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PubMed1988

Economic outcome under Medicare prospective payment at a tertiary-care institution: the effects of demographic, clinical, and logistic factors on duration of hospital stay and part A charges for medical back problems (DRG 243).

We investigated the effects of prospectively identified factors on the duration of hospital stay and part A charges in 240 hospitalizations (of 230 patients) for the diagnosis-related group "medical back problems" (DRG 243) at a tertiary-care institution in 1985 to determine whether heterogeneity existed within this reimbursement category. We confirmed our initial postulates that nonosteoporotic fractures and neck problems, as well as hospitalizations primarily for myelography after outpatient neurologic evaluation, had considerably different economic outcomes and thus excluded these categories from further analysis. Statistical analysis (forward stepwise regression) of the remaining 132 patients who had "general medical back problems" showed that increasing age, associated osteoporosis, and therapeutic injections best explained variation in the natural logarithm of duration of stay (R2 = 0.16). Total number of diagnoses, spondylosis, associated osteoporosis, age, therapeutic injections, and performance of special procedures best explained the variation in the logarithm of part A charges (R2 = 0.29). The ability to identify factors within a specified category that affect the duration of hospitalization and part A charges jeopardizes the fairness of prospective payment, and we believe that DRG 243 should be adjusted for age, comorbidity, and readily identifiable clinical syndromes that have disparate economic consequences. Because of poorly substantiated efficacy and a significant association with longer hospital stays and higher part A charges, clinicians should review the use of therapeutic injections for medical back problems. Analysis of case-mix such as ours should be helpful in promoting efficient practice and ensuring the fairness of any reimbursement system.

Adult↗
PubMed2004

[The Bryan cervical disc prosthesis. Preliminary clinical experience with nine implants].

PURPOSE: After an anterior cervical discectomy, immobility at the fused level may increase stress on adjacent disc spaces and causes disc degeneration in 92% of the cases with clinical manifestations in 25.6% of the patients within 10 years. The cervical disk prosthesis may help to prevent this problem. The Bryan prosthesis (Medtronic Sofamor Danek) is currently available in France after a European pilot study. METHODS: Since January 2002, 8 patients (9 implants) (mean age: 35 years) were operated on with a prosthesis implantation for disc degeneration after an adjacent previous interbody fusion in 2 patients and for disc herniation or spondylosis in 6 patients. The prosthesis were implanted at the C4-C5 level (one patient), C5-C6 (four patients), and C6-C7 (four patients). Post-operative radiological evaluations with dynamic X-rays and clinical status (Odom questionnaire) were analyzed. RESULTS: Surgical procedures, which were longer than the classical technique, were uneventful. Radicular pain resolved after surgery with excellent results with the Odom's score. With a mean follow-up of 12 months, the prosthesis mobility was 8.9 degrees . But one fusion of an implant was encountered 6 months after implantation. CONCLUSIONS: The general follow-up for the Bryan(R) cervical disc prosthesis implantation is still too short (2 years) for a definitive evaluation. If clinical results on pain are as good as expected, long-term mobility of the prosthesis has to be checked, as it is the main advantage over classical anterior cervical discectomy with fusion. Patient selection has to be considered.

Adult↗
PubMed2002

Surgical options for the treatment of cervical spondylotic myelopathy.

Cervical spondylotic myelopathy is a disease of the cervical spinal cord that results from circumferential compression of the degenerative cervical spine, often in a congenitally narrow spinal canal. Surgical recommendations must be based on patient characteristics, symptoms, function, and neuroradiologic findings. ACDF is an excellent option for one- or two-level spondylosis without retrovertebral disease. Anterior corpectomy and strut grafting may provide an improved decompression and is ideal for patients with kyphosis or neck pain. Laminectomy historically yields poor results from late deformity and late neurologic deterioration but yields improved results with good surgical technique. Laminoplasty was developed to address cervical stenosis of three or more segments and compares favorable with anterior corpectomy and fusion for neurologic recovery. Laminoplasty has a lower complication rate than corpectomy and strut grafting but has a higher incidence of postoperative axial symptoms.

