Long-term results of microvascular decompression for trigeminal neuralgia and hemifacial spasms according to preoperative symptomatology

Background

Microvascular decompression (MVD) is currently used in several centres for the treatment of trigeminal neuralgia (TN) and hemifacial spasms (HFS). How long-term results relate to the preoperative symptoms still needs to be documented. The primary aim of this study was to assess long-term results of MVD for TN and HFS, as related to the types of preoperative symptoms.

Methods

We performed a retrospective study including all first-time MVDs for TN and HFS done during the 11-year period (1999–2009) in the Department of Neurosurgery, The National Hospital (Rikshospitalet), Oslo. The patients were categorized depending on the pre-operative symptomatology.

Results

The study population includes 303 first-time procedures performed by the senior author (PKE), 243 TN patients (65 % TN without constant pain and 35 % TN with constant pain) and 60 HFS patients (95 % typical HFS and 5 % atypical HFS). The patients were followed for a mean 71 months (range, 14–147). In both the TN and HFS patients, MVD caused lasting symptom relief in a high proportion of patients, including patients with atypical symptoms.

Conclusion

After MVD for TN and HFS, regardless of preoperative symptoms, lasting relief is observed in a high proportion of patients, with a favorable complication profile.     

Emprical factors associated with Brainstem auditory evoked potential monitoring during microvascular decompression for hemifacial spasm and its correlation to hearing loss

Background

Cranial nerve VIII is at risk during microvascular decompression (MVD) for hemifacial spasm (HFS). The primary aim of this study is to evaluate the empirical factors associated with brainstem auditory evoked potential monitoring and its correlation to post operative hearing loss (HL) after MVD for HFS.

Methods

Pre-operative and post-operative audiogram data and BAEP from ninety-four patients who underwent MVD for HFS were analyzed. Pure tone audiometry (PTA) and Speech Discrimination Score (SDS) were performed on all patients before and after surgery. Intraoperative neurophysiological data were reviewed independently. HL was assessed using the AAO-HNS classification system for non-serviceable hearing loss (Class C/D), defined as PTA >50 dB and/or SDS <50 % within the speech range of frequencies.

Results

Patients with HL had higher rates of loss in the amplitude of wave V and prolongation in the interpeak latency of peak I-V latency during MVD. Gender, age, side, and MVD duration did not increase the risk of HL. There was no correlation between successive number of BAEP changes (reflective of the number of surgical attempts) and HL. There was no association between the speed of recovery of BAEPs and HL.

Conclusions

Patients with new post-operative HL have a faster rate of change in the amplitude of wave V and the interpeak I-V latency during intraoperative BAEP monitoring for HFS. Our alarm criteria to inform the surgeon about impending nerve injury might have to be modified and prospectively tested to prevent rapid change in BAEPs.     

Microvascular decompression for neurovascular conflicts in the cerebello-pontine angle: which role for endoscopy?

Background

Microvascular decompression (MVD) is the surgical intervention designed to resolve neurovascular conflicts (NCs) in the cerebellopontine angle (CPA). Today, endoscopy is commonly used in many neurosurgical procedures. This study aims to retrospectively assess the usefulness of endoscopy during MVD, focusing on microscopic endoscopic-assisted (MEA) MVD.

Methods

Between January 2010 and December 2012, 141 patients underwent MVD procedures: 119 (84.5 %) were affected by idiopathic trigeminal neuralgia (TN), 20 (14 %) by hemifacial spasm (HFS), 1 by glossopharyngeal neuralgia (GN) and 1 by TN and GN simultaneously; 128 (91 %) MVD were first time procedures, while 13 (9 %) were recurrences (10 TN, 3 HFS). Visualization techniques used were: pure microscopic in 89 (63 %) cases, fully endoscopic in 12 (8.5 %) and MEA in 40 (28.5 %). The MEA technique was used when the conflict was not clearly identified under microscopic view or it was not certainly resolved.

