Concordance between ANSI occupational back injury codes and claim form diagnoses and a lower bound estimate of the fraction associated with disc displacement/herniation

The current BLS Annual Survey of Occupational Illnesses and Injuries and several recent analyses of factors affecting missed worktime in occupational back injuries rely on ANSI-based injury codes derived from injury narratives to classify occupational injuries and estimate incidence and outcome. No population-based studies of the concordance between back injury codes and clinical diagnoses have been reported. Back injury cases were identified in two large work-injured populations totaling almost 80,000 cases in the states of Michigan and Minnesota. In both populations, cases had been coded by the single nature-of-injury and part-of-body-injured codes assigned by an ANSI-based injury-coding system and by as many as four (Michigan) or three (Minnesota) clinical diagnoses according to the International Classification of Diseases-Clinical Modification, 9th Revision. Concordance was measured by the sensitivity and predictive value positive (PVP, aka PV+ or PPA) of the injury coding scheme for related diagnostic groups. We also used an algorithm based on the limited clinical information available to corroborate the diagnosis of displaced/herniated disc for cases that underwent spinal surgery. Cases identified by the algorithm were then used to obtain a lower bound estimate of the fraction with disc injury. The injury coding scheme had PVPs of 82.9-90.1% and overall sensitivities of 69.7-75.9%. Sensitivities for individual diagnostic groups show that their distribution in ANSI-coded injury groups is skewed slightly toward cases with sprain and disc displacement/herniation, but these shifts are modest. The lower bound estimate of the fraction of cases with disc displacement/herniation in a population of cases with back injuries producing at least 1 day of missed worktime is 5.8%. The demographic comparisons indicate that, as the time between injury and cohort ascertainment increases during the first 8 days of missed worktime following injury, the proportion of younger workers in an injury cohort decreases. The relationship between increasing age and increasing missed worktime disability, reported in various outcome studies, is also present during the first few days following injury. The use of ANSI injury codes underestimates the contribution of back injuries to missed worktime because 24-30% of cases are missed by the ANSI coding system. However, the distribution of diagnostic groups in the injury-coded groups approximates that observed with all diagnosed cases and supports the use of such data to study outcome. Our estimate, and one from Quebec, suggest that disc displacement/herniation occurs more frequently in the subset of occupational back injuries compared to the set of back injuries from all sources.     

Serial gadolinium-enhanced MR imaging after lumbar disc resection: observation of the affected root

A prospective study was undertaken to clarify the relationship between postoperative morphological/pathological changes in the affected root and the clinical developments after disc resection. Gadolinium-enhanced magnetic resonance (MR) imaging was performed at 1 week, 5 weeks, 3 months, and 6 months after surgery for 28 patients of 34 consecutive patients who underwent single-level disc resection. Enhancement/thickening of the affected root was found to be 100%/89% at 1 week, 50%/57% at 3 months, and 32%/37% at 6 months after surgery. Patients with root enhancement and thickening at 3 and 6 months after surgery had less clinical improvement than patients without it. There was consistent correlation between postoperative clinical developments and nerve root enhancement/thickening in enhanced MR imaging. To use enhanced MR imaging as an evaluation tool after disc surgery might increase the diagnostic accuracy and reduce failed back surgery syndrome.     

Association of symptoms of depression with diagnostic test charges among older adults

