What is the clinical utility of the cervical extension rotation test as routinely applied in the premanipulative screening process?

Premanipulative screening tests aimed at assessing the risk of vascular accident resulting from cervical manipulation are widely advocated by professional bodies, consensus groups, and other experts. Evidence-based medicine provides a framework for clinical reasoning that integrates evidence derived from literature review, together with clinical experience and patient needs and circumstances. In this article we describe our application of this approach in the context of a presentation of uncomplicated neck pain and headache. A MEDLINE search using PubMed identified six studies of interest, although only one of these provided any quantitative analysis in estimating the utility of the test. Barriers to applying the framework in the practice setting are also discussed.     

Does the asymmetry and extension function of the preoperative cervical paraspinal extensor predict postoperative cervical sagittal deformity in patients who undergo modified laminoplasty?

BACKGROUND CONTEXTA previous study found that the cross-sectional area (CSA) of the preoperative cervical paraspinal extensors (CPEs) was associated with loss of cervical lordosis after laminoplasty, while a recent study found that CPE asymmetry was associated with symptoms of degenerative cervical myelopathy. Whether preoperative CPE asymmetry can predict cervical sagittal deformity (CSD) after laminoplasty is unknown.PURPOSETo assess whether asymmetry, degree of degeneration, and extension function of the CPE can be used as predictors of postoperative CSD in patients who undergo laminoplasty.STUDY DESIGNA retrospective study.PATIENT SAMPLEFrom January 2017 to December 2019, 55 patients with multilevel cord compression and myelopathic symptoms were enrolled.OUTCOME MEASURESThe visual analog scale (VAS), neck disability index (NDI), and modified Japanese Orthopedic Association (mJOA) were used to assess cervical spinal function and quality of life.METHODSFrom January 2017 to December 2019, 55 patients undergoing modified laminoplasty were included. The following parameters were measured preoperatively and 24 months postoperatively on X-ray: (1) C0–C2 Cobb angle; (2) C2–C7 Cobb angle (CL); (3) T1 slope (T1S); (5) C2–C7 sagittal vertical axis (SVA); (6) T1S minus CL; (7) Preoperative extension function: Extension CL minus Neutral CL (EF). Preoperative global alignment parameters: (8) spino cranial angle, (9) C7-S1 sagittal vertical axis (C7 SVA), (10) pelvic incidence, (11) lumbar lordosis, (12) thoracic kyphosis. (13) Preoperative CPE parameters: Summation of bilateral total cross-sectional area (STCSA), summation of bilateral total cross-sectional area ratio (STCSAR), total cross-sectional area asymmetry, summation of bilateral functional cross-sectional area of muscle (SFCSA), summation of bilateral functional cross-sectional area of muscle ratio (FCSAR), and functional cross-sectional area of muscle asymmetry (FCSAA). The VAS, mJOA, and NDI were used to evaluate cervical spine function and quality of life. Patients were divided into the CSD group and the non-deformed group (N-CSD) group postoperatively, and the parameters between the two groups were compared. The Pearson correlation coefficient was used to evaluate the relationship between the parameters, and multiple regression analysis and ROC curve analysis were used to determine the predictors and key values.RESULTSCompared with functional scores, mJOA in the CSD group was significantly lower than that in the N-CSD group, while NDI and VAS were significantly higher. Postoperative CL was significantly correlated with EF, SFCSA/STCSA (C3–C6), SFCSAR (C4 and C6), STCSAR (C6), and FSCAA (C6). T1S minus CL was significantly correlated with EF, SFCSA/STCSA (C3–4 and C6), SFCSAR (C4 and C6), STCSAR (C6) and FSCAA (C6). C2–7 SVA was significantly correlated with EF, SFCSAR (C4 and C6), STCSAR (C6), and FSCAA (C6). Multiple regression analysis showed that FCSAA (C6), SFCSAR (C6), SFCSAR (C4), and EF were significant predictors of postoperative CSD. ROC curve analysis showed that the optimal cutoff points were 18.405, 2.95, 4.47, and 11.96.CONCLUSIONSThe present study found that preoperative extension dysfunction of CPEs, asymmetry at the C6 level cervical extensors, and cervical extensor CSAs without fatty infiltration at the C4 and C6 levels were associated with cervical sagittal imbalance after modified laminoplasty. These factors can be considered when future spine surgeons formulate surgical plans.     

Is clinical measurement of anatomic axis of the femur adequate?

Background and purpose — The accuracy of using clinical measurement from the anterior superior iliac spine (ASIS) to the center of the knee to determine an anatomic axis of the femur has rarely been studied. A radiographic technique with a full-length standing scanogram (FLSS) was used to assess the adequacy of the clinical measurement.