Results

Overall, a NC was found in 130 (92 %) cases, while 11 patients had no intraoperative evidence of NC. Considering specifically the 40 MEA cases, 12 (8.5 % overall) conflicts not clearly visible with the microscope were revealed and solved, a complete conflict resolution was confirmed in 13 (9 % overall) cases, while an incomplete conflict resolution was shown in four cases (3 % overall).

Conclusion

Pure microscopic MVD remains the technique of choice. The endoscope is a useful adjunctive imaging tool in confirming NCs identified by the microscope, revealing conflicts missed by the microscopic survey alone and verifying adequate nerve decompression.     

Thyroid Surgery without Antibiotic Prophylaxis: Experiences with 1,030 Patients from a Teaching Hospital in China

Objective

Our objective was to evaluate the outcome of thyroidectomy without the use of prophylactic antibiotics. This study was held from January 2005 to May 2012 in a teaching hospital in Dongguan, China.

Methods

A total of 1,030 thyroidectomy patients were retrospectively reviewed and basic data were recorded, including age, sex, peri-operative antibiotic use, type of thyroid surgery done, and post-operative complications. Either an open approach or an endoscopic approach was performed according to the doctor’s or patient’s preference following a strict aseptic technique. The drain was routinely placed. Any complications were analyzed.

Results

A total of 834 (81 %) females and 196 (19 %) males were included, giving a ratio of 4.2:1. The average age was 38.3 years. The mean operation time was 85.3 min. Pathological type included 818 (79.4 %) nodular goiter, 34 (3.3 %) Graves’ disease, 102 (9.9 %) nodular papillary hyperplasia, 12 (1.2 %) Hashimoto’s disease, 62 (6 %) papillary carcinoma, and 2 (0.2 %) medullary carcinoma. Four patients had postoperative bleeding, four had temporally recurrent nerve paralysis. Only one had wound infection (0.09 %).

Conclusion

Antibiotic prophylaxis in elective thyroidectomy is not an essential pre-operation preparation for all patients, if guidelines for antibiotic prophylaxis in clean surgery are adhered to and surgeons have sophisticated skills in the procedure.     

Oxford phase 3 unicondylar knee arthroplasty through a minimally invasive approach: long-term results

Purpose

Surgical treatment options for medial compartment osteoarthritis of the knee include high tibial osteotomy, total knee arthroplasty or unicompartmental knee arthroplasty (UKA), depending on the patient’s age, level of physical activity and the degree of deformity.

Methods

In this study, we evaluated the long-term results of patients who underwent the Oxford cemented meniscal-bearing unicondylar knee prosthesis through a minimally invasive approach including a clinical, functional and radiographic assessment.

Results

Favourable clinical and radiological outcomes were registered overall at ten years after surgery. Overall results of UKA according to the American Knee Society (AKS) using Insall’s criteria showed an excellent or good outcome for 492 knees (96.28 %), fair for 11 (2.15 %) and poor for eight (1.57 %) in the post-operative long term.

Conclusions

We believe that with appropriate surgical technique, patient selection, prosthetic design and specific training, surgeons should achieve good outcomes with the added advantages of a minimally invasive approach. High volume for this technique is important in our opinion.     

Preoperative assessment of hemifacial spasm by the coronal heavily T2-weighted MR cisternography

Background

Microvascular decompression (MVD) has become a well-established surgical procedure for hemifacial spasm (HFS). Before surgery, it is essential to evaluate any possible deformity of the brainstem and establish the precise location of the offending vessels. In the present study of HFS patients we examined coronal sections taken by heavily T2-weighted MR cisternography in addition to routine axial sections, and assessed the usefulness of these images through comparison with intraoperative findings.

Methods

Eighty patients with HFS underwent preoperative coronal heavily T2-weighted MR cisternography before microvascular decompression surgery. Three neurosurgeons examined the preoperative axial and coronal MR images and evaluated vessel invagination into the brainstem. The usefulness of coronal sections was assessed statistically by the Mann-Whitney U test.

Results

Invagination of the offending vessel into the brainstem was observed in 24 cases (30.0%). In 19 patients, it was predicted preoperatively that compression of the flocculus and brainstem would be required in order to approach the offending vessels. Coronal MR cisternography was significantly more useful in cases with vessel invagination into the brainstem than in cases without invagination.

