Decompression for cervical spondylotic myelopathy has potential to reverse neurological damage

At the 1-year follow-up, researchers who performed surgical decompression in patients with cervical spondylotic myelopathy found significantly improved disability-related, functional and quality-of-life outcomes, according to a study recently published in Journal of Bone & Joint Surgery.

“The results of this trial support the use of decompression surgery as a viable treatment for cervical spondylotic myelopathy and could lead to a change in practice to treat this condition,” neurosurgeon Michael G. Fehlings, who is medical director of the Krembil Neuroscience Centre at Toronto Western Hospital, stated in a press release. “With few existing interventions available for these patients, it is encouraging to have data showing improvements in quality of life as a result of surgery, in some cases, even reversing serious neurological damage that could have resulted in paralysis.”

 

Fehlings and colleagues analyzed results from a trial with 278 patients who had mild, moderate or severe cervical spondylotic myelopathy (CSM) conducted between 2005 and 2007 at 12 centers in the United States and Canada. Of the patients enrolled, 222 patients had 1-year follow-up data available.

The researchers found improved modified Japanese Orthopaedic Association, Neck Disability Index, SF-36 version 2 and Nurick grade scores in all patients between baseline and 1-year postoperative, according to the abstract. The rate of improvement did not depend upon preoperative CSM severity, and after a multivariate analysis, the results were unchanged when they adjusted for confounders.

“Although all patients experienced improvement in their condition after surgery, the challenge now is to ensure patients suffering from CSM receive surgical intervention in the earlier stages of the disease,” Fehlings said. “This approach ensures patients avoid permanent neurological impairment, and will reduce costs to the healthcare system over the long term.”

Reference:
Fehlings MG. J Bone Joint Surg Am. 2013;doi:10.2106/JBJS.L.00589.

5 Myth busters in Orthopaedivcs

Five Things Physicians and Patients Should Question

According to the AAOS, there are 5 myths that do not bring a substantial EBM based benefit for the orthopaedc patient. 

1

Avoid performing routine post-operative deep vein thrombosis ultrasonography screening in patients who undergo elective hip or knee arthroplasty.

Since ultrasound is not effective at diagnosing unsuspected deep vein thrombosis (DVT) and appropriate alternative screening tests do not exist, if there is no change in the patient’s clinical status, routine post-operative screening for DVT after hip or knee arthroplasty does not change outcomes or clinical management.

2

Don’t use needle lavage to treat patients with symptomatic osteoarthritis of the knee for long-term relief.

The use of needle lavage in patients with symptomatic osteoarthritis of the knee does not lead to measurable improvements in pain, function, 50-foot walking time, stiffness, tenderness or swelling.

3

Don’t use glucosamine and chondroitin to treat patients with symptomatic osteoarthritis of the knee.

Both glucosamine and chondroitin sulfate do not provide relief for patients with symptomatic osteoarthritis of the knee.

4

Don’t use lateral wedge insoles to treat patients with symptomatic medial compartment osteoarthritis of the knee.

In patients with symptomatic osteoarthritis of the knee, the use of lateral wedge or neutral insoles does not improve pain or functional outcomes. Comparisons between lateral and neutral heel wedges were investigated, as were comparisons between lateral wedged insoles and lateral wedged insoles with subtalar strapping. The systematic review concludes that there is only limited evidence for the effectiveness of lateral heel wedges and related orthoses. In addition, the possibility exists that those who do not use them may experience fewer symptoms from osteoarthritis of the knee.

5

Don’t use post-operative splinting of the wrist after carpal tunnel release for long-term relief.

Routine post-operative splinting of the wrist after the carpal tunnel release procedure showed no benefit in grip or lateral pinch strength or bowstringing. In addition, the research showed no effect in complication rates, subjective outcomes or patient satisfaction. Clinicians may wish to provide protection for the wrist in a working environment or for temporary protection. However, objective criteria for their appropriate use do not exist. Clinicians should be aware of the detrimental affects including adhesion formation, stiffness and prevention of nerve and tendon movement.

American Academy of Orthopedic Surgeons. Choosing Wisely®. Five Things Physicians and Patients Should Question. Online 11. September 2013

Incidence of displacement after nondisplaced distal radial fractures in adults.

BACKGROUND:

It is standard practice to closely monitor distal radial fractures treated nonoperatively to ensure that there is no fracture displacement. Patients are often asked to initially return weekly for radiographs. To our knowledge, nondisplaced distal radial fractures in adults have not been specifically evaluated to determine if this level of vigilance is required. If this subset of fractures is unlikely to displace, the cost, radiation exposure, and inconvenience of weekly office visits could be spared.

METHODS:

Using our billing database, we identified 642 closed distal radial fractures among the patients who presented to our institution during the four-year period from the beginning of 2006 to the end of 2009. Radiographs of the injuries were reviewed to identify fractures for which radiographic measurements were within predefined radiographic norms. Only those fractures that were believed to be nondisplaced by all reviewers were classified as nondisplaced for the purposes of this study. Radiographic measurements were made at the time of injury and at the time of fracture union to evaluate for displacement over time. The total number of clinic visits and radiographs that were received were calculated from the longitudinal medical record for each patient.

RESULTS:

Eighty-two fractures were identified as nondisplaced. None displaced or required operative intervention. The largest measured difference from injury to fracture union for radial inclination was 3.6° (average 0.8°); for radial height, 2.1 mm (average 0.5 mm); and for palmar tilt, 3.1° (average 1.0°). These numbers are all within the error of measurement.

CONCLUSIONS:

Nondisplaced distal radial fractures in adults appear to be inherently stable, and it may be appropriate to treat this subset of distal radial fractures with cast immobilization (when swelling allows) and a single follow-up visit with radiographs to document union at the time of cast removal.

LEVEL OF EVIDENCE:

Prognostic Level III.

Roth KM, Blazar PE, Earp BE, Han R, Leung A: Incidence of displacement after nondisplaced distal radial fractures in adults.J Bone Joint Surg Am. 2013 Aug 7;95(15):1398-402. doi: 10.2106/JBJS.L.00460.