椎弓根内固定结合椎体成形术治疗胸腰椎体转移瘤临床研究

[目的]观察椎弓根内固定术结合直视下椎体成形术治疗胸腰椎体转移性肿瘤的临床疗效.[方法]对30例胸腰椎转移性肿瘤的患者采用后路椎弓根内固定术结合直视下骨水泥椎体成形术,共治疗32个椎体,患者均有顽固性腰痛及下肢神经症状,部分患者行椎管减压.随访观察临床疗效.[结果]本组32个椎体全部穿刺成功,骨水泥渗漏3例,均未出现神经症状,患者术后1周,3、6、12个月各时间点VAS评分疼痛缓解率＞80％,活动能力和生活质量评分明显改善,随访12个月期间生存患者有24例,胸腰椎疼痛未见明显加重,病椎高度未见明显压缩,1例肺癌患者术后10个月出现肿瘤复发,其余患者手术椎体未出现新的病理性骨折及神经症状加重.[结论]椎弓根内固定结合椎体成形术治疗胸腰椎转移性恶性肿瘤能明显改善患者生存质量,预防病理性骨折进一步塌陷,疗效满意,是综合治疗胸腰椎肿瘤的重要治疗方法之一.     

Treatment of lumbosacral radicular pain with epidural steroid injections

Fifty patients with an average age of 47 years received epidural steroid injections for lumbosacral radicular pain due to disk herniation or spinal stenosis. All patients had failed previous conservative treatment. Mean follow-up was 24 months (range: 12-36 months). Immediately after injection, all 50 patients reported various degrees of relief from leg and back pain. At the last follow-up examination, 68% of patients were asymptomatic, 20% had no change in preinjection radicular symptoms, and 12% had various degrees of relief. No significant correlation was found between pain relief, age, or number of injections. Early pain relief may be anticipated after epidural steroid injections in 80% of patients with radicular symptoms due to disk herniation or spinal stenosis.     

Percutaneous epidural neuroplasty: Prospective evaluation of 0.9% NaCl versus 10% NaCl with or without hyaluronidase

Background and Objectives. Percutaneous epidural neuroplasty (epidural neurolysis, lysis of epidural adhesions) is an interventional pain management technique that has emerged over approximately the last 10 years as part of a multidisciplinary approach to treating radiculopathy with low back pain. In addition to local anesthetic and corticosteroid, hypertonic saline (10% NaCl) and hyaluronidase are used for the technique. The objective of this study was to determine if hypertonic saline or hyaluronidase influenced treatment outcomes. Methods. Eighty-three subjects with radiculopathy plus low back pain were assigned to one of four epidural neuroplasty treatment groups: (a) hypertonic saline plus hyaluronidase, (b) hypertonic saline, (b) isotonic saline (0.9% NaCl), or (d) isotonic saline plus hyaluronidase. Subjects in all treatment groups received epidural corticosteroid and local anesthetic. Results. Twenty-four subjects did not complete the study. Most of the other 59 subjects receiving any of the four treatments as part of their pain management obtained significant relief immediately after treatment. Visual analog scale (VAS) scores for the area of maximal pain (VAS_max, back or leg) were reduced in 25% or more of subjects in all treatment groups at all post-treatment follow-up times (1, 3, 6, 9, and 12 months). A smaller fraction of subjects treated with hypertonic saline or hyaluronidase and hypertonic saline required more additional treatments than did subjects receiving the other treatments. Conclusions. Percutaneous epidural neuroplasty, as part of an overall pain management strategy, reduces pain (sometimes for over one year) in 25% or more of subjects with radiculopathy plus low back pain refractory to conventional therapies. The use of hypertonic saline may reduce the number of patients that require additional treatments.     

Anterior and combined anteroposterior fusion for lumbar disc pain. A preliminary study.