Conclusions

Coronal sections obtained by MR cisternography are able to demonstrate the severity of vessel invagination into the brainstem as well as revealing the presence of the offending vessel. This information is helpful for planning a suitable approach to the root exit zone.     

Comparison between patient and surgeon perception of degenerative spine disease outcomes—a prospective blinded database study

Background

Few have studied the correlation between patients’ and spine surgeons’ perception on outcomes, or compared these with patient-reported outcome scores. Outcomes studies are increasingly important in evaluating costs and benefits to patients and surgeons, and in developing metrics for payer evaluation and health care policy-making.

Objective

To compare patients’ and surgeons’ assessment of spine treatment outcome in a prospective blinded patient-driven spine surgery outcomes registry, and to correlate perceived outcomes ratings to validated outcomes scores.

Methods

Patients filled out surveys at baseline, 3 months and 6 months postoperatively, including Visual Analog Scale (VAS), and Neck Disability Index (NDI) or Oswestry Disability Index (ODI). Outcome was rated independently by patients and surgeons on a 7-point Likert-type scale.

Results

Two-hundred and sixty-five consecutive adult patients were surgical candidates. Of these, 154 (58.1 %) opted for surgery, with 69 (44.8 %) cervical and 85 (55.2 %) lumbar patients. One hundred and thirty-five (87.7 %) had both patient and surgeon postoperative ratings. Surgeons’ and patients’ ratings correlated strongly (Spearman rho?=?0.53, p?<?0.0001, 45.9 % identical, 88.2 % +/? 1 grade). The surgeon rated outcomes were better than patients in 29.8 % and worse in 21.15 %. Patient rating correlated better with the most recent NDI/ODI and pain scores than with incremental change from baseline. In multivariate analysis, age, location (cervical vs lumbar), pain ratings, and functional scores (NDI, ODI) did not have significant impact on the discrepancy between patient and surgeon ratings.

Conclusions

Patients’ and surgeons’ global outcome ratings for spinal disease correlate highly. Patients’ ratings correlate better with most recent functional scores, rather than incremental change from baseline.     

Current Status of Robotic Thyroid Surgery in South Korea: A Web-Based Survey

Background

More than 8,000 cases of robotic thyroidectomy (RoT) were performed in South Korea from 2007 to 2011 using either a transaxillary approach (TAA) or a bilateral axillo-breast approach (BABA). However, there is no consensus regarding patient selection for RoT. This study used a web-based survey questionnaire to examine the current status of RoT in South Korea.

Methods

Thirty-two of 50 surgeons (64.0 %) who had performed RoT in South Korea participated in the web-based survey in August 2011. The questionnaires comprised four main domains: surgeon characteristics, surgical approach, patient selection, and future prospects.

Results

In terms of surgical approach, 43.8 % respondents used the TAA method and 53.1 % used the BABA method. The main advantage cited by surgeons using the TAA method was that it made lateral lymph node dissection easier (35.7 %), whereas those using the BABA method cited more cosmesis (100 %) and ease of performing a contralateral thyroidectomy (88.2 %). Papillary thyroid cancer ≤2 cm (65.3 %), intracapsular lesion (76.7 %), nonposterior location (53.6 %), and no clinical evidence of lateral lymph node metastasis (76.7 %) were cited as main indications for RoT. Of respondents, 87.5 % agreed that RoT would play a future role as a treatment modality for thyroid disease.

Conclusions

Opinions differed regarding the advantages and disadvantages of two approaches for RoT. This may be due to differences in surgical procedure itself between two approach methods. Accumulation of RoT surgeon’s experiences might establish consensus regarding patient selection and indications for the RoT will need to be further investigated.     

Increasing Mastectomy Rates—The Effect of Environmental Factors on the Choice for Mastectomy: A Comparative Analysis Between Canada and the United States

Purpose

Unilateral mastectomy (UM) and contralateral prophylactic mastectomy (CPM) for early-stage breast cancer (ESBC) have been increasing. Numerous etiological factors for this rise have been suggested, including increasing use of magnetic resonance imaging (MRI) and reconstruction, surgeon’s preference, and patient’s choice. We conducted a qualitative study to explore what role the surgeon and their practice environment play in the increasing rates.

