Radiographic examination of the lumbar spine.
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Back Pain↗
Biomedical subjects
R W Porter
Publications and source records attributed to R W Porter.
Improving care: a study of orthopaedic outpatient referrals.
OBJECTIVE: To identify aspects of outpatient referral in which general practitioners', consultants', and patients' satisfaction could be improved. DESIGN: Questionnaire survey of general practitioners, consultant orthopaedic surgeons, and patients referred to an orthopaedic clinic. SETTING: Orthopaedic clinic, Doncaster Royal Infirmary. SUBJECTS: 628 consecutive patients booked into the orthopaedic clinic. MAIN OUTCOME MEASURES: Views of the general practitioners as recorded both when the referral letter was received and again after the patient had been seen, views of the consultants as recorded at the time of the clinic attendance, and views of the patients as recorded immediately after the clinic visit and some time later. RESULTS: Consultants rated 213 of 449 referrals (42.7%) as possibly or definitely inappropriate, though 373 of 451 patients (82.7%) reported that they were helped by seeing the consultant. Targets for possible improvement included information to general practitioners about available services, communication between general practitioners and consultants, and administrative arrangements in clinics. Long waiting times were a problem, and it seemed that these might be reduced if general practitioners could provide more advice on non-surgical management. Some general practitioners stated that they would value easier telephone access to consultants for management advice. It was considered that an alternative source of management advice on musculoskeletal problems might enable more effective use to be made of specialist orthopaedic resources. Conclusion--A survey of patients' and doctors' views of referrals may be used to identify aspects in which the delivery of care could be made more efficient. Developing agreed referral guidelines might help general practitioners to make more effective use of hospital services.
Attitude of Health Personnel↗
Prediction of hip fracture in elderly women.
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Aged↗
Prediction of hip fracture in elderly women: a prospective study.
OBJECTIVE: To assess the relative importance of osteoporosis of the os calcis, cognisance, and mobility in the risk of subsequent fracture of the hip in elderly women. DESIGN: Prospective study of elderly women in residential care over two years. SETTING: 21 Private or 38 local authority residential homes for the elderly and 4 geriatric hospitals in Doncaster and Hull. SUBJECTS: 1414 Ambulant women aged over 69, in private or local authority residential care or geriatric care. Those who had had bilateral hip surgery were excluded. MAIN OUTCOME MEASURES: Broad band ultrasonic attenuation (BUA) index, Clifton assessment procedures for the elderly test (for cognisance), and mobility on a six point scale, and fracture of the hip in the subsequent two year period. RESULTS: 73 Women fractured their hip during the two years. Their mean age was not significantly different from that of the women who did not have a fracture (85.3 (SD 5.6) v 83.9 (6.3); p = 0.07), but their mean BUA index (40.3 (19.3) v 50.9 (22.2) db/MH2), and score for cognisance (median 19 (interquartile range 10.5-27.0) v 24 (17-30)) were significantly lower (both p less than 0.001). These variables had independent associations with fracture of the hip. Women with fractures had a significantly lower score for the psychomotor component of the cognisance test (4.5 (1-8) v 7 (2-10); p less than 0.0025 and were significantly more mobile (1(1-3) v 3 (1-6); p less than 0.02). Subdividing women according to high, medium, and low scores for BUA index and cognisance testing disclosed a high risk group (118 women) with low BUA index and cognisance score, whose incidence of fracture was 12.8%; in the group at lowest risk (136 women) with high BUA index and cognisance score, the incidence of fracture was only 1.5% (relative risk 8.4 (95% confidence interval -2.0 to 35.5]. Further analysis showed that those most at risk were, additionally, most mobile but that less mobile women with good cognisance had a low incidence of fractures, regardless of the BUA index, (1.2%, high index, v 0.9%, low index). CONCLUSIONS: Elderly women most at risk of sustaining hip fractures were those with low BUA index, low cognisance test score, and high mobility. Improving bone strength and cognisance in elderly women may reduce their incidence of hip fracture.
Aged↗
Wrist fracture, heel bone density and thoracic kyphosis: a case control study.
The heel bone density measured by Broadband Ultrasound Attenuation (BUA), the thoracic kyphosis measured by a Kyphometer, height, and weight were compared between 294 women over 49 years of age who sustained a wrist fracture and 294 age-matched women who had not previous wrist, hip or spine fracture. The BUA was significantly less in the women who had wrist fracture (p less than 0.0005), though there was a considerable overlap between the two populations. The women with wrist fracture had significantly greater thoracic kyphosis (p less than 0.0005) and smaller stature (p less than 0.0005). There was no significant difference in weight. There was a significant tendency (p less than 0.0005) for women in the fracture patient group to have both poor BUA and greater kyphosis.
