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PubMed2000

Diagnostic yield and development of a neurocardiovascular investigation unit for older adults in a district hospital.

BACKGROUND: Dizziness, syncope, and falls are common occurrences in elderly people. Neurocardiovascular investigation units aim to detect those patients who fall due to disturbances of blood pressure control or cardiac conduction. Specialist units have a high diagnostic yield in the investigation of these problems. Does this translate to less specialized centers? We report on the diagnostic findings of a district general hospital neurocardiovascular investigation unit. METHOD: A total of 120 consecutive patients over the age of 65 presenting to a single geriatrician were assessed. After a full history and physical examination, patients underwent neurocardiovascular investigation: blood pressure and heart rate response to active stand, carotid sinus massage, and 30-minute head-up tilt. RESULTS: The 120 patients assessed had a mean age of 78 years (range 66-94 years); in this group, 85 were women. Of these patients, 23% presented with falls, 14% with blackouts, and 30% with dizziness. The remaining 33% had overlap of symptoms. Neurocardiovascular investigations produced a diagnosis in 57% of the patients: 22% had cardioinhibitory carotid sinus syndrome (CSS): 15% had vasodepressor CSS; 29% had orthostatic hypotension; and 3% had vasovagal syncope. Thirteen percent had more than one neurocardiovascular abnormality, and 18% had benign positional vertigo. Five patients had postural instability causing falls. Hyperventilation syndrome, aortic stenosis, dysrhythmia, cervical spondylosis, and epilepsy each accounted for one case. Seventeen percent of the subjects remained undiagnosed after integrated neurocardiovascular assessment. CONCLUSION: Management of falls requires access to neurocardiovascular assessment. It is feasible to provide such a service in the district general hospital setting, with a comparable diagnostic yield to tertiary referral centers.

Accidental Falls↗
PubMed1999

Repeatability and validity of an upper limb and neck discomfort questionnaire: the utility of the standardized Nordic questionnaire.

The repeatability and validity of a questionnaire for upper limb and neck complaints were assessed in a population of 105 hospital outpatients with a range of upper limb and neck disorders (including cervical spondylosis, adhesive capsulitis, lateral epicondylitis, carpal tunnel syndrome and Raynaud's phenomenon). Subjects were asked to complete a modified Nordic-style upper limb and neck discomfort questionnaire on two occasions closely spaced in time. The repeatability of their responses was assessed by calculating a kappa coefficient (kappa), and the sensitivity and specificity of component items in the questionnaire were determined for specific diagnostic categories of upper limb and neck disorder. Symptom reports for pain in the upper limb and neck, pain interfering with physical activities, neurological symptoms and blanching were all found to be highly repeatable (kappa = 0.63-0.90). A number of regional pain reports proved to be very sensitive in relation to specific upper limb disorders, but, with the exception of reported finger blanching in patients with Raynaud's phenomenon, none proved to have a good specificity (range = 0.33-0.38). We conclude that a modified Nordic-style questionnaire is repeatable and sensitive, and is likely to have a high utility in screening and surveillance. However a complementary examination schedule of adequate specificity and repeatability is essential to establish a clinical diagnosis.

Adult↗
PubMed1983

The acute cervical joint lock.

The purpose of this article is to describe a method for assessing and treating patients with acute cervical joint lock. The assessment method enables the therapist to differentiate between acute cervical joint lock and spondylosis or acute cervical joint sprain. Treatment by mobilization or manipulation or both according to the Maitland approach is described. The contraindications to this type of treatment are described, and the efficacy of the Maitland approach is supported.

Acute Disease↗
PubMed1977

Degenerative changes in the intervertebral discs of the lumbar spine and their sequelae.

Careful pathological examination of lumbar spines removed at autopsy has shown that degenerative changes are present in the intervertebral discs of all subjects by middle age. The degenerative changes are more marked and occur at an earlier age when evidence of vertical or posterior disc prolapse is also present. Degenerative changes in the discs are always accompanied by osteophyte formation on the margins of the vertebral bodies and remodelling changes in the apophyseal joints. There is a direct relationship between the degree of disc degeneration, marginal osteophyte formation on vertebral bodies, and apophyseal joint changes, which suggests that disc degeneration is the primary event leading to the clinical condition of 'degenerative spondylosis'.