This article reports on a study of 51 consecutive patients (83 lumbar discs) with back pain who underwent anterior interbody lumbar fusion or combined anterior and posterior fusion at the same operation during a 2-year period. All patients met the criteria for diagnosis of a painful internal disc disruption and/or failed back syndrome and have had a lengthy trial of conservative treatment consisting of rest, physical therapy, back support, nonsteroidal anti-inflammatory drug therapy, and guarded activity; this treatment was often supplemented by epidural cortisone injections, pain management, and functional rehabilitation. Patients with prolonged back pain who failed with conservative care after a minimum of 12 months of severely disabling symptoms were selected for surgery on the basis of a positive dynamic discogram reproducing their exact pain and demonstrating a morphologically degenerative disc (internal disc disruption). For the purpose of this study, patients were categorized into three groups and followed up for 15-36 months after the operation. There were no deaths or major complications, and the overall success in achieving measurable diminution of preoperative pain was 80%. This article discusses preliminary conclusions on the efficacy and safety on anterior and anteroposterior fusion for lumbar disc pain.     

Epiduroscopic diagnosis and treatment of epidural adhesions in chronic back pain syndrome of patients with previous surgical treatment: first results of 31 interventions

AIM: Scars in the epidural space play an important role in the chronic lumbar pain syndrome of patients with previous surgical treatment. The results of surgical resection are frequently unsatisfactory. Discrepancies to imaging diagnostics are conspicuous. These are known from experience with endoscopic operations. Minimal adhesions may promote pain. Epiduroscopy is available for visualization of the epidural space. The objective of this study was to examine its possibilities in patients with previous surgical treatment. METHOD: 31 patients with chronic lumbar pain syndrome who had previously received surgical treatment were operated epiduroscopically. Mechanical instruments and the holmium:YAG laser were used for epidural adhesion. RESULTS: All patients showed adhesions. 24 patients also presented with adhesions on the contralateral side. There were marked discrepancies between imaging and intraoperative findings. The use of mechanical instruments was limited. The use of laser fibers resulted in greater possibilities. Back pain could be better influenced than leg pain. The procedure was limited by still-existing technical problems. CONCLUSION: Epiduroscopy offers a novel view of this compartment. Minimal adhesions which are not visible in imaging ean promote pain. They can be partially diagnosed and treated by epiduroscopy. There are still marked limitations to epiduroscopy due to technical problems. These must be minimized.     

The effect of intravenous ketoprofen on postoperative epidural sufentanil analgesia in children.

We compared the effect of IV ketoprofen and placebo as an adjuvant to epidural sufentanil analgesia after major surgery. We used a prospective, randomized, double-blinded, placebo-controlled, parallel-group study design in 54 children aged 1-15 yr who received a standardized anesthetic. Either IV ketoprofen or saline was administered in addition to an epidural sufentanil infusion, which was adjusted as required clinically. The study drug infusions were discontinued when pain scores were <3 on 0-10 scale for 6 h at a sufentanil infusion rate of 0.03 microg x kg(-1) x h(-1). Children in the ketoprofen group had a better analgesic effect, as shown by decreased need for sufentanil (mean [10th-90th percentiles] 8.3 [3.1-15.1] microg/kg vs 12.5 [6.2-18.9] microg/kg; P = 0.002) and earlier possibility to discontinuation of the epidural sufentanil (11 [46%] vs 3 [13%]; P = 0.014) before the end of the 72-h study period. In the ketoprofen group, median (range) pain scores were lower during activity at 24 h (2 [0-5] vs 5 [0-7]; P = 0.01) and at 72 h (0 [0-3] vs 2 [0-6]; P = 0.033), and fewer children had inadequate pain relief during activity at 24 h (0 vs 5; P = 0.037). Children who received ketoprofen required fewer infusion rate adjustments (12 [4-20] vs 17 [6-42]; P = 0.016). In the ketoprofen group, the incidence of desaturation (1 [4%] vs 6 [26%]; P = 0.035) and fever (3 [12%] vs 11 [48%]; P = 0.008) was less than that in the placebo group. We conclude that ketoprofen improved postoperative pain in children. IMPLICATIONS: We compared the effect of the IV nonsteroidal antiinflammatory drug ketoprofen versus placebo as adjuvants to epidural opioid analgesia with sufentanil. The continuous IV nonsteroidal antiinflammatory drug improved pain after major surgery in children receiving an epidural opioid. Although ketoprofen reduced epidural sufentanil requirements, the incidence of opioid-related adverse effects was not changed.     