Methods

Semi-structured interviews were conducted with general surgeons to explore their current approach to treating ESBC and their experience with women requesting mastectomy. Purposive sampling identified surgeons across Ontario, Canada, and the United States (US). Constant comparative analysis identified key concepts.

Results

Data saturation was achieved after 45 interviews. ‘The effect of external factors on rising mastectomy rates’ was the dominant theme. All surgeons described increasing mastectomy rates over the last 5 years, and all surgeons discussed breast-conserving therapy (BCT) and UM as equivalent options. However, US surgeons discussed reconstruction early in the consultation process, reflecting legislative requirements. In contrast, Ontario surgeons discussed reconstruction only when a patient was considering mastectomy. Ontario surgeons often recommended BCT, whereas US surgeons rarely made a direct recommendation regarding the extent of surgery. Neither US nor Canadian surgeons recommended the use of UM + CPM in average-risk ESBC, and all surgeons described women initiating this request. MRI use and access to immediate breast reconstruction also impacted the choice for mastectomy.

Conclusions

Use of MRI, access to reconstruction, and legislative requirements regarding information disclosure, appeared to influence the surgical consultation process and the patient’s request for CPM.     

Combined intraoperative monitoring of abnormal muscle response and Z-L response for hemifacial spasm with tandem compression type

Background

Multiple neurovascular compression is present in about 38 % cases of hemifacial spasm (HFS). In these cases, the vertebral artery (VA) compresses another vessel, which in turn compresses the nerve. This type was named as “the tandem type”. In the tandem type, the real offending vessel is often concealed by the VA. It is sometimes neglected by the surgeons. In this study, we report our experience in using abnormal muscle response (AMR) and ZL-Response (ZLR) simultaneously as intraoperative monitoring for MVD surgery of HFS with “the tandem type” vascular compression involving VA.

Methods

Fourteen “tandem type” patients treated with microvascular decompression surgery (MVD) surgery were included. ZLR and AMR were recorded simultaneously to identify the offending vessels in operation.

Results

After MVD surgery, 13 patients achieved excellent resolution of spasm. In one case, the patient failed to attain resolution in the first operation, underwent early reoperation and had good resolution. There were no operative deaths or serious operative complications. In all 14 cases, we found that VA compressed the anterior inferior cerebellar artery (AICA) or posterior inferior cerebellar artery (PICA), which in turn compressed the root exit zone (REZ). A typical ZLR was identified from the AICA or PICA but not from the VA. AMR was absent in one case and persisted in one case. After the VA was transposed, the typical AMR was unchanged, unstable or disappeared, and ZLR from the AICA/PICA also existed. AMR and ZLR did not disappear until AICA/PICA was sufficiently decompressed.

Conclusions

The combination of AMR and ZLR provides more useful information than does the AMR alone, and ZLR may be the only useful intraoperative monitoring for MVD surgery in times when AMR is absent or persists. ZLR played a crucial role in finding the real offending vessel, which was often concealed by the VA in tandem type.     

What is the Work Environment of Orthopaedic Surgeons in China?

Background

Physicians in China face heavy demands from patients and the government for services but deal with the threat of unpredictable legal and physical conflicts with patients, some ending with the death of doctors. More than 40 doctors and nurses have been killed by patients since 2001.

Questions/purposes

We sought to evaluate (1) the demographics of orthopaedic practice, (2) duty periods, (3) practice support, and (4) job satisfaction among orthopaedic surgeons in China.

Methods

Questionnaires were posted online at www.OrthoChina.org for download by orthopaedic surgeons in 2006 to 2007, and sent to those attending meetings in 2013. In 2013, a total of 1350 surgeons were invited and 456 participated in the survey at meetings. In 2007, during the period of the survey, 9759 individuals were qualified orthopaedic surgeons, and 334 participated in the survey at www.OrthoChina.org.