Aged↗
Diurnal changes in straight leg raising.
Diurnal changes in straight leg raising were measured in 28 patients with criteria of lower lumbar disc protrusion, having first established an acceptable intra-observer repeatability using an oil-filled precision goniometer. Eight patients showed little change between the straight leg raising after a night of recumbancy, and after 180 minutes in the upright posture. Twenty patients, however, had 10 or more degrees of improvement in straight leg raising, with a mean improvement of 16.9 degrees (SD 7.1 degrees); most of the increase occurred in the first hour of being upright. The measurement returned again to the base level after 120 minutes of further recumbancy. Five of the eight patients who showed little diurnal change had discectomy, and four had a complete annular tear. Only one of the 20 patients with more than 10 degrees of diurnal change required surgery. Diurnal change in straight leg raising is probably related to the disc's proteoglycan content, its hydration, the tension of the protrusion and the presence of intact peripheral annular fibers.
Circadian Rhythm↗
Assessment in congenital talipes equinovarus.
We have examined the intra- and interobserver repeatability of several measurements of the original deformity and the postoperative correction in children with congenital talipes equinovarus deformity. A neonatal photograph and a preoperative soft tissue radiograph had acceptable repeatability as a method of early assessment. The postoperative range of movement measured by goniometer was adequate for one examiner, (mean: 2-6 degrees), but poor between examiners (mean: 5-14 degrees). Postoperative radiographic measurement between observers was more repeatable than the range of movement. The combined talocalcaneal angle had good repeatability in young children.
Child↗
Diurnal changes in spinal mechanics and their clinical significance.
Diurnal changes in the loads acting on the spine affect the water content and height of the intervertebral discs. We have reviewed the effects of these changes on spinal mechanics, and their possible clinical significance. Cadaveric lumbar spines subjected to periods of creep loading show a disc height change similar to the physiological change. As a result intervertebral discs bulge more, become stiffer in compression and more flexible in bending. Disc tissue becomes more elastic as its water content falls, and its affinity for water increases. Disc prolapse becomes more difficult. The neural arch and associated ligaments resist an increasing proportion of the compressive and bending stresses acting on the spine. Observations on living people show that these changes are not fully compensated for by modified muscle activity. We conclude that different spinal structures are more heavily loaded at different times of the day. Therefore, the time of onset of symptoms and signs, and any diurnal variation in their severity, may help us understand more about the pathophysiology of low back pain and sciatica.
Back Pain↗
Physical activity and the strength of the lumbar spine.
The cadaveric lumbar spines of nine young men killed in road accidents were subjected to a range of mechanical tests, and the results compared with the men's occupational and recreational histories. It was found that the compressive strength of the spines tended to increase with the level of physical activity in life, but the increase was significant only in the eight spines aged 18 or over. Compressive failure usually occurred in the vertebral body, but in three cases, the disc prolapsed into the vertebral canal; these discs came from three of the four most physically active individuals. It is concluded that physical activity strengthens both the vertebrae and the discs. A high level of activity can cause vertebral strength to exceed that of the discs.
Adolescent↗
Cross leg pain and trunk list.
The prognostic significance of gravity-induced trunk list and cross leg pain was investigated in 113 patients who had root tension signs from a lumbar disc lesion. Cross leg pain, (a positive contralateral straight leg raising sign) and list was associated with poor prognosis for conservative management. There was a high incidence of disc sequestration and extrusion in the operated patients with cross leg pain. It was concluded that cross leg pain is probably a contraindication to chymopapain injections, and the surgeon should be aware of the possibility of a migrated disc fragment during operation on patients with cross leg pain.
Adult↗
Walking and cycling tests in neurogenic and intermittent claudication.
The walking and cycling tolerance of 19 patients with neurogenic claudication and 11 with intermittent claudication was assessed, first in the upright and then in 30 degrees of flexion, repeating the tests on a second day. The flexed posture improved the walking and cycling distance, respectively, in 11 and six patients with neurogenic claudication. In two of the 11 patients, this posture significantly improved by more than 100% of both walking and cycling distances. In addition, one patient had claudication pain when he was walking, but could cycle unlimited distance. Only one of the patients with intermittent claudication could walk or cycle further in the flexed position. Although some patients with neurogenic claudication increase their walking distance by flexing forwards, we conclude that posture-related walking and cycling are insufficiently sensitive tests to distinguish between neurogenic and intermittent claudication.