BACKGROUND: Previous studies have documented greater use of health services by depressed persons and have postulated that health care costs could be reduced overall through better recognition and treatment of depression. OBJECTIVE: To determine whether a greater burden of medical illness contributes to excess charges for diagnostic tests among older adults with symptoms of depression. DESIGN: Prospective cohort study. SETTING: A primary care group practice at an academic institution. PATIENTS: 3767 patients 60 years of age and older who completed testing on the Centers for Epidemiologic Studies Depression Scale (CES-D) during routine office visits. MEASUREMENTS: Charges for all inpatient and ambulatory diagnostic testing for 2 years, including clinical pathology, diagnostic imaging, and special procedures; number of visits to the ambulatory care center or emergency department; and number of hospitalizations. The Ambulatory Care Group case-mix approach, which is based on ambulatory diagnoses, was used as a measure of health status and expected resource consumption. RESULTS: Patients with symptoms of depression (CES-D scores > or = 16) were significantly younger (66.6 compared with 68.1 years; P < 0.001), more likely to be white (50.5% compared with 33.9%; P = 0.001), and more likely to be female (75.8% compared with 67.6%; P = 0.001) than were those without these symptoms (CES-D scores < 16). They also had more nonpsychiatric comorbid conditions, had more visits to the ambulatory care center (9.2 compared with 7.8; P < 0.001), were more likely to use the emergency department (52.3% compared with 40%; P = 0.001), were more likely to be hospitalized (22.4% compared with 17%; P = 0.002), and had greater median total diagnostic test charges for a period of 1 year ($583 compared with $387; P < 0.001). The difference in charges, most of which were clinical pathology charges (54.2%), persisted into the second year. Ambulatory Care Group assignment was independently associated with diagnostic test charges. The CES-D summary score was not independently associated with diagnostic test charges when controlling for Ambulatory Care Group assignment. CONCLUSIONS: Patients with symptoms of depression accrue greater average diagnostic test charges. However, these data suggest that such patients also have a greater burden of comorbid nonpsychiatric illness. Efforts to improve outcome and decrease cost for patients who have late-life depression must target interventions to improve the care of psychiatric and medical illness concurrently.     

Patient characteristics associated with diagnostic imaging evaluation of persistent low back problems

STUDY DESIGN: Post hoc analysis of data from the National Low Back Pain Study, a prospective observational multicenter study of patients referred for the evaluation and treatment of persistent low back problems. OBJECTIVE: To identify patient characteristics associated with use of particular diagnostic imaging examinations in patients with persistent low back problems. SUMMARY OF BACKGROUND DATA: The Agency for Health Care Policy and Research clinical practice guidelines on low back problems suggest that the use of particular diagnostic imaging tests for a given patient should be based on specific characteristics of that patient. METHODS: Use of diagnostic imaging examinations in 2,374 patients with persistent low back problems who were enrolled in the National Low Back Pain Study from 1986 to 1991 was analyzed. Stepwise logistic regression was used to identify patient characteristics that distinguish between enrollees who underwent particular imaging studies. RESULTS: Characteristics that distinguished patients who had undergone magnetic resonance imaging from those who had received only lumbo-sacral spine radiographs included higher socioeconomic status, greater resource use in the preceding 12 months, more functional impairment, presence of sciatica, and presence of neurologic signs/symptoms suggestive of nerve root compromise. Suspected soft tissue involvement was characteristic of enrollees who had undergone magnetic resonance imaging, whereas suspected structural involvement characterized patients who received noncontrast computed tomography. Only nonclinical factors, such as higher annual household income, disability compensation, and male gender distinguished enrollees who had undergone both magnetic resonance imaging and computed tomography-myelography from those who received only computed tomography-myelography. CONCLUSION: Particular patient socioeconomic and clinical characteristics are associated with receipt of specific imaging studies in evaluation of persistent low back problems.     

Neurologic findings in coronary artery bypass patients: perioperative or preexisting?

