The practical assessment and management of bladder outflow obstruction

The initial management of bladder outflow obstruction typically related to benign prostatic hyperplasia (BPH) falls to a large extent within the remit of general practice and the family physician. Referral onwards to secondary care typically arises following the failure to respond to conservative measures or when complications have supervened – the most significant of which is urinary retention. In the hospital setting, anaesthesia, constipation and immobility are the common precipitants. What follows is a practical guide to the management of these situations and provides an overview of the conservative, medical and surgical treatments available.     

Acral myxoinflammatory fibroblastic sarcoma: A case report and literature review

Acral myxoinflammatory fibroplastic sarcoma is an extremely rare soft-tissue sarcoma. It typically presents as an inflammatory mass in the distal extremities of adult patients. The authors present a review of the available literature as well as a discussion on the surgical management of a patient with acral myxoinflammatory fibroplastic sarcoma who originally requested conservative management but ultimately required a two-digit ray amputation after local recurrence.     

Case report: conservative management of a large capnothorax following laparoscopic renal surgery

As indications for laparoscopy surgery continue to grow for management of upper urinary tract pathology, knowledge of the potential complications that may be encountered and their respective management are essential. Pneumothorax during laparoscopic renal surgery is typically related to a diaphragmatic injury that allows pressurized CO(2) to enter the thoracic cavity. The placement of a chest tube is usually required for large defects and symptomatic patients. However, in selected patients, with understanding of the favorable absorptive properties of CO(2), conservative management may be elected. We report a case of an asymptomatic, large pneumothorax that was allowed to resolve spontaneously, thus reinforcing the notion of noninvasive capnothorax management incurred during laparoscopic renal surgery.     

Spinal stenosis and disc herniation in a 14-year-old male. A case report

Spinal stenosis should be considered in the differential diagnosis of disc disease when evaluating an adolescent presenting with unrelenting back and leg pain. Although they typically exhibit mechanical signs alone without neurological findings, they nevertheless may prove more vulnerable to rapidly progressive neurological changes. If motor deficits occur, protracted courses of conservative care should be avoided, and proper surgical management considered. Our recent experience with a 14-year-old boy with disc disease and stenosis indicated that aggressive surgical management facilitates a rapid return to an asymptomatic existence.     

Stent implantation for treatment of symptomatic spontaneous cervical internal carotid artery dissecting aneurysm. A case report.

Cervical internal carotid dissections are rare. Approximately one third of the cases are associated with pseudoaneurysm. The first-choice management of cervical carotid dissecting aneurysms consists in anticoagulation or antiplatelet therapy. Surgery is typically indicated in cases of failure of conservative therapy with recurrent cerebral ischemic attacks. In recent years, stent implantation has been also employed for the management of patients with carotid dissecting aneurysms whose neurological conditions were refractory to medical treatment. In the present case we describe the treatment of a patient with a carotid dissecting aneurysm, by means of endovascular stent application and provide angiographic control 24 months after the intervention.     

Treatment of an open infected type IIB distal clavicle fracture: case report and review of the literature

Clavicle fractures are common skeletal injuries that are typically managed nonoperatively, which results in a high rate of fracture union with few or no long-term sequelae. Type II distal clavicle fractures are an exception, with reported rates of nonunion ranging from 22% to 44%. This high rate of nonunion has led to controversy regarding the appropriate treatment of type II injuries. The following case report describes a type IIB distal clavicle fracture, in which nonoperative management was complicated by the breakdown of skin over the fracture site and the subsequent development of infection. This is a rare complication of conservative management. Thorough operative debridement, fracture stabilization via external fixation, and identification of the causative organism allowed for successful outcome in the management of this complex presentation.     

Coccydynia: a review of pathoanatomy, aetiology, treatment and outcome

Coccydynia is a painful disorder characterised by coccygeal pain which is typically exaggerated by pressure. It remains an unsolved mystery because of the perceived unpredictability of the origin of the pain, some psychological traits that may be associated with the disorder, the presence of diverse treatment options, and varied outcomes. A more detailed classification based on the aetiology and pathoanatomy of coccydynia helps to identify patients who may benefit from conservative and surgical management. This review focuses on the pathoanatomy, aetiology, clinical features, radiology, treatment and outcome of coccydynia.     

Endoscopic compartment release for chronic exertional compartment syndrome

Chronic exertional compartment syndrome is a condition that typically fails conservative management and requires a fasciotomy for the patient to return to activity. Fasciotomies performed through single or multiple incisions may fail to fully release the fascia of the afflicted compartment(s) and also may result in injury to neurovascular structures that cannot be visualized. Endoscopic assistance may minimize the intraoperative and postoperative complications associated with compartment release and offer improved cosmesis. This article describes an endoscopically assisted technique using a balloon dissector designed to address the shortcomings of open and semi-blind techniques.     