Results

Ninety-one percent of orthopaedic surgeons work in public and 9% in private hospitals. Ninety-four percent work more than 8 hours per day 6 to 7 days a week. Twenty-five percent work more than 12 hours per day 6 to 7 days a week without extra compensation. The majority of orthopaedic surgeons must work on national statutory holidays. Almost none received contractually mandated income for weekends and national holidays. Approximately 80% of participants reported an attack of some kind, including physical or psychologic harm. With respect to job satisfaction, 73% stated they would not choose to be a physician again and 86% reported that they do not want their children to become a physician.

Conclusions

China’s rapid economic growth and resulting demands for modern health care have resulted in heavy pressure on orthopaedic surgeons, financially and personally. Chinese orthopaedic surgeons are overworked, suffer lack of respect, and face the possibility of serious personal harm. As a consequence, they are demoralized and unsatisfied. Significant reforms are needed.     

Microvascular decompression in patients with coexistent trigeminal neuralgia,hemifacial spasm and glossopharyngeal neuralgia

Background

Trigeminal neuralgia(TN), hemifacial spasm (HFS) and glossopharyngeal neuralgia (GPN) were referred to hyperactive dysfunction syndromes (HDSs) of the cranial nerves. These symptoms may occur synchronously or metachronously, but the combination of three diseases is extremely rare.

Methods

From 2007 through 2013, six patients with coexistent GPN-HFS-TN were treated in our department. The combined symptoms occurred on the same side in three and on both sides in three. These patients underwent nine microvascular decompression (MVD) procedures in total. The clinical data including operative findings were respectively analyzed, and the etiological factors as well as treatment strategies were discussed.

Results

Intraoperatively, in all the cases a small posterior fossa was found, which was crowded with cranial nerve roots and cerbellar vesels. Postoperatively, spasm was stopped immediately in four and within 3 months in two; the symptom of TN disappeared immediately in four and within 2 weeks in two; the symptom of GPN was relieved immediately in four and improved with medication in two. During the up to 77 months’ follow-up, no changes, recurrence or any dysfunctions of cranial nerves were observed in any of the patients.

Conclusions

The combination of HFS-TN-GPN is extremely rare and is often associated with a looped VBA and a smaller posterior fossa. However, MVD is still a good choice for treatment. To achieve a safe and effective outcome, dissection of the caudal cranial nerves and proximal transposition of the vertebral artery before decompression of the affected nerve roots are strongly recommended.     

Factors Influencing Surgeons’ Intraoperative Leadership: Video Analysis of Unanticipated Events in the Operating Room

Background

The achievement of surgical goals and the successful functioning of operating room (OR) teams are dependent on leadership. The attending surgeon is a team leader during an operation, with responsibility for task accomplishment by the clinical team. This study examined surgeons’ leadership behaviors during surgical procedures, with particular reference to the effect of intraoperative events on leadership.

Methods

Videos of operations (n = 29) recorded at three UK teaching hospitals were analyzed to identify and classify surgeons’ intraoperative leadership behaviors using the Surgeons’ Leadership Inventory. The frequency and type of leadership behaviors were compared before and after the point of no return (PONR) (n = 24), and during an unexpected intraoperative event (n = 5).

Results

Most of the surgeons’ leadership behaviors were directed toward the resident during an operation. No significant differences were found for the overall number or type of leadership behaviors pre- and post-PONR. The frequency of leadership behaviors classified as “Training” and “Supporting others” significantly decreased during an unanticipated intraoperative event.

Discussion

Overall, surgeons engaged in the same leadership behaviors throughout the course of an operation unless they were dealing with an unanticipated event. Surgeons appeared to adopt a “one size fits all” leadership style approach regardless of the team or situation. Additionally, surgeons seemed to limit their intraoperative leadership focus to other surgeons rather than to the wider OR team.     

Does the surgeon’s experience influence the outcome of laparoscopic treatment of common bile duct stones?

Background

The aim of this study was to assess laparoscopic treatment of choledocholithiasis with respect to the surgeon’s experience.