化学去细胞同种异体神经移植术后病人的护理

[目的]探讨对化学去细胞同种异体神经修复周围神经损伤的护理及康复。[方法]自2003年4月-2006年4月，应用化学去细胞同种异体神经移植治疗完全断裂周围神经损伤患者39例，术后及出院后进行专项护理及康复，术后6个月以上患者随访共21例，对结果进行统计分析。[结果]21例患者中，16例神经损伤恢复效果达到优良，修复优良率达到71．4％。[结论]对化学去细胞同种异体神经移植术后的患者进行康复及护理，可以获得良好的临床效果。     

Recurrent cubital tunnel syndrome. Etiology and treatment.

Controversy surrounds the treatment of recurrent cubital tunnel syndrome after previous surgery. Irrespective of the surgical technique, namely pure decompression in the ulnar groove and the cubital tunnel distal of the medial epicondyle, and the different methods of volar transposition (subcutaneous, intramuscular, and submuscular), the results of surgical therapy of cubital tunnel syndrome are often not favorable, especially in cases of long-standing symptoms and severe deficits. Twenty-two patients who had previously undergone surgical treatment for ulnar nerve entrapment at the elbow were evaluated because of persistent or recurrent pain, paresthesia, numbness, and motor weakness. Ten patients had undergone a nerve transposition, 5 patients underwent a simple decompression of the ulnar nerve, and 7 patients experienced two previous operations with different surgical techniques. Two patients underwent surgery at our hospital, whereas 20 patients underwent their primary surgery at other institutions. Various surgical techniques were used during the subsequent surgery, such as external neurolysis, subcutaneous anterior transposition, and subsequent transfer of the nerve back into the sulcus. The causes of continued or recurrent symptoms after initial surgery included dense perineural fibrosis of the nerve after subcutaneous transposition, adhesions of the nerve to the medial epicondyle and retention of the medial intermuscular septum. The average follow-up after the last procedure was 7 months (2 - 20 months). All 7 patients with subsequent transfer of the ulnar nerve back into the sulcus became pain-free, whereas only 11 of 15 patients who had external neurolysis or subcutaneous transposition became free of pain or experienced reduced pain. The recovery of motor function and return of sensibility were variable and unpredictable. In summary, reoperation after primary surgery of cubital tunnel syndrome gave satisfactory results in 18 of 22 cases. Subsequent transfer of the ulnar nerve back into the sulcus promises to be useful in cases in which subcutaneous transposition had not been successful.     

Targeted methylprednisolone acetate/hyaluronidase/clonidine injection after diagnostic epiduroscopy for chronic sciatica: a prospective, 1-year follow-up study

BACKGROUND AND OBJECTIVES: It has been claimed that epiduroscopy offers an ideal combination of diagnostic and therapeutic interventions in one session. We prospectively evaluated whether abnormalities at the lumbar level as diagnosed by magnetic resonance imaging (MRI) are confirmed by epiduroscopy, and assessed if targeted epidural injection of medication alleviates sciatic pain. METHODS: A flexible, 0.9-mm fiberoptic endoscope was introduced through a disposable steering shaft into the caudal epidural space and advanced until the targeted spinal nerve was identified. Adhesions were mechanically mobilized under direct vision, and a mixture of 120 mg methylprednisolone acetate, 600 IU hyaluronidase, and 150 microg clonidine was applied locally. Pain scores were measured by visual analog scale (VAS) and global subjective efficacy rating. RESULTS: Nineteen of 20 patients studied showed adhesions via epiduroscopy. In 8 patients, 6 of whom had never undergone surgery, these were not detected with earlier magnetic resonance imaging. Six patients showed concomitant signs of active root inflammation. Of 20 patients treated with a targeted epidural injection, 11 patients (55%) experienced significant pain relief at 3 months. This was maintained at 6, 9, and 12 months for 8 (40%), 7 (35%), and 7 (35%) patients, respectively. Mean VAS at 3 months was significantly reduced (n = 20; DeltaVAS = 3.55; P <.0001), and this persisted at 12 months (DeltaVAS = 1.99, P =.0073). CONCLUSIONS: Epiduroscopy is of value in the diagnosis of spinal root pathology. In sciatica, adhesions unreported by MRI can be identified. Targeted epidural medication, administered near the compromised spinal nerve, results in substantial and prolonged pain relief.     