Closing the gap on Achilles tendon rupture: A cadaveric study quantifying the tendon apposition achieved with commonly used immobilisation practices

The relative benefits of surgical and conservative treatment of Achilles tendon rupture are widely debated. With modern conservative management protocols, the re-rupture risk appears to fall to one similar to surgical repair with negligible loss of function. Conservative management typically employs a period of time in an equinus cast with sequential ankle dorsiflexion in a functional orthosis. The optimal duration of immobilisation and rate of dorsiflexion is unknown. We aimed to quantify the change in Achilles tendon approximation achieved in common immobilisation techniques to assist the design of rehabilitation protocols.Twelve fresh-frozen cadaveric specimens had 2.5 cm of Achilles tendon excised. The gap between the tendon ends were measured via windowed full equinus casts and compared with functional boots with successively removed heel wedges.The greatest tendon apposition was achieved with the equinus cast. Each wedge removed decreased the reapproximation by approximately 5 mm.This paper supports the early use of maximal equinus casting in early management of acute Achilles tendon ruptures.     

Isolated renal vein thrombosis after blunt trauma

Renal vein thrombosis typically occurs in the setting of nephrotic syndrome, tumor thrombus, primary retroperitoneal processes with vein compression, oral contraceptive use, steroid therapy, transplanted kidney, or trauma. Trauma-induced renal vein thrombosis usually presents in combination with renal arterial or parenchymal injury. We report a case of isolated renal vein thrombosis secondary to blunt abdominal and flank trauma. The diagnosis was made with computed tomography, which revealed a filling defect in the affected renal vein and persistent nephrogram on delayed images. In general, conservative management is the preferred treatment approach with anticoagulation.     

High-pressure injection injuries of the hand. A review

High-pressure injection injuries to the hand are associated with severe morbidity if treated improperly. Injuries typically occur in the nondominant hand of patients using industrial equipment in the workplace. Tissue damage is produced by the delivery of both kinetic energy and foreign substances into the hand. The initial clinical course can be deceptively benign and lead to delay in instituting therapy. Early conservative management dramatically increases the likelihood that the injured part will eventually require amputation. Thorough examination for functional and structural impairment is mandated. Aggressive and definitive operative debridement is then undertaken. Postoperatively, a physical program of early mobilization is warranted to prevent fibrosis and the formation of contractures. Although the institution of prophylactic antibiotics is warranted the use of corticosteroids in the management of these injuries remains controversial.     

Acute urinary retention secondary to Herpes simplex meningitis.

We report a case of acute urinary retention in a 24-year-old man with Herpes simplex meningitis without genital lesions. Since the differential diagnosis in young patients who present with acute urinary retention also includes multiple sclerosis, lumbosacral disk herniation, rheumatological disorders and drug intoxication, a thorough history and careful neurological examination are of paramount importance in distinguishing these syndromes. As part of a directed neurological evaluation prompt performance of lumbar puncture is indicated; a lymphocytic pleocytosis is suggestive of herpetic meningitis. Culture of Herpes simplex virus from the cerebrospinal fluid should be attempted. We recommend conservative management only, typically with intermittent catheterization, since bladder function usually normalizes within 10 to 14 days.     

Imaging of genitourinary trauma

The kidney, bladder and male urethra are the organs typically injured by blunt and penetrating trauma to the urinary tract, whereas the ureter is only rarely injured. The staging of genitourinary tract trauma has recently gained tremendous significance due to improvements in ultrasound, CT and MRI, including contrast-enhanced magnetic resonance angiography, and has become a helpful tool for decision making with regard to conservative and surgical management. Furthermore, interventional radiology may be helpful to control hemorrhage from vessels in the pelvic region that may not be easily accessed by open surgery. Therefore, this pictorial essay gives examples of the radiological presentation of genitourinary trauma and describes technical details of the diagnostic imaging modalities used.     

Diagnosis and Treatment of the Adrenal Cyst

Adrenal cysts, first described in 1670, typically presented with abdominal pain or palpable mass. In the modern era, incidentally identified adrenal cysts are commonplace, as imaging studies have become a mainstay in patient evaluation. The rubric of adrenal cysts comprises a broad differential diagnosis, rendering definitive diagnosis and subsequent management difficult. These cysts are categorized into four subtypes: endothelial, pseudocyst, epithelial, and parasitic. Endocrine workup should rule out functional status. Radiologic differentiation is helpful; however, imaging characteristics, such as hemorrhage in a pseudocyst, can confound identification of benign versus malignant lesions. Any functional lesion, potentially malignant lesion, or benign lesion more than 5 cm in diameter deserves surgical treatment. For small, benign lesions, conservative management is a viable option, although no surveillance protocols have been described.     

Atrophic coarctation of the abdominal aorta.