Patients and methods — 100 consecutive young adult patients (mean age 34 (20–40) years) with chronic unilateral lower extremity injuries were studied. The pelvis and intact contralateral lower extremity images in the FLSS were selected for study. The angles between the tibial axis and the femoral shaft anatomic axis (S-AA), the piriformis anatomic axis (P-AA), the clinical anatomic axis (C-AA), and the mechanical axis (MA) were compared between sexes.

Results — Only the S-AA and C-AA angles were statistically significantly different in the 100 patients (3.6° vs. 2.8°; p = 0.03). There was a strong correlation between S-AA, P-AA, and C-AA angles (r > 0.9). The average intersecting angle between MA and S-AA in the femur in the 100 patients was 5.5°, and it was 4.8° between MA and C-AA.

Interpretation — Clinical measurement of an anatomic axis from the ASIS to the center of the knee may be an adequate and acceptable method to determine lower extremity alignment. The optimal inlet for antegrade femoral intramedullary nailing may be the lateral edge of the piriformis fossa.     

Internal fixation on the lower cervical spine – biomechanics and clinical practice of procedures and implants

The decision to opt for a particular internal fixation procedure of a traumatized unstable lower cervical spine should be based on analysis and implementation of scientific and clinical data on the biomechanics of the intact, the unstable and the implant-fixed spine. The following recommendations for surgical stabilization of the lower cervical spine seem, therefore, to be justified. Firstly, the surgical procedure should be to bring about decompression, realignment, and stability. Secondly, the anterior approach should be the primary and preferred one. With regard to surgical and positioning technique, this access clearly involves fewer problems than the posterior approach; if required, unrestricted additional cord decompression can take place; implant fixation is technically simple, and the fusion is under direct compression, thus allowing optimal fusion healing. The awareness of instability and type of implant permits functional therapy, above all for the paraplegic patient. Thirdly, for traumatic conditions, posterior methods should be reserved for exceptional indications. The restriction to this approach is that the anterior column must be intact and a multi-segmental fixation must be used. Posterior fixation seems, therefore, to be more appropriate for degenerative, rheumatoid or tumorous instabilities than for traumatic instabilities. The cerclage wire technique depends on intact osseous posterior elements, while after laminectomy only implants fixed with screws can create safe stability. The disadvantages of the posterior access for the proprioception of the cervical muscles and the subjective symptoms of the patient are known and must be taken into account. Fourthly, combined techniques are indicated for highly unstable or particularly complex injuries. On the cervicothoracic junction, or in cases of Bechterew's disease, the decision is justifiably made in favor of this technique, which can be performed as a one-stage or two-stage operation. Finally, whenever possible, selection of the implant should take into account the foreseeable developments in diagnostic procedures, and therefore, in view of the modern imaging techniques likely to be used in any follow-up examinations required later, the implant chosen should be made of titanium.     

Is the lateral cervical spine plain film obsolete?

BACKGROUND: The objective of this study was to determine the utility of a lateral cervical spine plain film in the evaluation of blunt trauma patients. METHODS: We prospectively evaluated blunt trauma patients from February 2004 to September 2006 who had both a lateral cervical spine (LCS) film and a computed tomography of the cervical spine (CTC), comparing the diagnostic accuracy of the LCS to the CTC. RESULTS: There were 1004 patients who met inclusion criteria. Eighty-four patients had a cervical spine fracture while 920 patients had no fracture on CTC. Of the 84 patients with fractures by CTC, 68 had a negative or incomplete LCS. Of the 920 negative CTC, there were 7 false positive LCSs. LCS compared with CTC showed a sensitivity of 19% (16/84) and positive predictive value of 69.6% (16/23). Of the 981 negative or incomplete LCS films, 96.9% were incomplete (951/981). Of the seven patients with a false positive LCS (negative CTC), none was subsequently found to have a cervical spine fracture on further evaluation. Elimination of the LCS would result in charge savings of $265,056.00 (LCS charges with interpretation, $264 each) and increase patient safety by eliminating error. CONCLUSIONS: LCS has no value as a screening tool in the blunt trauma patient since most are either inaccurate or incomplete. It should be eliminated from the Advanced Trauma Life Support algorithm, and CTC should receive emphasis as the diagnostic gold standard.     

The clinical characteristics and therapy of syndrome of craniocerebral- cervical vertebral injury

Thesyndromeofcraniocerebral cervicalvertebralinjuryiscommonincraniocerebral cervicalvertebralinjury.Becauseofitsanatomicalandphysiologicalparticularity,neckmalformation,spinal nervedamageandinsufficientblood supplyof vertebral basalarterymaybealsocausedin…     

What is the best clinical test for Achilles tendinopathy?