Methods

From January 1994 to December 2006, 130 patients underwent laparoscopic treatment for common bile duct stones found with intraoperative cholangiography. Two types of surgeons were defined: junior surgeons with fewer than ten laparoscopic common bile duct explorations performed and experienced surgeons with more than ten. The two patient populations (n = 65 in each group) were similar in regard to demographic data, clinical presentations (complicated or not), and ASA score.

Results

Results show that junior surgeons had significantly more patients with a common bile duct (CBD) diameter <7 mm compared to experienced surgeons (66 % vs. 38 %; p = 0.002). Primary closure of choledochotomy was performed by senior rather than junior surgeons significantly more often (87.5 % vs. 69 %; p = 0.05). Mean operating time was found to be longer for junior operators than for experienced surgeons (220 ± 71 min vs. 169 ± 71 min; p = 0.0006). There was no difference between group 1 (juniors) and group 2 (experienced surgeons) in regard to laparotomy conversion rate (9 % vs. 1.5 %; p = 0.1), complete common bile duct clearance (98 % vs. 100 %, p = ns), postoperative complications (two bile leaks in group 1 and one in group 2), and hospital stay (9 days vs. 7.5 days). In multivariate analysis, the transcystic approach was not influenced by the surgeon’s experience. Experienced surgeons performed choledochotomy with primary closure more easily [RR = 3 (range = 1.1–8); p = 0.04]. Complicated presentations [RR = 2 (0.7–3); p = 0.08] and CBD diameter [RR = 2.5 (0.96–7); p = 0.06] influenced the choice of type of closure of choledochotomy without any significant value.

Conclusion

Surgeon’s experience influenced operating time and type of choledochotomy closure performed but had no influence on postoperative results of the laparoscopic treatment of common bile duct stones.     

Anatomical measurements of the gastric cardia in obese patients

Background

Currently, surgeons implant a variety of laparoscopic adjustable gastric bands. However, there is little data to guide the selection process. This study aims to determine the relationship between a patient’s body mass index (BMI), height, and weight and the anatomical measurements of the gastric cardia in morbidly obese patients undergoing laparoscopic adjustable gastric band (LAGB) surgery.

Methods

A total of 67 morbidly obese patients undergoing LAGB surgery were studied. Intraoperative measurements of the gastric cardia were obtained. The relative circumference and posterior diameter of the gastric cardia were measured along with the patient’s height, weight, and BMI. Pearson’s correlation coefficient was used to measure the relationship between the circumference and posterior diameter of the gastric cardia and the BMI, height, and weight. A p < 0.05 was considered significant.

Results

No correlation exists between a patient’s BMI or weight and the circumference or diameter of the gastric cardia. A correlation exists between a patient’s height and the posterior diameter of the gastric cardia (p = 0.02). Of note, there is a correlation between the relative circumference and the posterior diameter of the gastric cardia for each patient (p = 0.05).

Conclusion

Our unique data show no significant correlation between a patient’s BMI and weight and the measurements of the gastric cardia. There was a correlation between a patient’s height and the posterior diameter of the gastric cardia. These intraoperative measurements may help surgeons objectively select the appropriate band for each respective patient undergoing LAGB surgery. This may potentially decrease postoperative dysphagia.     

A proposal for standardized analysis of the results of microvascular decompression for trigeminal neuralgia and hemifacial spasm

Background

The purpose of this study was to evaluate and analyze overall postoperative results from microvascular decompression (MVD) by combining the cure rate of symptoms with the complication rate. A new scoring system for obtaining objective surgical results from MVD for trigeminal neuralgia (TN) and hemifacial spasm (HFS) is proposed to document treatment results using consistent criteria in a standardized manner.

Method

Surgical results combining complications , if any, were obtained from a questionnaire sent to patients who had undergone surgery for TN or HFS in recent years and had been followed-up for more than 1?year after surgery (TN patients, n?=?54; HFS patients, n?=?81) When surgical outcome is complete resolution of symptoms, the efficacy of surgery (E) is designated E-0, but when moderate symptoms are still persist postoperatively, the score is designated E-2. When no complications are seen after surgery, the complication score (C) is C-0, while the score is C-2 if troublesome complications remain. In addition, total evaluation of the results (T) is judged by combining the E and C scores. For example, when E is 0, and C is C-2, the total evaluation is scored as T-2, which is diagnosed as fair.