Fracture rate and back pain during and after discontinuation of teriparatide: 36-month data from the European Forsteo Observational Study (EFOS)

Summary

In this observational study in postmenopausal women with severe osteoporosis, the incidence of fractures was decreased during 18?months of teriparatide treatment with no evidence of further change in the subsequent 18-month post-teriparatide period when most patients took other osteoporosis medications. Fracture reduction was accompanied by reductions in back pain.

Introduction

To describe fracture outcomes and back pain in postmenopausal women with severe osteoporosis during 18?months of teriparatide treatment and 18?months post-teriparatide in normal clinical practice.

Methods

The European Forsteo Observational Study (EFOS) was a prospective, multinational, observational study. Data on incident clinical fractures and back pain (100?mm Visual Analogue Scale [VAS] and questionnaire) were collected. Fracture data were summarised in 6-month intervals and analysed using logistic regression with repeated measures. Changes from baseline in back pain VAS were analysed using a repeated measures model.

Results

A total of 208 (13.2%) of 1,576 patients sustained 258 fractures during 36?months of follow-up: 34% were clinical vertebral fractures and 66% non-vertebral fractures. The adjusted odds of fracture were reduced during teriparatide treatment and there was no evidence of further change in the 18-month post-teriparatide period, during which 63.3% patients took bisphosphonates. A 74% decrease in the adjusted odds of fracture in the 30- to <36-month period compared with the first 6-month period was observed (p?<?0.001). Back pain decreased during teriparatide treatment and this decrease was sustained after teriparatide discontinuation. Adjusted mean back pain VAS decreased by 26.3?mm after 36?months (p?<?0.001) from baseline mean of 57.8?mm.

Conclusions

In a real-life clinical setting, the risk of fracture decreased during teriparatide treatment, with no evidence of further change after teriparatide was discontinued. The changes in back pain seen during treatment were maintained for at least 18?months after teriparatide discontinuation. These results should be interpreted in the context of the design of an observational study.     

Microsurgical treatment of juxta facet cysts of the lumbar spine

OBJECTIVES: Juxta facet cysts are a common cause of low back and radicular pain. They are mostly associated with degenerative facet joints and spondylolisthesis. The study focuses on long-term outcomes after microsurgical treatment without fusion. METHOD: From April 2002 to April 2004, 31 patients (23 female and 8 male) underwent microsurgical resection of lumbar juxta facet cysts. The patient age ranged from 31 to 83 years (mean 67.2 years). The most affected level was L4-L5 (19 patients), followed by L3-L4 (9 patients). Fourteen patients additionally had spondylolisthesis of the involved segment. All patients had signs of nerve root compression and had received conservative treatment preoperatively. We performed limited bone removal (sparing the facet joints) and cyst resection in 27 patients. In four patients, cyst resection and standard laminectomy were performed owing to spinal stenosis. RESULTS: Conservative treatment was without any effect in all patients. At follow-up, 12-30 months after surgery, excellent to good outcome was achieved in 25 of 31 patients (80.7%), and 6 patients (19.3%) showed fair results. Persistent low back pain was more common in patients with spondylolisthesis than in the other group (6/14 vs 3/17); this may be due to instability. Spondylolisthesis did not progress or become mobile after surgery radiographically in any of our patients. CONCLUSIONS: Conservative therapy does not adequately improve symptoms in patients with intraspinal juxta facet cysts and radicular signs. Juxta facet cysts can be treated effectively with a minimally invasive microsurgical approach. This may be of particular significance when the cysts are associated with spondylolisthesis, minimizing the risk of instability and the need for fusion. In a selected group of patients with persistent low back pain, fusion may become necessary to improve symptoms.     