Cervical Vertebrae↗
PubMed1998

Comprehensive radiographic evaluation of diffuse idiopathic skeletal hyperostosis: development and interrater reliability of a scoring system.

OBJECTIVE: To develop a scoring system for radiographic findings in diffuse idiopathic skeletal hyperostosis (DISH) and to test interrater reliability. MATERIALS AND METHODS: Fifty-five DISH patients and 35 spondylosis patients underwent two views (anteroposterior and lateral) of the cervical, thoracic, and lumbar spine, lateral views of both ankles, knees, and elbows, and anteroposterior views of the pelvis and shoulders. Two raters reviewed and scored the x-rays. Interrater reliability was assessed with the alpha statistic (alpha) for categorical variables and with the intraclass correlation coefficient (ICC) for continuous variables. RESULTS: The agreement was similar for the three spinal segments (alpha = 0.44 to 0.71). The lower extremity agreement ranged from 0.28 to 0.76, with higher agreement at the knee (alpha > or = 0.46) and the ankle (alpha > or = 0.56) than at the pelvis (ICC < or = 0.58). The agreement at the shoulders and elbows ranged from 0.50 to 0.75. The agreement between the readers was higher with summary measurements than with single (site-by-site) measurements: for each spinal segment, the ICC was 0.83 or greater; for the lower extremity, the ICC = 0.79; and for the upper extremity, the ICC = 0.68. CONCLUSION: We have described a comprehensive scoring system to assess the spinal and peripheral involvement of DISH.

Aged↗
PubMed1999

Postoperative prognosis of Brown-Séquard-type myelopathy in patients with cervical lesions.

BACKGROUND: Postoperative prognosis of the hemihypalgesia in patients with Brown-Séquard-type myelopathy (BSM) caused by cervical lesions is of great interest to surgeons. However, there are very few reports discussing the postoperative prognosis of BSM. METHODS: We evaluated the prognosis of BSM using the criteria of the Japanese Orthopaedic Association (JOA) score in 16 (seven ossification of the posterior longitudinal ligament [OPLL], 5 cervical spondylosis [CS], and 4 disc herniation patients) out of 233 surgically treated patients with cervical diseases. The mean follow-up duration was 2 years and 11 months. RESULTS: After surgery, none of these patients showed complete resolution of hemihypalgesia, although the most rostral level of hemihypalgesia moved in a caudal direction in 13 patients (81%), whose recovery ratios of JOA score were significantly better than those of hemihypalgesia-level-persisted patients. In our BSM series, OPLL occurred most frequently and the anterior element compressing the spinal cord existed most frequently in the central area of the vertebra (44%). Postoperative improvement in the motor function of the legs in the disc herniation group was significantly better than in the OPLL and CS groups (p < 0.05, respectively). There were no significant differences in the functional prognosis between the BSM and non-BSM patient groups. CONCLUSIONS: BSM patients can expect almost the same functional outcome as non-BSM patients, with the exception of the disappearance of hemihypalgesia.

Adult↗
PubMed1999

Posterior decompression of the vertebral artery narrowed by cervical osteophyte: case report.

BACKGROUND: Symptomatic vertebral artery compression caused by cervical spondylosis usually is caused by compression of the artery by osteophytes arising from the uncinate process. Compression from facet joint osteophytes is seldom reported. CASE DESCRIPTION: A 69-year-old male developed symptomatic vertebral artery stenosis secondary to an osteophyte arising from the superior facet of the sixth cervical vertebra posterior to the artery. A posterior decompression of the vertebral artery with removal of the offending facet joint complex relieved the patient's transient neurologic events. CONCLUSION: Symptomatic vertebral artery stenosis may be caused by osteophytes compressing the vertebral artery anteriorly from the uncinate process or posteriorly from the facet complex.

Aged↗
PubMed2000

Increased MRI signal intensity in association with myelopathy and cervical instability: case report and review of the literature.