Adolescent↗
PubMed1981

A double-blind study of benorylate and chlormezanone in musculoskeletal disease.

In a double-blind, cross-over study of 90 patients with degenerative disease of the hip, knee, cervical or lumbar spine, and capsulitis of the shoulder the analgesic drug benorylate (either alone or in combination with chlormezanone, a muscle relaxant anxiolytic drug) favourably modified pain, stiffness, quality of sleep and ability to work. Chlormezanone significantly reduced the number of breaks in sleep. There was no significant difference in the number of patients reporting side-effects on each of the four treatments, but drowsiness occurred significantly more in the chlormezanone weeks. There appeared to be no advantage in adding chlormezanone in patients suffering from osteoarthritis of the hip or knee, lumbar spondylosis or capsulitis of the shoulder, but there was significant improvement in both pain relief and quality of sleep in those patients with neck pain.

Chlormezanone↗
PubMed1997

Rheumatic symptoms following adjuvant therapy for breast cancer.

Twenty-three women with a diagnosis of breast cancer who subsequently developed new nonmetastatic rheumatic symptoms, and/or had a history of rheumatic symptoms prior to their diagnosis of breast cancer, were identified from the oncology and rheumatology practices of a 400-bed tertiary-care teaching hospital. For each patient a structured telephone interview and detailed chart review were conducted. Of eight women with no previous rheumatic history (Group I), four developed polyarthritis (1 seropositive), three fibromyalgia, and one spondylosis after the diagnosis of breast cancer, which in four cases occurred during or shortly after cyclophosphamide-based combination chemotherapy, in two cases during tamoxifen therapy, and in one case after radiotherapy only. Of 15 women who had previous rheumatic symptoms (Group II), 12 developed worse and/or new symptoms, five after chemotherapy and seven on tamoxifen. In both groups the symptoms had a significant negative impact on functional status, and in some cases resolution was only partial even after many years of followup. Prospective studies are needed to determine the incidence, risk factors, and optimal management of nondestructive polyarthropathy or fibromyalgia in women who receive systemic adjuvant therapy for breast cancer.

Adult↗
PubMedDate not supplied

Failure of magnetic resonance imaging to reveal the cause of a progressive cervical myelopathy related to postoperative spinal deformity: a case report.

Imaging studies have achieved a high degree of diagnostic accuracy for many disorders of the spinal cord but have significant limitations. We report on the case of a 49-yr-old man who developed neck pain and arm numbness. He was found to have extensive cervical spondylosis, with spinal cord impingement at C3-4 and cervical radiculopathy. He underwent a C3-7 laminectomy, with transient improvement in his symptoms. During the ensuing year, he developed increased weakness of the upper limbs, evidence of cervical myelopathy, and a severely flexed posture of the cervical spine. Magnetic resonance imaging (MRI) revealed cervical spinal cord atrophy but no evidence of extrinsic spinal cord compression. Cervical flexion and extension films revealed reversal of the normal cervical lordosis without segmental instability. Despite the absence of confirmatory radiologic studies, the patient was felt to have clinical evidence of intermittent compression of his cervical spinal cord attributable to excessive cervical kyphosis, was provided with a cervical collar, and subsequently underwent surgical stabilization. His cervical myelopathy showed marked improvement with these treatments. We conclude that intermittent compression of the spinal cord, occurring in the erect position, was not apparent on the MRI films obtained in the supine position. Flexion and extension films, obtained in the upright position, documented his abnormal cervical anatomy but did not reveal substantial segmental instability. Spinal deformity without segmental instability may cause cervical myelopathy after multilevel cervical laminectomies without evidence of extrinsic compression on MRI.

Braces↗
PubMedDate not supplied

Efficacy of home cervical traction therapy.