Two cases illustrate the clinical manifestations and angiographic findings associated with segmental stenosis of the abdominal aorta. Such lesions represent the chronic occlusive stage of Takayasu's disease, a nonspecific inflammatory arteritis of uncertain etiology. While the disease is considered autoimmune, an infectious process may be involved. Complications typically associated with stenotic lesions of the abdominal aorta are secondary renal hypertension and ischemic symptoms secondary to vascular insufficiency. Surgical correction, the treatment of choice, has achieved excellent results for these well-localized lesions. Secondary renal hypertension was relieved by a spenorenal shunt and the disease has since been controlled with conservative management in the first patient. An aortofemoral bypass graft successfully alleviated the vascular insufficiency in the second patient, although the patient unfortunately expired from a refractory postoperative cardiac complication.     

Axillary block complicated by hematoma and radial nerve injury.

BACKGROUND AND OBJECTIVES: Hematoma is typically cited as one mechanism of nerve injury following axillary block. However, documented cases of this are lacking. METHODS: A healthy 38-year-old man was scheduled for surgical removal of a tumor of the hand. A transarterial axillary block was performed with a 22-gauge short-bevel needle using 40 mL of a mixture of equal volumes of 1.5% lidocaine and 0.5% bupivacaine containing 1:200,000 epinephrine. No paresthesias were reported. Postoperative, the patient developed a large axillary hematoma accompanied by paresthesias and radial nerve weakness. RESULTS: With conservative management, nerve recovery was complete in 6 months. CONCLUSIONS: Hematoma complicating axillary block may result in nerve dysfunction.     

Delayed vesicovaginal fistula after ring pessary usage

Vaginal pessaries are commonly used in the conservative management of pelvic organ prolapse, and are generally viewed as safe alternatives to surgery. Serious complications are rare, but can and do arise, typically as a result of the pessary not being fitted and maintained correctly. This case describes delayed development of a vesicovaginal fistula (VVF) 8 months after vaginal ulceration was noted and the ring pessary removed. The 82-year-old patient was managed with a urinary diversion via ileal conduit. This case highlights the importance of meticulous follow-up when a pessary is removed in the setting of ulceration. It is the third documented case of a genitourinary fistula resulting from a vaginal ring pessary, and is the first reported case of this surgical technique being successfully used in this setting.     

Surgical management of acute pancreatitis: Historical perspectives,challenges, and current management approaches

Acute pancreatitis(AP) is a serious condition presenting catastrophic consequences. In severe AP, the mortality rate is high, and some patients initially diagnosed with mild-to-moderate AP can progress to a life-threatening severe state. Treatment of AP has evolved over the years. Drainage was the first surgical procedure performed for AP; however, later, surgical approaches were replaced by more conservative approaches due to the availability of advanced medical care and improved understanding ...     

Clinical and radiological outcome of non-surgical management of thoracic and lumbar spinal fracture-dislocations — a historical analysis in the era of modern spinal surgery

Context: It is well established that traumatic spinal dislocations (AO Type C injuries) should be surgically treated. However, no recent comparative study of surgical versus non-surgical management of type C injuries was found attesting the superiority of surgical treatment.

Objective: Due to the lack of information about the natural history of non-surgical management of type C injuries, we evaluated the outcome of historical conservative treatment of type C injuries.

Methods: An extensive manual search of articles was performed in the Pubmed Database. We included articles that reported the clinical and/ or the radiological outcome of non-surgical management of thoracic and/ or lumbar spinal fracture-dislocations.

Results: Three well described retrospective studies where fracture-dislocations of the thoracolumbar spine were managed non-surgically were included. Non-surgical management typically consisted in postural reduction and prolonged bed rest (about 10-13 weeks on average). Residual deformity was common, and some studies reported a high rate of post treatment pain syndromes. Some studies reported surgery for gibbus deformity after conservative treatment or persistent instability requiring further bed rest. Neurological deterioration was rare, and some patients had some improvement, although the vast majority of the patients had persistent, severe neurological deficits.

Conclusions: Compared with historical non-surgical care, surgery for type C injuries decreases the chances of post-operative pain, late spinal deformity and also allowed early rehabilitation, once no bed restriction is necessary. Ethical issues based on this historical analysis may preclude performing a comparative study of non-surgical versus surgical management of these injuries in the modern spine era.     

Impingement syndrome and its conservative management

Shoulder impingement syndrome is a common problem encountered in athletes and the general population. Etiology, pathology, and treatment differ throughout the literature. The purpose of this review is to examine the current literature with respect to the mechanism and conservative management of impingement syndrome. Focus is on anatomy, pathology, diagnosis, and conservative treatment. It is concluded that there is little experimental research evaluating the efficacy of conservative management techniques. It is recommended that further studies regarding the efficacy of conservative treatment be initiated. J Orthop Sports Phys Ther 1989;11(5):183-191.