Nonoperative active management of critical limb ischemia: initial experience using a sequential compression biomechanical device for limb salvage

Critical limb ischemia (CLI) patients are at high risk of primary amputation. Using a sequential compression biomechanical device (SCBD) represents a nonoperative option in threatened limbs. We aimed to determine the outcome of using SCBD in amputation-bound nonreconstructable CLI patients regarding limb salvage and 90-day mortality. Thirty-five patients with 39 critically ischemic limbs (rest pain = 12, tissue loss = 27) presented over 24 months. Thirty patients had nonreconstructable arterial outflow vessels, and five were inoperable owing to severe comorbidity scores. All were Rutherford classification 4 or 5 with multilevel disease. All underwent a 12-week treatment protocol and received the best medical treatment. The mean follow-up was 10 months (SD +/- 6 months). There were four amputations, with an 18-month cumulative limb salvage rate of 88% (standard error [SE] +/- 7.62%). Ninety-day mortality was zero. Mean toe pressures increased from 38.2 to 67 mm Hg (SD +/- 33.7, 95% confidence interval [CI] 55-79). Popliteal artery flow velocity increased from 45 to 47.9 cm/s (95% CI 35.9-59.7). Cumulative survival at 12 months was 81.2% (SE +/- 11.1) for SCBD, compared with 69.2% in the control group (SE +/- 12.8%) (p = .4, hazards ratio = 0.58, 95% CI 0.15-2.32). The mean total cost of primary amputation per patient is euro29,815 ($44,000) in comparison with euro13,900 ($20,515) for SCBD patients. SCBD enhances limb salvage and reduces length of hospital stay, nonoperatively, in patients with nonreconstructable vessels.     

Transpedicular decancellation osteotomy in the treatment of peridural fibrosis

From 1992 to 1997 a series of 12 multiply operated (averaging 2.5 previous operations) patients with recurrent peridural fibrosis and postlaminectomy kyphosis underwent surgery at our clinic. The surgery was designed to restore the physiological lordosis and relax tethered cord and epidural veins by transpedicular decancellation osteotomy at a vertebra other than the vertebra with peridural fibrosis. This paper presents the long-term functional outcome of these 12 patients. Clinical assessments were conducted pre-operatively and at 3-month intervals postoperatively and included X-ray assessment and evaluation of the patients’ functional status by Oswestry Disability Index (ODI) and of pain by visual analogue scale (pain VAS). All symptoms and the pain due to peridural fibrosis disappeared in the early postoperative period. Patients had lower disability and pain scores at their early and long-term follow-ups (follow-up period 24–74 months, mean 36.3 months). For patients with failed medical therapy for peridural fibrosis accompanied by lumbar kyphosis or hypolordosis, transpedicular decancellation osteotomy should be the surgical treatment of choice. Received: 30 July 2000     

Change of barometric pressure influences low back pain in patients with vacuum phenomenon within lumbar intervertebral disc

The present study investigates whether changes in barometric pressure influence low back pain in patients with vacuum phenomenon within lumbar intervertebral discs. Twenty-four patients with low back pain were examined: 12 with vacuum phenomenon within the intervertebral discs (VP [+] group) and 12 without the vacuum phenomenon (VP [-] group). All patients consented to an evaluation of low back pain in a hyperbaric oxygen chamber. In the VP (+) group, low back pain became more severe in one patient when atmospheric pressure was elevated, and in eight patients when atmospheric pressure was decreased. In the VP (-) group, two patients experienced more severe low back pain when atmospheric pressure was decreased. Our study demonstrated that low back pain might be aggravated by atmosphere depression in patients with lumbar disease associated with the vacuum phenomenon.     

Back pain following epidural anaesthesia in labour

Purpose

To determine the factors associated with the development of post-partum back pain following epidural anaesthesia for labour and delivery and its incidence.

Methods

A prospective observational cohort study was conducted in a University affiliated tertiary care hospital. Women presenting for labour and delivery who were planning to have epidural anaesthesia were eligible for study. Baseline data were obtained from the women and obstetrical and anaesthetic data from the hospital chart. Women were contacted by phone at four to six weeks post-partum and questioned regarding the presence of any back pain and pain lasting longer than 14 days.