Exercise↗
Metastasis from an unknown primary presenting as a tumor in the internal auditory meatus.
A 40-year-old male presented with a 2-month history of sudden hearing loss and tinnitus in his left ear. Mild vertigo was present initially but disappeared spontaneously without treatment. Facial nerve paralysis and retroauricular pain appeared 3 months after the onset of hearing loss on the same side. Computerized tomography and magnetic resonance imaging demonstrated a 1-cm mass in the left internal auditory canal. Translabyrinthine removal of tumor revealed metastatic adenocarcinoma. The patient died 3 months postoperatively from multiple metastatic deposits. A primary tumor was never found. The course of illness in this patient differs significantly from the typical course of other conditions involving the internal auditory canal. A metastatic work-up should be considered for patients with a similar history before a craniotomy is performed.
Adenocarcinoma↗
Mechanical disorders of the lumbar spine.
The lumbar spine is an impressive mechanical system but it can fail from injury or abuse. This paper reviews four recognisable back pain syndromes, which result from mechanical failure, symptomatic disc protrusion, root entrapment syndrome, segmental instability and neurogenic claudication--their clinical presentation, and what is understood about their multifactoral aetiology.
Back Pain↗
Neurogenic claudication and root claudication treated with calcitonin. A double-blind trial.
Forty-two patients with either neurogenic claudication or unilateral root claudication were analyzed in a double-blind comparison of salmon calcitonin (SCT) and placebo, receiving either 100 IU SCT or 1 ml saline four times a week for 8 weeks. Five of 20 SCT and one of 22 placebo patients were classified as responders. There was no statistically significant difference between the treatment groups in the proportion of responders. Seven of eighteen of the placebo group who later received salmon calcitonin improved their walking distance. The authors have not established that this is an organic response.
Back Pain↗
Ulnar nerve entrapment at the elbow localized by short segment stimulation.
The purpose of the study was to evaluate the differences in the amplitudes of the compound muscle action potentials of the hypothenar muscles and the differences in conduction times. Differences in shoot segment responses were determined by stimulating the ulnar nerve at 2-cm intervals across the elbow in 20 normal adults. Thirteen ulnar nerves on the left side and 12 nerves on the right of 14 men and six women were studied for motor nerve conduction velocity. The amplitudes of the hypothenar compound muscle action potentials and the conduction times after supramaximal stimulation of the ulnar nerve were also determined. The distal-to-proximal reduction in the amplitude of the potentials was 6% on the left and 4.2% on the right. The maximum conduction time in a 2-cm segment on the right side was 0.63msec (mean +2SD = 0.43 + 0.20) and on the left, 0.60msec (mean +2SD = 0.44 + 0.16). Using the same short segment stimulation technique, ulnar nerve motor conduction was also studied in 13 patients with suspected ulnar neuropathy at the elbow in order to localize the nerve lesion. Conduction time only was abnormal in one patient, both conduction time and amplitude in nine, amplitude only in one, and conduction time and mild reduction in amplitude in two. It was concluded that short segment stimulation of the ulnar nerve at the elbow is useful in localizing the exact site of entrapment/compression of the nerve at the elbow.
Adult↗
Myelopathy after the intrathecal administration of hypertonic saline.
The neuropathological effects of intrathecally administered hypertonic saline have not been described previously. We report a patient who, within a day of receiving 20 ml of hypertonic (7.5%) saline intrathecally, developed flaccid paraplegia and complete sensory loss below the umbilicus. Subsequently, there was some transitory return of motor and coarse sensory function. The patient died 16 months after the injection. At autopsy, there was peripherally accentuated loss of myelinated fibers within the spinal cord from T12 downward, as well as dense collagenous thickening of the dorsal leptomeninges from T9 to T11. The findings in this case, coupled with observations made by others, serve to emphasize the need for extreme caution whenever planning any form of intrathecal therapy.
Humans↗
Measurement of lumbar sagittal mobility. A comparison of methods.
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Humans↗
Congenital talipes equinovarus: I. Resolving and resistant deformities.
Comparisons were made between 54 children with resolving congenital talipes equinovarus deformity and 81 children whose feet required surgical correction. There was a significant difference in the incidence of bilateral deformity, sex ratio and family history of congenital talipes in the two groups. The children with resolving deformity had feet which were indistinguishable from the normal side of unilaterally affected children in their calf muscle measurements at six weeks of age, and in the range of movement and radiographs at four years of age. Those requiring surgery had varying degrees of muscle reduction, and although often well corrected, had a reduced range of movement and altered joint anatomy at four years of age. This suggests that they are two distinct populations.
Casts, Surgical↗