腰椎间盘突出症是一种常见病、多发病,是引起腰痛或腰腿痛的主要原因。腰椎间盘突出症除保守治疗和开放手术外,近年开展的微创介入手术治疗正逐渐被临床认识和应用。微创外科手术治疗腰椎间盘突出症具有疗效显著,损伤小,并发症少,术后恢复快等优点。正确认识腰椎间盘微创手术,严格适应证和熟练的操作技巧是取得良好疗效的关键。     

椎间盘源性下腰痛

慢性下腰痛是普遍存在的健康问题,其中40%是椎间盘源性下腰痛,而大部分医师对其认识不足,易造成误诊。本文从病史、流行病学、病因、发病机制、临床表现和治疗等方面对该病进行综述,以提高临床对此病的认识。     

胶原酶对腰椎间盘髓核组织中蛋白多糖的影响

 【目的】探讨胶原酶在作用时间内是否会引起腰椎间盘髓核组织中蛋白多糖的水解。【方法】经皮腰椎间盘切除术中获得髓核组织标本,-70℃保存。胶原酶15u作用于1mL(0.1g/mL)髓核组织匀浆,测定不同时间段的溶解效应。在胶原酶对髓核组织饱和溶解时间条件下,选择不同剂量的胶原酶作用于1mL(0.1g/mL)髓核组织匀浆,通过测定糖胺多糖的含量变化,推测蛋白多糖的含量变化情况。【结果】本实验的胶原酶对髓核组织饱和溶解时间为12h。胶原酶作用后髓核组织中糖胺多糖在9u胶原酶以内的各组呈独立散在分布,组间差异有统计学意义(P<0.05)。9u胶原酶以后组间差异没有统计学意义(P>0.05)。9u胶原酶时吸光度达到最大值,经与总量对照组比较,糖胺多糖最大水解程度为57.14%～64.76%。【结论】本实验初步证实胶原酶可以在短期内引起腰椎间盘髓核组织中蛋白多糖含量的降低,这可能与胶原酶溶解术后椎间盘退变的加重有关。