Results

Three hundred women entered the study and follow-up was obtained in 270 (90%). The incidence of back pain was 30.7% and back pain lasting longer than 14 days was 8.5%. Nulliparity was associated with a decreased risk of developing back pain post-partum but this decrease was only associated with pain lasting more than 14 days: Odds Ratio (OR) [95% confidence interval] 0.32 [0.11-0.94]. A previous history of back pain was strongly associated with the development of any back pain (OR 43.85 [9.97-192.9] but not with pain lasting longer than 14 days (OR 2.16 [0.71–6.58]). Age, weight and the duration of the second stage of labour were not associated with the development of back pain,

Conclusions

Back pain following epidural anaesthesia is common but persistent back pain is much less common. A previous history of back pain increases the likelihood of post-partum back pain following epidural anaesthesia. Nulliparity is associated with a decreased risk.     

Post-thoracotomy pain after thoracic epidural analgesia: a prospective follow-up study

BACKGROUND: Pain becomes chronic in 22-67% of patients who undergo a thoracotomy. Thoracic epidural analgesia (TEA) has replaced less invasive methods to manage postoperative pain. We wanted to find out if active use of TEA, combined with extended pain management at home, reduces the incidence of chronic post-thoracotomy pain. METHODS: All consecutive thoracotomy patients during a 16-month period were included. On the ward, pain was measured daily by VAS during rest and coughing and the consumption of analgesics was registered. The patients were interviewed one week after discharge by telephone and by a questionnaire after 3 and 6 months to find out how much pain they had. RESULTS: A total of 114 patients were recruited. The data were analysed from 89 patients who had had TEA and 22 who had had other methods. TEA was effective in alleviating pain at rest and during coughing. In the TEA patients the incidence of chronic pain of at least moderate severity was 11% and 12% at 3 and 6 months, respectively. One week after discharge 92% of all patients needed daily pain medication. CONCLUSIONS: TEA seems effective in controlling evoked postoperative pain, but technical problems occurred in 24% of the epidural catheters. The incidence of chronic pain was lower compared with previous studies where TEA was not used. The patients had significant pain and needed regular pain medication and instructions during the first week after discharge. Extended postoperative analgesia up to the first week at home is warranted.     

Surgical experience of gas-containing disk herniation

Disk herniation with gas or gas-containing disk herniation (GCDH) is rare, although epidural gas is associated with the vacuum phenomenon. The clinical, radiologic, and surgical findings were retrospectively analyzed of 18 patients with GCDH. The demographic, clinical, and radiologic findings including computed tomography and magnetic resonance imaging, as well as operative methods were examined. The mean age was 64.4 years (range 51-84 years). All patients presented with acute radiculopathy or exacerbation of chronic pain associated with GCDH of the lumbar spine. All lumbar GCDHs were related to the vacuum phenomenon. Ruptured disks predominantly compressed the nerve root with gas in 17 cases, except in one with only compressed nerve root by gas without disk herniation. All patients had confirmed GCDH at surgery. All patients underwent removal of GCDH and five with another level of spinal stenosis or disk herniation underwent selective decompression. The six patients with instability underwent fusion. Visual analogue scale score of radicular pain was improved from 7.4 ± 0.9 before surgery to 3.2 ± 0.7 at the 3-month follow-up examination. No recurrence occurred after surgery. GCDH can occur as a space-occupying lesion in epidural space as well as a cause of radiculopathy. GCDH may indicate the source of clinical symptoms in the degenerative spine, especially combined with spinal stenosis or multiple spinal disk herniations.     

