Objective: Cauda equina syndrome (CES) is a feared complication of lumbar disc herniation. It is generally accepted that CES requires decompression within 6 hours of symptom onset, but this time goal is rarely met, and the relative benefit of delayed decompression on functional status and quality of life (QOL) remains unknown. The study objective was to describe the functional status and quality of life outcomes for patients who undergo delayed surgical decompression for CES. Methods: Patients with CES who underwent decompression of a herniated lumbar disc during a 10-year period were assessed at hospital discharge and at least 4 months after the procedure. Evaluation of functional outcomes was based on a previously validated scale and QOL outcomes on the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) questionnaire. Results: During the study period, 1100 patients with herniated discs were identified, and 14 underwent surgical decompression for CES. All 14 had had symptoms for more than 38 hours before surgery. Ten patients were available for long-term follow-up. There was a strong correlation between long CES symptom duration and poor functional outcome: of 8 patients with symptoms for less than 10 days before decompression (range, 1.6-7.5 d), all had good functional outcomes. The 2 patients with more prolonged symptoms (10.6 and 14.2 d) had poor outcomes. SF-36 scores demonstrated declines in physical roles (p = 0.03), social function (p = 0.03) and increased pain (p = 0.003) compared with population norms. Correlation between SF-36 domain scores and CES symptom duration failed to achieve statistical significance, perhaps because of small sample size. Conclusions: Patients who undergo delayed decompression for CES have increased pain and impaired social and physical function. Longer delays correlate with worse functional outcomes. Beyond 24 hours, decompression delay may be associated with a poorer quality of life but, because of the rarity of CES, the sample size in this study was too small to provide definitive conclusions. Since no patients underwent surgery within 38.4 hours of symptoms, it is not possible to comment on the importance of emergent decompression in early presenters. RÉSUMÉObjectif : Le syndrome de la queue de cheval (SQC) est une complication redoutée de l'hernie discale lombaire. Il est généralement reconnu que ce syndrome nécessite une décompression dans les six heures suivant l'apparition des symptômes, mais ce délai-cible est rarement respecté et les bienfaits relatifs d'une décompression retardée du point de vue fonctionnel et de la qualité de vie demeurent inconnus. L'objectif de cette étude était de décrire le devenir de patients soumis à une EM ADVANCES • PROGRÈS DE LA MU
Background The value of a combination of items defining inflammatory back pain (IBP) to screen for axial spondyloarthritis (SpA) in primary care has recently been studied. However, whether and how measurement of the HLA B27 status contributes to that is not clear. Objectives To study the additional value of HLA B27 determination as screening parameters for axial SpA in a cohort of patients with chronic back pain. Methods Consecutive patients <45 years (n=950) with back pain >2 months who presented to orthopedic surgeons (n=143) were randomized based on 4 primary key questions related to inflammatory back pain (IBP) for referral to rheumatologists (n=36) who made the diagnosis. HLA B27 was either assessed in primary or in secondary care. The primary outcome was the predictive value of a combination of items for a diagnosis of axial SpA. Logistic regression analyses and modeling techniques were used for the statistical analyses. Results Rheumatologists saw 322 randomly selected representative patients, mean age 36 years (y), 50% female, median duration of back pain 30 months: 113 patients were diagnosed as axial SpA (35%), 62% B27+, 47 as ankylosing spondylitis (AS, 15%), 66 as non-radiographic axial SpA (nr-axSpA, 21%). Major differences between AS and nr-axSpA have been described. Excluding HLA B27 from the analysis led to a list of criteria ≥4 of which had a sensitivity and specificity of 58.4 and 70.8%, respectively (area under ROC 69%). Adding HLA B27 to the analyses induced changes in the list of relevant items: past/present enthesitis came in, and the sensitivity (68.1%) but not the specificity (68.4%) of the criteria list improved (area under ROC 73.8%). Conclusions This study shows that patients with axial SpA can be identified by different methods in primary care. Combining HLA B27 and clinical items indicative of IBP increased the likelihood of having axial SpA in primary care. References Braun A, Saracbasi E, Grifka J, Schnitker J, Braun J. Identifying patients with axial spondyloarthritis in primary care: how useful are items indicative of inflammatory back pain? Ann Rheum Dis 2011;70:1782-7. Disclosure of Interest None Declared
The appearance of contrast-enhancing computed tomographic (CT) lesions at the site of an irradiated brain tumor often has sinister implications. We present the case of a 43-year-old woman who received cranial irradiation as treatment for cerebral metastases from lung cancer. Follow-up radiographic studies revealed complete tumor regression; however, 26 months after treatment, enhanced CT scanning showed a radiodense nodule at the site of one of the previous metastatic deposits. Neuropathological examination of the surgically excised tissue identified benign reactive changes only. The natural history of irradiated brain lesions is discussed.
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