BackgroundDifferential diagnosis of Achilles pathology is demanding. This study evaluates the diagnostic accuracy of clinical tests identified for a chronic mid body Achilles tendinopathy. Ultrasound scanning provides the reference standard.MethodsTwenty-one participants with, and without, an Achilles tendinopathy, had an ultrasound scan followed immediately by the application of ten clinical tests. The accuracy and reproducibility of each test was determined.ResultsThe most valid tests are; pain on palpation of the tendon (sensitivity 84%, specificity 73%, kappa 0.74–0.96) and the subjective reporting of pain 2–6 cm above the insertion into the calcaneum (sensitivity 78%, specificity 77%, kappa 0.75–0.81).ConclusionOnly location of pain and pain on palpation were found to be sufficiently reliable and accurate, to be recommended for use.     

The clinical characteristics and therapy of syndrome ocraniocerebral- cervical vertebral injury

To explore the clinical characteristics and new treatment for syndrome of craniocerebral-cervical vertebral injury. Methods: The clinical data of 52 patients with head injury accompanied by neck injury were analyzed retrospectively. Results: Craniocerebral injury could result in damage to cervical vertebrae, muscles, vessels and nerves, and even cause vertebral artery injury, which may lead to insufficient blood-supply of vertebral-basal artery. All patients were treated with cervical vertebral traction and the results were good. Conclusions : Acute craniocerebral injury with symptom of insufficient blood-supply of vertebral-basal artery, evident neurosis and atlas-axis half-dislocation in X-ray should be treated by cervical vertebral traction, which will yield better outcome.     

Is there a clinical relevance of partial androgen deficiency of the aging male?

PURPOSE: Aging in men is characterized by a progressive, generally moderate decrease in plasma testosterone (T) levels and T substitution is increasingly prescribed. However, the association of partial androgen deficiency of the aging male with clinical symptoms and the ideal screening test are controversial. We investigate the association between various T measures and clinical and biochemical parameters of the aging male. MATERIALS AND METHODS: We investigated the association between total (TT), calculated free (FTcalc) and bioavailable (BT) testosterone, and various clinical and biochemical parameters in 51 healthy community living male volunteers, 55 and 75 years old. The parameters included serum levels of sex hormone-binding globulin, estradiol and lipid profile after an overnight fast; questionnaires assessing clinical symptoms, erectile function and mood; bone mineral density and body composition. RESULTS: TT correlated with FTcalc (r2 = 0.71, p <0.001) but not with BT (r2 = 0.04, p not significant) and FTcalc correlated moderately with BT (r2 = 0.23, p <0.001). Testicular volume correlated with TT levels (r2 = 0.17, p <0.001) and FTcalc (r2 = 0.17, p <0.001) but not with BT. There was neither a correlation of TT, FTcalc nor BT values with clinical symptoms nor with biochemical and radiological parameters, ie affective symptoms and sexual interest, circulating estradiol, lipid levels, bone mineral density or lean body mass. CONCLUSIONS: T values in our study sample did not correlate with clinical signs and symptoms of hypogonadism. Thus, according to our data, symptoms of the aging male could be rather multifactorial and should not be indiscriminately assigned to the age associated decrease in T levels.     

Is the likelihood of dysphagia different in patients undergoing one-level versus two-level anterior cervical discectomy and fusion?

BACKGROUND CONTEXTDysphagia following anterior cervical discectomy and fusion (ACDF) is a common complication, the etiology of which has not been established. Given that one potential mechanism for dysphagia is local tissue edema, it is thought that a greater number of operative levels may result in higher dysphagia rates. However, prior reports comparing one-level to two-level ACDF have shown varying results.PURPOSETo determine if there is a difference in dysphagia between one-level and two-level ACDF.STUDY DESIGN/SETTINGRetrospective review of prospectively collected data.PATIENT SAMPLEPatients who underwent one- or two-level ACDF with a plate-graft construct by a single-surgeon at a high-volume academic medical center.OUTCOME MEASURESNeck Disability Index, Visual Analog Scale for neck pain and arm pain, Short Form-12 physical and mental health components, and Swallowing Quality of Life (SWAL-QOL) Questionnaire.METHODSPatient demographics, operative data, and patient-reported outcome measures (PROMs; Neck Disability Index, Visual Analog Scale, Short Form-12, and SWAL-QOL) of patients undergoing one- and two-level ACDF were compared using Fisher exact test for categorical variables and Student's t test for continuous variables. Regression analyses were conducted to identify factors associated with 6- and 12-week SWAL-QOL scores in order to determine whether the number of surgical levels impacts these outcomes.RESULTSFifty-eight patients (22 one-level and 36 two-level ACDF) were included. Patients undergoing two-level fusions were older (54.17+8.67 vs 48.06+10.68 years, p=.02) and had longer operative times (69.08+10.51 vs 53.5+14.35 minutes, p<.0001). There were no other significant differences in demographics or operative data. Both groups showed a statistically significant improvement in PROMs from preoperatively to 12 weeks. There was no difference in PROMs or dysphagia rates between groups at any time-point. Younger age (p=.023), male sex (p=.021), longer operative times (p=.068), and worse preoperative SWAL-QOL (p<.0001) were associated with dysphagia at 6 weeks. Preoperative SWAL-QOL was the only variable associated with dysphagia at 12 weeks (p=.003). Operative time of >61.5 minutes had a sensitivity and specificity of 62.1% for worse dysphagia scores at 6 weeks compared with baseline.CONCLUSIONSThe results of our study indicate that there is no difference in the degree of postoperative dysphagia in one- versus two-level ACDF. However, other variables associated with increased postoperative dysphagia in our population included younger age, male sex, procedural time >61.5 minutes, and worse preoperative dysphagia. Larger studies are required to confirm these findings and identify additional risk factors for postoperative dysphagia.     