经皮全脊柱内镜经椎板间隙入路治疗中央型腰椎管狭窄症

目的探讨经皮全脊柱内镜经椎板间隙入路治疗单节段中央型腰椎管狭窄症的临床疗效。方法2016年1月~2017年12月我科对腰椎中央管狭窄在连续硬膜外麻醉下行经皮全脊柱内镜椎板间隙入路椎管扩大减压术,采用疼痛视觉模拟评分(Visual Analogue Scale,VAS)、Oswestry功能障碍指数(Oswestry Disability Index,ODI)和MacNab标准评价疗效。结果26例均顺利完成手术。1例术中损伤撕裂硬膜囊,保守治疗后痊愈。1例术后出现单侧下肢一过性肌力下降,1例术后出现腰背部及双下肢疼痛症状。住院时间(6.4±2.1)d。腰痛术前VAS评分(7.5±0.8)分,显著高于术后第1天(3.4±0.6)分和术后12个月(1.7±0.7)分(P均=0.000)。腿痛VAS评分术前(7.3±0.8)分,显著高于术后第1天(4.0±0.7)分和术后12个月(1.7±0.7)分(P均=0.000)。术前ODI(77.8±4.6)%,显著高于术后1个月(45.4±4.6)%和术后12个月(8.8±2.9)%(P均=0.000)。术后12个月采用MacNab进行疗效评定:优14例,良10例,可2例,优良率92.3%(24/26)。结论经皮全脊柱内镜经椎板间隙入路治疗单节段腰椎中央管狭窄症,手术风险低,临床疗效满意。     

Fast-track barium enema: meeting the two-week wait rule for patients with suspected colorectal cancer

OBJECTIVES: To meet the introduction of the two-week wait (TWW) rule for patients with suspected colorectal cancer, a fast-track barium enema (FTBE) service was set up. This study was conducted to evaluate the success of this approach in preparation for meeting the forthcoming targets on waiting times to treatment from referral and diagnosis. METHODS: All patients were offered a double-contrast barium enema within two-weeks, except those with a palpable rectal mass. FTBE were double-reported by specialist gastrointestinal radiologists. Patients with a suspected malignancy were booked for an urgent staging CT and outpatient appointment, whilst the remaining patients were referred back to their general practitioner with a report. Prospective data were collected and two 16-month periods analysed. RESULTS: Three hundred and nine patients had a FTBE over the first 16-month period and 277 (89.6%) were seen within two-weeks. Mean times from initial referral to staging CT and first outpatient appointment were 30.7 and 36.0 days, respectively. Cancer was confirmed histologically in 32 (10.4%) patients. Of 267 patients without a malignancy, 46 (17.2%) were referred back to the colorectal outpatient or endoscopy service within 6-months. The number of referrals increased with time from a mean of 19.3 per month in the first period to 27.8 in the second, but the percentage with a suspected malignancy remained similar at 13.6% and 10.1%, respectively. CONCLUSION: FTBE diagnosed malignancy accurately and facilitated rapid staging. The TWW target was met in almost 90% of patients, whilst the impact on the colorectal outpatient and endoscopy service was minimized.     

The failed ulnar nerve transposition. Etiology and treatment

Various procedures have been recommended for the treatment of cubital tunnel syndrome. Simple decompression in situ, medial epicondylectomy, subcutaneous transposition, intramuscular transposition, and submuscular transposition all have their advocates. The results of the surgical treatment for cubital tunnel syndrome are related to the severity of the compressive neuropathy at the time of diagnosis and to the adequate decompression of the nerve at all sites of potential compression at the time of surgical treatment. Fourteen patients who had previously undergone surgical treatment for cubital tunnel syndrome were evaluated because of persistent pain, paresthesia, numbness, and motor weakness. All patients had documented persistent compression of the ulnar nerve on clinical and electromyographic evaluation. The indication for repeat surgical exploration in all patients was unremitting pain despite nonoperative treatment. All patients had been treated by neurolysis and submuscular transposition of the ulnar nerve as described by Learmonth. The causes of continued pain after initial surgery included retention of the medial intermuscular septum, dense perineural fibrosis of the nerve after intramuscular and subcutaneous transposition, adhesions of the nerve to the medial epicondylectomy site, and recurrent subluxation of the nerve over the medial epicondyle after subcutaneous transposition. Revision surgery was found to be highly successful for relief of pain and paresthesias; however, the recovery of motor function and return of sensibility were variable and unpredictable.