BACKGROUND: Increased T2-weighted signal intensity in patients with cervical myelopathy has been extensively reviewed in the literature. A variety of etiologies with similar MRI appearances have been described; attempt at correlation of MRI findings with clinical presentation and outcomes after treatment has led to a limited consensus. METHODS: We present a case of cervical myelopathy with associated hyperintense T2-weighted signal characteristics, secondary to cervical spondylosis and instability. RESULTS: Rapid resolution of radiographic abnormalities after surgical decompression and fusion was noted. Clinical improvement did not parallel radiographic resolution. CONCLUSION: These findings are important in considering the pathophysiology of MRI changes in cervical myelopathy.

Aged↗
PubMed1999

Should radiologists image and report sacroiliac joints in patients referred for examination of the lumbar spine?

It is routine to image the sacroiliac joints (SIJs) in patients referred for radiographic examination of the lumbar spine but there were only two consistent with ankylosing spondylitis in a review of 392 radiographic reports of lumbar spine examinations. A more sensible policy would be to only image and report on the SIJs if the clinical history were indicative of ankylosing spondylosis.

Adult↗
PubMed1997

Musculoskeletal system. Joint and vertebral column diseases.

Owner complaints that refer to the musculoskeletal system are common in older dogs and cats. When the veterinarian is presented with these types of complaints, the differential lists include chronic intervertebral disk disease, diskospondylitis, degenerative joint disease, spondylosis with nerve root compression, joint/ ligament instability, and/or cancer. The diagnosis and management of some of these conditions is presented in detail with the general goal in mind that the older dog or cat is provided the best quality of life possible through good mobility along with being pain free.

Aging↗
PubMed2000

Loss of the muscle silent period evoked by transcranial magnetic stimulation of the motor cortex in patients with cervical cord lesions.

The silent period following motor evoked potentials in small hand muscles after transcranial magnetic stimulation (TMS) of the human motor cortex is considered to be cortical origin. The authors report three patients with cervical spinal cord lesions who showed loss of the cortical silent period (CSP) after TMS. One patient had traumatic cervical cord injury, and the other two patients had cervical spondylosis. All the patients had cervical cord compression on magnetic resonance imaging. TMS study showed loss of the CSP in both the hand and foot muscles in two patients and only in the foot muscle in one patient. Paired TMS study in one patient with pseudoathetotic hands showed reduced inhibition within the motor cortex. The hand weakness or interrupted sensory afferents might have caused motor cortical reorganization or hyperexcitability, leading to the loss of the CSP.

Adult↗
PubMed1996

"Aging bull'.

An old bull, it is said by those who know, can have his troubles. Included among these are vertebral osteosclerosis and ankylosing spondylosis; this stiffening up limits, rather than accentuates, the value and reproductive potential of a stud bull past his prime. Associated with these abnormalities, however-and not seen in age-matched cows of comparable breeds-are fascinating endocrine neoplasms suggestive of a pattern that could be productive as a model of human hereditary endocrine abnormalities. Adjacent to the thyroid gland in other vertebrates are ultimobranchial bodies that are incorporated into the lateral thyroid lobes in primates as the parafollicular "C cells' of the thyroid. These are the cells in man that give rise to medullary thyroid cancer and are associated with calcitonin secretion, useful as a tumor marker. In aging bulls of whatever breed, nearly half exhibit abnormality of these ultimobranchial bodies: 20% show hyperplasia, and 30% have frank neoplasia. These ultimobranchial tumors appear in bulls passing 6 1/2 years in age, and are absent in young bulls and all cows of any age. Calcitonin can be demonstrated in the ultimobranchial tumors from bulls, and secretion is stimulated by calcium infusion, though serum calcium remains normal. The ultimobranchial tumors themselves can range from hyperplasia through adenoma to metastasizing carcinoma-in fact, representing one of the commoner cattle cancers. Parathyroid glands taken from bulls with these ultimobranchial tumors initially show evidence of inhibited secretory activity and morphologic atrophy, but later go on to develop hyperplasia and, eventually, autonomy. Cattle forage on calcium-rich diets. Bulls appear to respond to this calcium excess from the positive balance, but breeding cows have the unique calcium deficits of the high net loss of calcium through lactation and the large requirements of calcifying a fetal skeleton. Chronic stimulation of the APUD-derived ultimobranchial bodies by high calcium intake, not counterbalanced by calcium losses in the bulls, may account for the development over time of the ultimobranchial neoplasms. Further, a number of the bulls who have the ultimobranchial tumors are found to have multiple endocrine tumors in other glands-bilateral pheochromocytomas and pituitary acidophil adenomas.