Cervical traction is administered by various techniques ranging from supine mechanical motorized cervical traction to seated cervical traction using an over-the-door pulley support with attached weights. Duration of cervical traction can range from a few minutes to 20 to 30 min, once or twice weekly to several times per day. Anecdotal evidence suggests efficacy and safety, but there is no documentation of efficacy of cervical traction beyond short-term pain reduction. Because of a clinical impression that a simplified, inexpensive, over-the-door home cervical traction method of treatment requiring 5 min of cervical traction twice daily was efficacious for both cervical pain and radiculopathic syndromes, we undertook a retrospective study of 58 outpatients treated between 1994 and 1996. Age range was 29 to 84 (mean, 56) yr. Twenty-three males and 35 females were classified as Grade 1 to Grade 3 according to the Quebec Task Force of Whiplash-Associated Disorders Cohort Study. Outcomes were as follows: Grade 1 (mild)--4 of 4 (100%) patients improved; Grade 2 (moderate)--34 of 44 (77%) patients improved (P < 0.01), 5 were unchanged, and 5 felt their symptoms were aggravated by cervical traction; Grade 3 (patients with radiculopathy)--9 of 10 (90%) patients improved (P < 0.01). In a retrospective study, a brief (3-5 min), over-the-door home cervical traction modality provided symptomatic relief in 81% of the patients with mild to moderately severe (Grade 3) cervical spondylosis syndromes. Prospective, randomized assessment of cervical traction for this and other methods is needed.

Adult↗
PubMed1989

Long-term results of cervical epidural steroid injections.

Fifty-eight patients undergoing cervical epidural injection of corticosteroids were followed for a 6-month period. Patients with 90% pain relief lasting 6 months were considered to have excellent results, those with greater than 50% pain relief lasting at least 6 weeks were considered to have good results, and all others were considered to have poor results. Six months after the injection, 41.4% of patients had excellent pain relief by our criteria. Twenty-nine percent of patients reported good results and 29.3% had poor results. Those patients with the diagnosis of cervical spondylosis and those with subacute cervical strain had statistically significantly (p less than 0.001, difference of proportions test) better results than patients with other diagnoses. The procedure of cervical epidural steroid injection may be most effective in patients with cervical degenerative joint disease as the etiology of their cervical pain.

Adrenal Cortex Hormones↗
PubMed1993

An analysis of failures in primary cervical anterior spinal cord decompression and fusion.

Recently, postoperative results of cervical spondylosis, disc herniation, and ossification of the posterior longitudinal ligament (OPLL) after anterior cervical surgeries have improved. However, occasional unsatisfactory cases needing a second operation remain. We analyzed and developed strategies for multioperated neck (MON) cases; all patients had two operations. From 1965 to 1988, 443 cervical anterior surgeries were performed in our hospitals; 53 (12.0%) of these patients needed second operations. These MON cases were classified by the following causes: pseudarthrosis, graft fracture, insufficient decompression, misdiagnosis, and adjacent disc problems. These groups were analyzed, and the resulting surgical strategies, including indications and techniques of anterior surgery, are described.

Adolescent↗
PubMed1995

The significance of dorsal migration of the cord after extensive cervical laminectomy for patients with traumatic central cord syndrome.

Central cord syndrome (CCS) resulting from traumatic cervical injury is often associated with cervical stenosis and/or spondylosis. The efficacy of multilevel laminectomy in the treatment of this condition has been controversial. The objective of this study was to validate by magnetic resonance (MR) imaging the occurrence of dorsal cord migration after extensive laminectomy for patients with the clinical syndrome of central cord damage and its relationship to the short-term outcome. During a 28-month period, the authors evaluated 20 patients (mean age 54 years) who sustained CCS after cervical spine trauma. Pre- and postoperative MR imaging assessed the adequacy of cervical cord decompression by multilevel laminectomy. All patients had cervical canal stenosis with complete obliteration of the anterior subarachnoid space over multiple levels. Seventeen patients initially had CCS of different degrees of severity. One had no motor deficit and two had motor complete with sensory deficits greater in their arms. Laminectomy, generally from C2 to C7 without facetectomy, was performed after plateau of neurological recovery (mean 17 days postinjury). Neurological assessment 3 months after operation revealed improvement in 12, stable function in 7, and progression of deficit in one with no mortality. The postoperative midsagittal MR images demonstrated adequate decompression with restoration of anterior cerebrospinal fluid space and posterior cord migration in 12 patients (60% of the 20), but only 8 of them also had improved function. MR imaging demonstrated that, in the presence of multilevel spondylosis/stenosis, laminectomy may provide adequate spinal cord decompression in patients with traumatic CCS.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed2000

Acute cervical spinal cord injury secondary to air bag deployment without proper use of lap or shoulder harnesses.