Is endosonography an effective method for detection and local staging of the ampullary carcinoma? A prospective study

Background  

The relatively rare carcinoma of the ampulla of Vater is a neoplasia with a good prognosis compared to pancreatic cancer. Preoperative staging is important in planning the most suitable surgical intervention.     

Reliability of the isokinetic trunk extensor test, Biering-Sørensen test, and Astrand bicycle test: assessment of intraclass correlation coefficient and critical difference in patients with chronic low back pain and healthy individuals

STUDY DESIGN: A reliability study was performed. OBJECTIVE: To determine the intersession reproducibility of the isokinetic trunk extensor strength test, the Biering-S?rensen test, and the Astrand test by calculation of the intraclass correlation coefficient and the critical difference. SUMMARY OF BACKGROUND DATA: Several physical measurements have been used in clinical evaluation of patients with chronic low back pain. Reliability can be evaluated by calculation of either intraclass correlation coefficient or critical difference, but interpretation of the results may vary depending on which method is used. METHODS: For this study, 31 patients with chronic low back pain carried out the isokinetic trunk extensor test, the Biering-S?rensen test, and the Astrand test as also did age- and gender-matched healthy individuals. Measurements were performed in three separate sessions at the same time of the day and by the same experienced examiner. The intervals between the sessions were 5 to 10 days. RESULTS: The isokinetic tests showed a learning effect between Tests 1 and 2. For the isokinetic test, the critical difference increased with increased angular velocities from 28% to 63% in the patients and from 27% to 39% in the healthy subjects. The critical differences for the patients and the healthy individuals were 57% vs 54% for the Biering-S?rensen test and 21% vs 23% for the Astrand test, respectively. The intraclass correlation coefficient ranged from 93% to 98% in the patients and 80%-98% in the healthy individuals. CONCLUSIONS: The reliability was found to be acceptable for the Astrand test and the isokinetic test at 60 degrees per second, as evaluated by the critical difference. All the tests were highly reliable according to the intraclass correlation coefficient, except for Biering-S?rensen test for healthy individuals. The critical difference is the preferable measure because calculation of the intraclass correlation coefficient may give a misleading high estimate of reliability.     

Is a digital rectal examination necessary in the diagnosis and clinical staging of early prostate cancer?

OBJECTIVE: To assess the role of a digital rectal examination (DRE) in the clinical diagnosis of prostate cancer and in predicting the pathological stage, as the diagnosis of early prostate cancer usually comprises prostate-specific antigen (PSA) testing, a DRE and transrectal ultrasonography (TRUS)-guided biopsies. PATIENTS AND METHODS: Over the 4 years between 2000 and 2004, 408 consecutive patients (mean age 63.8 years) referred with age-specific PSA levels of 2.5-10.0 ng/mL and who had a TRUS-guided 12-core prostate biopsy were included in the study. They had a DRE by either of two experienced consultant urologists. The results of the DRE and core biopsy histology were compared with the histology and the radical prostatectomy specimen in a subset (82 men) of the study population. RESULTS: Cancer was detected on biopsy in 152 patients; of the 196 with an abnormal DRE, 47% had cancer on biopsy. In the patients with a normal DRE, 59 cancers were detected. Men with cancer were older and had a higher median PSA level. There was no correlation between the DRE and biopsy findings, and none between an abnormal DRE and histological diagnosis of cancer. Of the patients who had a radical prostatectomy, 38% had a normal DRE. CONCLUSION: There was no correlation between the DRE, biopsy findings and pathological staging. The DRE did not contribute to managing patients with prostate cancer, but this does not mean that there is no longer a place for the DRE in assessing the urological patient. If patients are appropriately counselled before PSA testing, a DRE may not be essential for patients with a PSA level of 2.5-10 ng/mL.