Aging↗
PubMed1996

Chronic neck pain.

The disorders most commonly seen in rheumatologic practice are acute to chronic cervical disc-related strains, radiculopathies, and degenerative spondylosis. Inflammatory disorders including ankylosing spondylitis and rheumatoid arthritis, although generally rare, are not uncommonly seen in a rheumatologic practice. The pertinent anatomic and pathologic features of cervical disorders are examined in the context of their implications for the hierarchy of specific therapeutic interventions. The basis for the usually favorable prognosis for these conditions, particularly in response to a rational, structured, and phased conservative regimen, is delineated.

Anatomy, Artistic↗
PubMedDate not supplied

Complications of transesophageal echocardiography in ambulatory adult patients: analysis of 1500 consecutive examinations.

Transesophageal echocardiography is a new approach that can be used to image cardiac structures. It combines two existing technologies: cardiac ultrasound and endoscopy. To obtain a cardiac image, the transesophageal probe has to be positioned properly within the esophagus. The first 1500 consecutive transesophageal echocardiographic examinations in ambulatory adult patients from one center were analyzed to identify conditions associated with failed esophageal intubation and procedural complications. Esophageal intubation was not achieved in 11 patients (0.73%). The reasons for the failure of intubation were operator inexperience, hypersensitive pharynx despite topical anesthesia, and cervical spondylosis. Six of those patients also had a history of dysphagia. Procedural complications were identified in seven patients (0.47%). Tracheal intubation was present in four patients, with immediate development of stridor and incessant cough in two patients. Atrial fibrillation developed in two patients--one had atrial myxoma and one had mitral stenosis. Bronchospasm developed during the transesophageal examination in one patient who was receiving long-term treatment for bronchial asthma. We conclude that transesophageal echocardiography is feasible in most adult patients in the ambulatory setting and that the complication rate is very low. Proper patient selection and preparation are crucial to the successful performance of this procedure.

Adult↗
PubMedDate not supplied

Screening for abdominal aortic aneurysms during routine lumbar CT scan: modification of the standard technique.

INTRODUCTION: Abdominal aortic aneurysms (AAAs) are often incidental findings in patients undergoing US, CT or MRI studies. The recommended field of view (FOV) for standard CT examinations of the spine is 14 cm. This FOV does not allow full visualization of the abdominal aorta. PURPOSE: To justify a larger FOV for male smokers older than 55 years and women older than 65 years, with a higher incidence of AAA. MATERIALS AND METHODS: The lumbar CT examinations of 100 consecutive patients (age: mean 68 years, range 55-85 years) presented with low-back pain were retrospectively reviewed. Measurements of the abdominal aorta and lumbar abnormalities were analysed. A control study in 850 patients who underwent abdominal CT scans for other causes was available for comparison. RESULTS: There were three men with AAAs measuring 4.5, 5.5 and 5.6 cm (mean 5.2 cm). Findings related to the clinical problem were disk prolapse or herniation, spondylosis, spinal stenosis and grade I spondylolesthesis. In the control group, 17 patients were found with AAAs with diameter greater than 4 cm (2%). CONCLUSIONS: Patients with low-back pain, older than 55 years of age, examined with lumbar spine CT, should also be screened for aortic disease, since the prevalence of AAA is similar with that of an age-matched control group. Appropriate modification in the applied FOV is recommended.

Age Distribution↗
PubMed1998

Power Doppler imaging in the evaluation of extracranial vertebral artery compression in patients with vertebrobasilar insufficiency.