OBJECTIVES/DESIGN: This prospective study compares the incidence of preexisting neurologic findings in elective cardiac surgery patients presenting with and without coronary atherosclerosis. SETTING: This single-center study was conducted at a tertiary care hospital. PARTICIPANTS/INTERVENTIONS: After Review Board approval and obtaining written informed consent, 11 patients undergoing valvular heart surgery, 9 patients undergoing similar valvular procedures with concomitant coronary artery bypass surgery, and 4 patients undergoing coronary artery bypass surgery alone were enrolled. Preoperatively, all patients underwent a structured neurologic assessment, and the latter four additionally had preoperative magnetic resonance imaging. MEASUREMENTS AND MAIN RESULTS: The patients, 9 of 24 of whom were female, were aged 46 to 78 years and, other than ischemic heart disease, had medical histories that were similar between groups, with the exception of one patient having scleroderma. None of the patients had a clinical history of neurologic or cerebrovascular disease. Nine percent (1 of 11) of the valve-only patients showed subtle preoperative neurologic abnormalities, compared with 89% (eight of nine) of the valve patients having concomitant coronary surgery and 100% (four of four) of coronary artery bypass-only patients. Additionally, brain imaging scans of all four coronary bypass patients showed nonspecific changes reported as scattered punctate areas of high signal less than 3 to 4 mm in diameter. CONCLUSION: This survey shows that both subtle neurological abnormalities and magnetic resonance imaging lesions can be found in a high percentage of patients with coronary atherosclerosis. Furthermore, this study indicates that without a standardized preoperative neurological examination, postoperative neurologic dysfunction cannot necessarily be ascribed to perioperative events.     

Results of NAON's Nursing Diagnosis Survey. A contribution to nursing's minimum data set

Use of nursing diagnoses allows nurses to name and classify the judgments nurses apply to analysis of a patient's assessment data. Such classification systems are an important part of the proposed Nursing Minimum Data Set (NMDS) (see sidebar on next page). This article describes the findings of NAON's survey of members' (N = 1500) use of nursing diagnoses in the care of patients undergoing surgery and major invasive procedures. The response rate for this survey was 37.5% (n = 563) and found to be representative of NAON's general membership. Seven nursing diagnoses were reported as primarily used during the care of surgical patients. Six nursing diagnoses were reported to be applied in the care of patients undergoing significant invasive procedures. Findings of this study may be used to contribute orthopaedic nurses' unique perspective to the formation of the Nursing Minimum Data Set (NMDS).     

Familial predisposition for degenerative disc disease. A case-control study

STUDY DESIGN: This case-control study was undertaken to determine if relatives of patients who had been admitted for surgery for degenerative disc disease-related problems were at increased risk for lower back pain or sciatica. OBJECTIVES: To determine if familial factors play a role in placing a person at risk for development of degenerative disc disease of the lumbar spine. SUMMARY OF BACKGROUND DATA: It is known that smoking and various occupational factors can place a person at risk for degenerative disc disease problems. It is not known if a familial predisposition may also exist. METHODS: The family members and relatives of 65 patients who had undergone surgery for lumbar degenerative disc disease were interviewed with a standardized questionnaire and compared with a control group of 67 patients who had been admitted to hospital for non-spine-related orthopedic procedures. The same interview and standardized questionnaire was used for both groups by a single observer. RESULTS: In the study group of 65 patients who had undergone surgery for degenerative disc disease, 44.6% were noted to have a positive family history, whereas 25.4% of the patients in the control group had a positive family history. Eighteen and one-half percent of relatives in the study group had a history of having spinal surgery, compared with only 4.5% of the control group. CONCLUSIONS: The results indicate that a familial predisposition to degenerative disc disease can exist along with other risk factors.     

An assessment of the early management of spine problems and appropriateness of diagnostic imaging utilization

Low back pain may affect up to 80% of all adults and is the second leading reason for physician visits in ambulatory medicine. Estimates for the annual direct medical costs for treating patients with back pain approach $25 million, despite the fact that it is a self-limited condition in at least 90% of patients with recovery occurring within 6 to 12 weeks. Recent scrutiny of health care delivery has produced numerous observations documenting a high variability in use of resources for medical conditions including low back pain, but few studies have attempted to examine the medical appropriateness of diagnostic and therapeutic decisions.     