Findings

The response rate of the questionnaire was 80.7% (109/135). Overall surgical data were evaluated and analyzed using our new scoring system. Analysis of the collected data revealed an outcome of T-0 was 70% (35/50 patients) and T-1 was 24% (12/50) and T-2 was 6% (3/50) in TN, whereas in HFS, T-0 was 61% (36/59) and T-1 was 27.1% (16/59) and T-2 was 6.8% (4/59) and T-3 was 5.1% (3/59).

Conclusion

The total results of MVD should be evaluated and analyzed by combining the cure rate of symptoms together with the complication rate. This new scoring system could allow much more objective analysis of the results of following MVD. Adopting this scoring system to objectively judge treatment results for TN and HFS, individual surgeons can compare their own overall surgical results with those of other institutes. Comparative results of MVD can also be provided to patients considering therapy to allow informed decision-making on the basis of good quality evidence.     

Orthopedic surgeon perspectives on appropriate referral of trauma patients to physical therapy (PT)

Objectives

To evaluate orthopedic surgeon referral of trauma patients to PT.

Design

Cross-sectional survey.

Setting

Alberta, Canada.

Participants

Orthopedic surgeons and residents.

Methods

A web-based survey was utilized to poll orthopedic surgeons and residents on referral practices. Statistical analysis using Kruskal–Wallis One-Way Analysis of Variance by Ranks; Post hoc analysis using the minimum significant difference method for multiple comparisons and nonparametric correlations using Spearman’s rho.

Results

The overall response rate was 48 %. Key indications for referral were range of motion deficits, failure to progress, strength and gait training. Of those surveyed, 72.5 and 26.1 % felt that there was either moderate or significant improvement following PT, respectively. Years in practice had a significant effect on survey responses. Residents and surgeons in practice for >20 years viewed PT as being less important in orthopedic trauma (p < 0.05) and were less likely to refer orthopedic trauma patients to PT (p < 0.05). Residents were less likely to view PT in orthopedic trauma as evidence-based (0.05) and more likely to disagree with the statement that formalized PT results in better outcomes than a prescribed home exercise program (p < 0.05).

Conclusions

There are potential differences in the referral practices of orthopedists of varying levels of experience. Although outcome is viewed as positive following PT, it appears that many orthopedists view a prescribed home exercise program as an acceptable equivalent to formalized PT in the setting of orthopedic trauma. Future research should be directed at determining indicators for formalized PT.     

Microvascular decompression surgery is effective for the laterocollis subtype of spasmodic torticollis: a long-term follow-up result

Background

Spasmodic torticollis (ST) is characterized by sustained, involuntary, and painful spasms of specific muscle (s), which results into abnormal posture of the neck and head. Although various treatments for ST have been introduced, none of them shows absolute effectiveness. Earlier research from our department showed that microvascular decompression (MVD) surgery is effective in the short-term for ST patients with confirmed accessory nerve compression. However, the long-term outcome of MVD remains unknown.

Method

Twelve ST patients with confirmed accessory nerve compression received MVD surgery of their accessory nerves. We utilized the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) to evaluate the long-term outcome (5.4?±?0.87 years).

Results

The MVD lowered total TWSTRS scores by 42.8 % in all ST patients. This result, however, only counted for moderate relief. Interestingly, we observed that the laterocollis (LC) subtypes of ST (n?=?3) obtained a higher TWSTRS score improvement (86.9?±?6.2 %), compared to that of the non-LC (28.1?±?12 %) (P?=0.0001). Additionally, the disability (92.7?±?2 %) subscale score in the LC subtypes had the most prominent improvement compared to the pain (88.1?±?5.1 %) and severity (81.3?±?10.5 %).

Conclusions

In the cases of confirmed accessory nerve compression, the MVD could be considered as a treatment alternative for ST, especially for the LC subtypes.