OBJECTIVE: The recent introduction of Power Doppler Imaging (PDI) made a promise for better visualization of blood vessels lying in regions anatomically difficult for ultrasound imaging, i.e. vertebral arteries. The purpose of our study was to assess usefulness of PDI technique in visualization of vertebral artery course and to assess its utility in the detecting spondylotic vertebral artery compression in patients with vertebrobasilar insufficiency (VBI). METHODS: A total of 428 patients with VBI symptoms was evaluated. A total of 282 (66%) patients related their symptoms to a specific head position. Thus, all Doppler examinations were performed in four head positions: hyperextension, flexion and right/left rotation and also in a position reported by a patient to produce symptoms. PDI technique was employed as vertebral artery mapping for precise PW-Doppler range gate placing. RESULTS: Vertebral artery compression was found in 73 (17%) patients: 65 unilateral and eight bilateral. The diagnosis was based on flow decrease or its absence shown on PW-Doppler scans, after a specific head turning. CONCLUSION: Vertebral artery compression, related to a specific head position is relatively frequent in patients with VBI symptoms, especially in an older population commonly suffering from cervical spondylosis. PDI facilitates noninvasive Doppler US diagnosis by showing the real course of vertebral artery, particularly its intertransverse portion.

Aged↗
PubMed1995

The spondyloarthropathies.

The spondyloarthropathies occur with variable frequency in the tropics. Ankylosing spondylitis, in particular, is thought to be rare in tropical Africa, reflecting a low frequency of the HLA B27 gene. However, in the Melanesian populations of Papua New Guinea where there is a relatively high frequency of HLA B27, ankylosing spondylosis is infrequent. These diverse observations may be related to variations in B27 sub-types. Reactive arthritis is a common and important form of acute arthritis in the tropics and in Papua New Guinea at least has a strong association with HLA B27. In Africa an increasing prevalence of reactive arthritis may be related to the spread of HIV infection. Extra-articular features such as balanitis and enthositis are helpful pointers to the diagnosis. Disseminated gonococcal infection and tuberculosis must always be considered and treatment offered if doubt exists. The mainstay of treatment of reactive arthritis is, as always, an anti-inflammatory drug, supplemented by hydrocortisone injections; docycline is available for chlamydia-triggered arthritis and chloroquine or dapsone for more chronic, unresponsive cases.

Arthritis, Psoriatic↗
PubMed2002

Long term results of diaphragmatic plication for unilateral diaphragm paralysis.

OBJECTIVES: To examine whether diaphragmatic plication is an effective and lasting treatment option for non-malignant diaphragmatic paralysis. METHODS: Nineteen patients who had undergone diaphragm plication (1983-1990) were recalled for interview, pulmonary function testing and chest X-ray. RESULTS: There were 13 men and six women aged 24-73 (mean 55). Diaphragm paralysis was idiopathic (n=9), postsurgical (n=3), related to cervical spondylosis (n=4) and neck injury (n=2). Patients presented with breathlessness (18/19) or orthopnoea (1/19). Symptoms had lasted 3-60 months (mean 24 months). All patients had a raised hemidiaphragm on chest X-ray with paradoxical movement on ultrasound. Mean preoperative FVC was 71% predicted (range 38-93, SD 12.9) and mean FEV(1) was 67% predicted (range 33-90, SD 10.8). Supine lung volumes were 81% (mean) of sitting values. There were six right plications and 13 left. There were no postoperative deaths. One patient required re-plication. Follow-up (18/19 of original operated patients) ranged from 7-14 years (mean 10 years). Three patients had died of unrelated causes and one patient failed to attend long term follow-up, leaving 15 patients of the original 19 operated on. Positional change in lung volumes was not affected by surgery at early (6 week) or late (>5 year) follow-up. FVC, FEV(1), FRC and TLC improved by 10.1*, 11.8*, 16.9* and 9.2*%, respectively, at early follow-up and 11.8*, 15.4*, 26 and 13.3*% at late follow-up (*P<0.005 signed rank). Dyspnoea scores at long term follow-up improved 1 point (n=5), 2 points (n=5) and 3 points (n=2), remained unchanged (n=1) or dropped 1 point (n=2). Of the 15 patients followed up all but one who had been employed returned to work. 14/15 patients expressed satisfaction with their surgery. CONCLUSION: Diaphragm plication is an effective procedure with lasting results.

Adult↗