Unusual computerized tomography and magnetic resonance imaging of cerebellar metastasis

AIM: To see whether increasing use of ultrasound scans in pyloric stenosis is leading to false-positive diagnoses, and even negative laparotomies. METHODS: Over a 2-year period, 76 neonates underwent laparotomy with a preoperative diagnosis of pyloric stenosis (PS). There were 57 males and 19 females, age ranged from 10 days to 7 weeks. RESULTS: Six patients proceeded straight to surgery after undergoing a test feed. The remaining 70 patients had one or more imaging investigations. Of these; 56 patients had an ultrasound only, 5 had a barium meal only while 9 patients had both investigations. Ultrasound showed evolving lesions in 2 patients. It was equivocal or falsely negative in 8 - all were diagnosed correctly after undergoing barium meals. Fifty-two patients were diagnosed correctly on ultrasound. There were, however, 3 false-positive ultrasonic diagnosis--i.e., at laparotomy the pylorus was found to be normal. One of these patients even had a "diagnostic" barium meal. The factors leading to these negative explorations are discussed. CONCLUSION: Pyloric "tumours" can be difficult to palpate early in the evolution of the disease. Reliance upon the ultrasound appearance of the pylorus without taking into account other important diagnostic evidence will increase the risk of false-positive diagnoses and unnecessary laparotomy. The importance of clinical examination and test feed is emphasised.     

Results of disc prosthesis after a minimum follow-up period of 2 years

STUDY DESIGN: This study analyzed retrospectively 46 patients undergoing artificial disc replacement. OBJECTIVE: To assess the clinical and radiographic outcomes of patients who had Charitè SB III disc prosthesis. SUMMARY OF BACKGROUND DATA: Results of disc prosthesis have been reported only at very short-term follow-up periods; preoperative diagnosis and criteria used to evaluate the clinical outcomes were not reported. METHODS: Forty-six patients who had had a disc prosthesis were evaluated clinically and radiographically at least 2 years after surgery. Preoperative diagnosis included disc degeneration in 22 patients and failed disc excision in 24 patients. Disc prosthesis was implanted at a single vertebral level in 36 patients and at two levels in 10 patients. Follow-up evaluation was performed after an average of 3.2 years (range, 2-5 years). RESULTS: Sixty-three percent of patients reported satisfactory results. The success rate was 69% in patients who underwent isolated disc replacement and 77% in those with no previous back surgeries. Seven patients who had unsatisfactory results underwent posterolateral fusion without removing the artificial disc. Two patients underwent removal of the prosthesis. No failure of the implants or loosenings or wear of the polyethylene core were found. Vertebral motion averaged 9 degrees at the operated levels and 16 degrees at the adjacent levels. CONCLUSION: A wrong surgical indication, rather than failure of the prosthesis, appears to be the main cause of unsatisfactory results of disc replacement at medium-term evaluations. Prospective and longer term studies are needed to establish whether disc prosthesis may offer advantages compared with spinal fusion.     

Referral and diagnosis of common rheumatic diseases by primary care physicians

OBJECTIVE: To describe primary care patterns of referral and diagnoses of patients with rheumatic diseases referred to rheumatologists. METHODS: The medical records of all consecutive patients referred in 1994 by >300 primary care physicians to two rheumatologists at an academic centre were reviewed. The referring physician diagnosis was compared with the rheumatologist's diagnosis. Sensitivity, specificity and predictive values of primary care diagnoses were estimated using the rheumatologist diagnosis as the 'gold standard'. SETTING: University-based rheumatology out-patient clinic. RESULTS: Over half of the patients referred had a rheumatologist diagnosis of soft-tissue rheumatism or a spinal pain syndrome. Three hundred and forty-seven patients (49%) had a primary care diagnosis of a defined rheumatic disease. Of these, 142 (41%) of the primary care diagnoses were subsequently modified by the rheumatologist. The highest agreement between primary care physician and rheumatologist was observed for crystal-induced arthritis (kappa = 0.86), and the lowest agreement for polymyalgia rheumatica (kappa = 0.39) and systemic lupus (kappa = 0.46). Sensitivity was lowest for a primary care diagnosis of fibromyalgia (48%) and highest for ankylosing spondylitis (94%). Positive predictive values were generally low, in particular for systemic lupus erythematosus (33%) and polymyalgia rheumatica (30%). CONCLUSION: Most patients referred to an academic rheumatology centre had soft-tissue rheumatism or other pain syndromes. In general, diagnostic agreement between rheumatologists and primary care physicians was low. Increased emphasis on musculoskeletal disorders should be encouraged in medical education to increase the efficiency of rheumatology referrals.     