The authors present a case report of a patient with cervical central spinal cord syndrome caused by a hyperextension injury after a motor vehicle collision in which the air bag deployed in the absence of shoulder or lap belt harnesses. The potential for cervical spine and spinal cord hyperextension injuries in passengers positioned in front of air bags without proper use of shoulder or lap belt harnesses is discussed. Cervical central spinal cord quadriplegia occurred with cervical spondylosis and kyphosis that was managed by early three-level cervical corpectomy in a 58-year-old patient. Early improvement in the patient's neurological status occurred but was incomplete at the time of this report. Cervical hyperextension injuries are possible in passengers positioned in the front seat of cars with air bags when shoulder or lap belt harnesses are not used properly. Previous biomechanical studies have documented the potential for these types of injuries.

Accidents, Traffic↗
PubMed2000

Results of cervical laminoplasty and a comparison between single and double trap-door techniques.

Thirty-seven patients were studied for an average of 32.1 months after canal-expansive laminoplasty for the treatment of multiple-level cervical stenosis caused by spondylosis, ossification of posterior longitudinal ligament, prolapsed intervertebral disc, and other conditions. Short-term and medium-term results were recorded clinically, using the scoring system proposed by the Japanese Orthopedic Association. The canal expansion was also recorded with radiological studies. The improvement rate was good to excellent in 58.3% of the patients. Postoperative neurological deterioration occurred in only four patients. Poorer results were observed in female patients and in those in whom surgery was delayed. Surgery within 12 months of onset of symptoms gave good results. Serious complications occurred in only two patients. There were 12 patients who were treated with the single trap-door (unilateral) laminoplasty and 25 patients treated with the double trap-door (sagittal splitting of the spinous processes) laminoplasty; their results were compared. There was no significant difference in neurological outcome between the two methods.

Adult↗
PubMed1999

Modern alternatives and techniques for one-level discectomy and fusion.

Monosegmental cervical spondylosis with radiculopathy requiring operative intervention responds well to anterior disc excision and fusion with autograft. However, there is a 20% to 25% morbidity from the donor site. Several new surgical techniques using biomechanical spacers or internal fixation have been developed that can be used with local bone or allograft, thus eliminating donor site morbidity. Surgical outcomes are comparable with those of traditional anterior cervical discectomy and fusion.

Bone Transplantation↗
PubMed2002

Autograft versus allograft in degenerative cervical disease.

Cervical spondylosis, common among people older than 50 years, may produce symptoms of cervical radiculopathy, myelopathy, or both. When patients with degenerative cervical disease require surgery, an anterior decompression of the neural elements and reconstruction of the anterior column with allograft or autograft is common. Allograft incorporates more slowly and less completely than autogenous bone graft, although harvest of autograft from the anterior iliac crest or the middle 1/3 of the fibula may be associated with postoperative morbidity. Overall, higher rates of fusion have been reported with autograft than allograft. However, similar fusion rates have been reported among nonsmokers having single-level anterior cervical interbody fusions. For patients requiring multilevel reconstruction surgery, fusion rates of approximately 100% have been achieved using autogenous strut grafts from the iliac crest and fibula, with a lower rate of incorporation for fibula allograft. The potential for a patient with a nonunion requiring additional operative treatment must be weighed against the potential for graft-related complications when choosing between autograft and allograft for anterior cervical reconstruction.

Aged↗
PubMed1996

Monitoring of median nerve somatosensory evoked potentials during cervical spinal cord decompression.

