No clinical diagnostic support tool can help identify patients with LSS. Simple diagnostic tool may improve the accuracy of the diagnosis of LSS. The aim of this study was to develop a simple clinical diagnostic tool that may help physicians to diagnose LSS in patients with lower leg symptoms. Patients with pain or numbness of the lower legs were prospectively enrolled. The diagnosis of LSS by experienced orthopedic specialists was the outcome measure. Multivariable logistic regression analysis identified factors that predicted LSS; a simple clinical prediction rule was developed by assigning a risk score to each item based on the estimated beta-coefficients. From December 2002 to December 2004, 104 orthopedic physicians from 22 clinics and 50 hospitals evaluated 468 patients. Two items of physical examination, three items of patients' symptom, and five items of physical examination were included in the final scoring system as a result of multiple logistic regression analysis. The sum of the risk scores for each patient ranged from -2 to 16. The HosmerLemeshow statistic was 11.30 (P = 0.1851); the area under the ROC curve was 0.918. The clinical diagnostic support tool had a sensitivity of 92.8% and a specificity of 72.0%. The prevalence of LSS was 6.3% in the bottom quartile of the risk score (-2 to 5) and 99.0% in the top quartile (12 to 16). We developed a simple clinical diagnostic support tool to identify patients with LSS. Further studies are needed to validate this tool in primary care settings.

IMPORTANCEThe optimal management for acute traumatic cervical spinal cord injury (SCI) is unknown. OBJECTIVE To determine whether early surgical decompression results in better motor recovery than delayed surgical treatment in patients with acute traumatic incomplete cervical SCI associated with preexisting canal stenosis but without bone injury. DESIGN, SETTING, AND PARTICIPANTSThis multicenter randomized clinical trial was conducted in 43 tertiary referral centers in Japan from December 2011 through November 2019. Patients aged 20 to 79 years with motor-incomplete cervical SCI with preexisting canal stenosis (American Spinal Injury Association [ASIA] Impairment Scale C; without fracture or dislocation) were included. Data were analyzed from September to November 2020. INTERVENTIONS Patients were randomized to undergo surgical treatment within 24 hours after admission or delayed surgical treatment after at least 2 weeks of conservative treatment. MAIN OUTCOMES AND MEASURES The primary end points were improvement in the mean ASIA motor score, total score of the spinal cord independence measure, and the proportion of patients able to walk independently at 1 year after injury. RESULTS Among 72 randomized patients, 70 patients (mean [SD] age, 65.1 [9.4] years; age range, 41-79 years; 5 [7%] women and 65 [93%] men) were included in the full analysis population (37 patients assigned to early surgical treatment and 33 patients assigned to delayed surgical treatment).Of these, 56 patients (80%) had data available for at least 1 primary outcome at 1 year. There was no significant difference among primary end points for the early surgical treatment group compared with the delayed surgical treatment group (mean [SD] change in ASIA motor score, 53.7 [14.7] vs 48.5 [19.1]; difference, 5.2; 95% CI, −4.2 to 14.5; P = .27; mean [SD] SCIM total score, 77.9 [22.7] vs 71.3 [27.3]; P = .34; able to walk independently, 21 of 30 patients [70.0%] vs 16 of 26 patients [61.5%]; P = .51). A mixed-design analysis of variance revealed a significant difference in the mean change in ASIA motor scores between the groups (F 1,49 = 4.80; P = .03). The early surgical treatment group, compared with the delayed surgical treatment group, had greater motor scores than the delayed surgical treatment group at 2 weeks (mean [SD] score, 34.2 [18.8] vs 18.9 [20.9]), 3 months (mean [SD] score, 49.1 [15.1] vs 37.2 [20.9]), and 6 months (mean [SD] score, 51.5 [13.9] vs 41.3 [23.4]) after injury. Adverse events were common in both groups (eg, worsening of paralysis, 6 patients vs 6 patients; death, 3 patients vs 3 patients).

A vertebral artery could be ligated uneventfully when the diameter of the vertebral artery was not larger than the one not involved. Where vertebral artery ligation could not be avoided, it should be confirmed by preoperative angiogram that the other vertebral artery is large enough and that simultaneous occlusion testing of the involved vertebral artery is uneventful.

The McGregor line is the most reproducible and reliable method for measurement of the occipitocervical angle.

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