Folliculotropic mycosis fungoides with large-cell transformation presenting as dissecting cellulitis of the scalp

MRI is routinely used in the evaluation and management of patients with failed back surgery syndrome (FBSS). However, its value is unclear in the early detection of signs that can negatively affect that later course of surgical cases. The purpose of the present study is to describe the MR images of early postoperative MRI at 3 days in 30 unselected patients who underwent lumbar microdiscectomy, and to correlate the findings with follow up MRI at 8 weeks and with final outcome. The findings are correlated with literature data. Early postoperative MRI findings were consisting of pseudohernia in 24 patients (80%), annular rent in 23 patients (80%), and other non-specific postoperative findings. On the late MRI the pseudohernia persisted in 12 patients (50%), the annular rent in 4 patients (15%) and asymptomatic pseudo-spondylodiscitis was apparent in 3 patients (10%) as was a case of true spondylodiscitis. Therefore, early postoperative findings have limited value in the management of patients after surgery for lumbar disc herniation, since the images were not correlated with the immediate clinical course after surgery nor with the late radiological and clinical outcome. The evident imaging changes in the early postoperative period after lumbar disc surgery limit the accuracy of the interpretation of MRI examinations.     

Diagnosis of osteomyelitis. Accuracy and limitations of antigranulocyte antibody imaging compared to three-phase bone scan

Thirty-seven patients with suspected osteomyelitis in conjunction with diabetic gangrene (N = 14, group 1), arthroplasty (N = 8, group 2), and various diseases (N = 15, group 3) were examined. Three-phase bone scans, followed by granulocyte imaging using I-123 labeled anti-NCA 95 monoclonal antibodies, were performed to evaluate and compare the diagnostic accuracy of both procedures. Final diagnosis was established histologically, bacteriologically, or by both methods either through the clinical course or by long-term follow-up in patients in group 1. Osteomyelitis was proven in 17 out of the 37 patients. Bone and antigranulocyte imaging demonstrated positive results in all patients with osteomyelitis (sensitivity 100% for each method). No signs of skeletal infection were found in 20 patients. Fifteen of these patients had no antigranulocyte antibody accumulation, resulting in 75% specificity. Ten patients without infection had normal three-phase bone imaging results (specificity 50%). Antigranulocyte imaging results were negative in 6 out of 10 patients without osteomyelitis in groups 2 and 3 whose bone imaging results were questionable. However, because of identical bone and granulocyte imaging results, no increase of diagnostic accuracy could be obtained by additional granulocyte imaging in patients with diabetic gangrene. Final diagnoses of false-positive antigranulocyte studies were aseptic osteonecrosis (N = 2), loosening of prostheses, gouty arthritis, and pain after arthrolysis. In summary, antigranulocyte antibody imaging offered high sensitivity and acceptable specificity for the diagnosis of osteomyelitis. Diagnostic accuracy can be improved through the adjuvant use of antigranulocyte imaging for patients with suspected osteomyelitis, especially when radiographic and scintigraphic results are questionable or unreliable.     

Magnetic resonance imaging of the musculoskeletal system: the spine

Magnetic resonance imaging in the patient who has had surgery is discussed. The most common indication for postoperative imaging is in the distinction between postoperative fibrosis and recurrent disc herniation. Magnetic resonance imaging is invaluable in the assessment of potential causes of failed back surgery syndrome such as postoperative infection, arachnoiditis and adjacent segment degeneration. Magnetic resonance imaging assumes a less important role in postoperative patients with metal hardware owing to image degradation secondary to metal artifact. Magnetic resonance imaging has a complementary role with computed tomography evaluation of spinal trauma. It excels at the noninvasive evaluation of spinal deformities and neoplasms.     