We evaluated the intraoperative utility of monitoring median nerve somatosensory evoked potentials (SEPs) in 31 consecutively hospitalized neurosurgical patients (mean age 55.3 +/- 2.1 years) who underwent spinal cord decompression for cervical herniated disc, spondylosis, or tumor. Pre- and postoperative standard neurological examinations included evaluation of motor function, sensory responses, gait, tone, and reflexes. Evoked potentials were recorded from clavicular Erb's (N9) and contralateral cortical (N20) points. Intraoperatively, SEP measurements were obtained after the onset of anesthesia (baseline control) and were repeated throughout the operative procedures. N20 and N9-N20 conduction latencies were measured for each SEP recording; disappearance of the SEP waveform was interpreted as a nonquantifiable increase in latency. Follow-up neurological examinations were made immediately after and up to 6 months following surgery. Postoperatively, the 31 study subjects were assigned to one of two groups based on neurological evaluation: 27 group I subjects had either no change or improvement (good outcome) whereas four group II subjects had postoperative neurological deterioration (poor outcome). Intraoperative N9-N20 interpeak latency was found to increase during cervical decompression in six of 27 group I and in two of four group II subjects. Only two of the Group I subjects exhibited increases > 10% (14 and 19%, respectively). Intraoperative communication to the surgeon of a marked increase of N9-N20 latency during positioning for cervical traction clearly obviated a poor outcome in one group I subject; Upon removal of traction, latency decreased and significant changes in neurological function were not detected postoperatively. The SEP waveform disappeared in two of the group II and in none of the group I subjects. In the two group II subjects exhibiting increases of N9-N20 latencies, increments were > 20%. These findings indicate that in patients undergoing cervical spinal cord decompression, disappearance of SEPs or increases > 20% in the N9-N20 interpeak latency are suggestive of operative conditions that place patients at risk for poor neurological outcome.

Adult↗
PubMedDate not supplied

The use of bone scan to investigate back pain in children and adolescents.

Children with back pain frequently undergo detailed investigation because of the perception that a high percentage will have a treatable spinal condition. The purposes of this study was (i) to determine the percentage of children with disabling back pain presenting to our institution who had a diagnosis (i.e., to explain their back pain), (ii) to evaluate the clinical markers that should alert clinicians to underlying pathology, (iii) and to determine the prognosis of children with back pain and no specific diagnosis. This study was a retrospective analysis of consecutive children undergoing single-photon emission computed tomography for a primary complaint of back pain. Data collection included chart review, radiographic analysis, and clinical follow-up with the Roland and Morris scale for pain and disability. Two hundred and seventeen patients with an average age of 13 years (range, 2.7-17.7) were reviewed on average 4.4 years after presentation (range, 1.1-7.2 years). One hundred and seventy children (78.3%) had no specific diagnosis to explain their back pain, 15 children (6.9%) had spondylosis, 10 children (4.6%) had tumor, and the remaining 22 children (10.1%) had various diagnoses including infection, Scheuermann's kyphosis, herniated disc, kidney disease, facet arthritis, degenerative disc disease, congenital anomalies, and tethered cord. Factors associated with positive diagnoses were constant pain and male gender. Night pain, constant pain, and duration of symptoms <3 months were associated with the diagnosis of a tumor. Although the majority of children presenting with persistent back pain had no demonstrable cause, of 132 contactable patients 94 (71%) had persisting pain at the time of clinical follow-up. In conclusion, the majority of children with disabling back pain has no demonstrable cause and the majority will continue to have pain years after initial presentation.

Adolescent↗
PubMedDate not supplied

Cervical and lumbar MRI in asymptomatic older male lifelong athletes: frequency of degenerative findings.

OBJECTIVE: The athletic activity of the adult U.S. population has increased markedly in the last 20 years. To evaluate the possible long-term effects of such activity on the cervical and lumbar spine, we studied a group of asymptomatic currently very active lifelong male athletes over age 40 (41-69 years old, av. age 53). MATERIALS AND METHODS: Nineteen active, lifelong male athletes were studied with MRI and the results compared with previous imaging studies of other populations. An athletic history and a spine history were also taken. RESULTS: Evidence of asymptomatic degenerative spine disease was similar to that seen in published series of other populations. Degenerative changes including disk protrusion and herniation, spondylosis, and spinal stenosis were present and increased in incidence with increasing patient age. In this group, all MRI findings proved to be asymptomatic and did not limit athletic activity. CONCLUSION: The incidence of lumbar degenerative changes in our study population of older male athletes was similar to those seen in other populations.

Adult↗