Patterns of ordering diagnostic tests for patients with acute low back pain. The North Carolina Back Pain Project

BACKGROUND: Low back pain is a common reason for visiting a physician. Authors of guidelines and insurance payers are currently scrutinizing use of radiography and computed tomography (CT) or magnetic resonance imaging (MRI). OBJECTIVE: To study the determinants of the use of lumbar spine radiography and either CT or MRI in patients with acute low back pain. DESIGN: Prospective cohort study. SETTING: Community-based practices in North Carolina in six strata: urban primary care physicians, rural primary care physicians, urban chiropractors, rural chiropractors, orthopedic surgeons, and practitioners at a group-model health maintenance organization. PATIENTS: 1580 patients with acute low back pain. MEASUREMENTS: Telephone interviews done after the index office visit and at 2, 4, 8, 12, and 24 weeks or until complete recovery; survey of practitioners; and chart abstraction. RESULTS: During the acute back pain episode, 46% of patients had radiography and 9% had CT or MRI. Patient variables related to use of radiography included pain that began more than 2 weeks before the index visit and no previous episodes of low back pain. Practitioner variables associated with use of radiography were being a chiropractor or orthopedic surgeon and having a solo practice. Use of CT or MRI was associated with white race, neurologic deficit at baseline, sciatica, poor functional status at baseline, and small group-practice size. Practitioners' responses to clinical vignettes were associated with aggregate practitioner behavior: In the vignettes and in real life, practitioners were more likely to order CT for patients with sciatica. However, a practitioner's response to a vignette did not predict that practitioner's use of CT or MRI for similar patients in his or her own practice. CONCLUSION: Radiography is commonly used as a diagnostic test for patients with acute back pain. Clinical factors and provider specialty are major correlates of the use of imaging studies.     

Obsessive-compulsive disorder limited to pregnancy

Two patients with fulminant amebic colitis with colon perforation and concomitant liver abscess were collected over the last 5 years. One patient underwent emergency laparotomy to treat amebic cecal perforation. Diverted ileostomy saved his life. The ileostomy was successfully reversed 6 months later. The other patient underwent 4 laparotomies with more invasive procedures in less than 1 month due to sequential complications of amebiasis. Colon resection with enterostomy miraculously allowed him to survive. In comparison with the latter, who underwent more aggressive surgery and experienced more catastrophic complications, the former with conservative surgery had a smoother clinical result. Thus, conservative operation for colon perforation due to amebiasis is recommended. Besides, thanks to the alertness of doctors, the favorable age of the patients, the advent of new antiamebic and antimicrobial agents, excellent hyperalimentation, the great improvement in medical facilities and postoperative care, the two critical patients eventually survived after several operations, and had a better outcome as compared with the high mortality rate of 87.5% in our hospital 2 decades earlier.     

Efficient identification of postdischarge surgical site infections: use of automated pharmacy dispensing information, administrative data, and medical record information

Although most surgical site infections (SSIs) occur after hospital discharge, there is no efficient way to identify them. The utility of automated claims and electronic medical record data for this purpose was assessed in a cohort of 4086 nonobstetric procedures following which 96 postdischarge SSIs occurred. Coded diagnoses, tests, and treatments were assessed by use of recursive partitioning, with 10-fold cross-validation, and logistic regression with bootstrap resampling. Specific codes and combinations of codes identified a subset of 2% of all procedures among which 74% of SSIs had occurred. Accepting a specificity of 92% improved the sensitivity from 74% to 92%. Use of only hospital discharge diagnosis codes plus pharmacy dispensing data had sensitivity of 77% and specificity of 94%. All of these performance characteristics were better than questionnaire responses from patients or surgeons. Thus, information routinely collected by health care systems can be the basis of an efficient, largely passive, surveillance system for postdischarge SSIs.     

Occurrence of hemophilia in the United States. The Hemophilia Surveillance System Project Investigators

OBJECTIVE: To discuss a case of sciatica associated with lower back pain that originates in a disc. We discuss the use of manipulative therapy as a conservative approach and compare it with other conservative methods and with surgery. CLINICAL FEATURES: The patient suffered from lower back and left leg pain that had increased in severity over a 6-day period. There was decreased sensation in the dorsum of the left foot and toes. Computed tomography demonstrated the presence of a small, contained disc herniation. INTERVENTION AND OUTCOME: The patient was initially treated with ice followed by flexion-distraction therapy. This was used over the course of her first three visits. Once she was in less pain, side posture manipulation was added to her care. Nine treatments were required before she was released from care. CONCLUSION: We need a nonsurgical, conservative approach to treat lower back pain with sciatica as an alternative to and before beginning the more aggressive, and potentially hazardous, surgical treatment. There is some support for the idea that lumbar disc herniation with neurological deficit and radicular pain does not contraindicate the judicious use of manipulation. Although significant questions remain for the evaluation and treatment of lumbar radiculopathy (sciatica) with disc herniations, there is ample evidence to suggest that a course of conservative care, including spinal manipulation, should be completed before surgical consult is considered.     

Injuries in Australian Army recruits. Part II: Location and cause of injuries seen in recruits

Simple and reliable diagnostic aids need to be available for clinicians to consider sacroiliac joint dysfunction in the differential diagnosis of low back pain. The Fortin finger test was used as a means to identify patients with low back pain and sacroiliac joint dysfunction. Provocation-positive sacroiliac joint injections were used to ratify or refute the applicability of this new clinical sign for identification of patients with sacroiliac joint dysfunction. Sixteen subjects were chosen from 54 consecutive patients by using the Fortin finger test. All 16 patients subsequently had provocation-positive joint injections validating sacroiliac joint abnormalities. A subset of 10 individuals underwent additional evaluation to exclude the possibility of confounding discogenic or posterior joint pain sources. All 10 patients had no indication of either discogenic or zygapophyseal joint pain generators. These results indicate that positive findings of the Fortin finger test, a simple diagnostic measure, successfully identifies patients with sacroiliac joint dysfunction.     

Indication and clinical results of laminoplasty for cervical myelopathy caused by disc herniation with developmental canal stenosis

STUDY DESIGN: The outcome of a herniated disc in patients with cervical myelopathy treated by laminoplasty without discectomy and in those treated conservatively was studied by magnetic resonance imaging. OBJECTIVES: To compare the surgical results of laminoplasty with those of anterior spinal fusion in patients with myelopathy caused by to cervical disc herniation and to make a treatment strategy for cervical disc herniation depending on these results. SUMMARY OF BACKGROUND DATA: Anterior discectomy and spinal fusion have had acceptable surgical results, but many complications have been reported, especially adjacent segment degeneration and bone graft complications. METHODS: Forty-seven patients with cervical disc herniation were examined in this study. Of them, 32 patients (mean age, 56 years) underwent laminoplasty without resection of the herniated disc. Seven patients with mild cervical myelopathy and 8 patients with radiculopathy (mean age, 53 years) were treated conservatively. As a control group, 44 patients (mean age, 50.3 years) who underwent anterior spinal fusion were examined. All patients in the laminoplasty group also had congenital spinal canal stenosis in which the ventrodorsal canal diameter was less than 13 mm. The association between the outcome of a herniated disc and clinical features was investigated. The severity of myelopathy was evaluated according to the Japanese Orthopaedic Association's scoring system. Surgical outcomes were evaluated by the system of Hirabayashi for determining recovery rate. RESULTS: The recovery rate averaged 67.9% in laminoplasty and 68.8% in anterior spinal fusion. There were no significant differences between the groups. No patients underwent anterior spinal fusion after laminoplasty. Follow-up magnetic resonance imaging showed regression of the size of the herniated disc in 15 of the 20 patients in the laminoplasty group and in 12 of 15 patients treated conservatively. In the MRI studies of the natural course of disc herniation, the size of the herniated disc decreased to almost half in 1 to 2 months and almost disappeared within 3 months after surgery. CONCLUSIONS: The size of the herniated disc in cervical lesions regressed as it does in the lumbar lesions. Laminoplasty for patients with narrowed spinal canals showed favorable surgical results. Therefore, the therapeutic method for cervical disc herniation should be chosen after taking the natural history of the disc herniation into consideration.