scholarly journals Risk Factors for Failure of Nonoperative Treatment for Unilateral Cervical Facet Fractures

2017 ◽  
Vol 11 (3) ◽  
pp. 356-364 ◽  
Author(s):  
Carola Francisca van Eck ◽  
Mitchell Stephen Fourman ◽  
Amir Mohamad Abtahi ◽  
Louis Alarcon ◽  
William Fielding Donaldson ◽  
...  
Keyword(s):  
Risk Factors ◽  
Conservative Management ◽  
Radiographic Progression ◽  
Surgical Intervention ◽  
Nonoperative Management ◽  
Classification Systems ◽  
Retrospective Clinical Study ◽  
Radicular Symptoms ◽  
Time Of Presentation

<sec><title>Study Design</title><p>Retrospective clinical study.</p></sec><sec><title>Purpose</title><p>The purpose of this study was to determine what percentage of patients who underwent nonoperative management of unilateral non-displaced or minimally displaced facet fractures progressed radiographically and to determine what percentage of patients required surgical intervention and to identify risk factors for failure of conservative management.</p></sec><sec><title>Overview of Literature</title><p>According to most commonly used classification systems, unilateral, non-and minimally displaced facet fractures are be amendable to nonoperative management.</p></sec><sec><title>Methods</title><p>A retrospective review of the Trauma Registry of a Level I trauma center was performed to identify all patients diagnosed with a non- or minimally displaced unilateral facet fracture which was managed nonoperatively. Several demographic variables and clinical outcomes were recorded. Using computed tomography scanning and plain radiographs, fracture pattern, listhesis, displacement, angle and percentage of the facet that included the fracture were determined. Radiographic progression was defined as the occurrence of listhesis of more than 10% of the anterior-posterior dimensions of the inferior vertebral body during radiographic follow-up. Failure of conservative management was defined as a patient requiring surgical intervention after initially being managed nonoperatively.</p></sec><sec><title>Results</title><p>Seventy-four patients were included. Fifteen patients (20%) progressed radiographically. However, only 2 developed radicular symptoms and none developed myelopathy or other catastrophic cord related symptoms. Seven patients (9%) underwent surgery. Indications for surgery included significant radiographic progression and/or radicular symptoms. Risk factors for failure of conservative management included presence of radiculopathy at the time of presentation, a higher body mass index, increased Injury Severity Score, greater initial fracture displacement and more than 2 mm of listhesis.</p></sec><sec><title>Conclusions</title><p>Patients with non-displaced or minimally displaced facet fractures who do not have neurological symptoms at the time of presentation can safely be managed conservatively with careful observation and follow-up.</p></sec>

scholarly journals Risk Factors for Long-term Hip Osteoarthritis in Patients With Femoroacetabular Impingement Without Surgical Intervention

2020 ◽  
Vol 48 (12) ◽  
pp. 2881-2886
Author(s):  
Heath P. Melugin ◽  
Rena F. Hale ◽  
Jun Zhou ◽  
Matthew LaPrade ◽  
Christopher Bernard ◽  
...  
Keyword(s):  
Risk Factors ◽  
Femoroacetabular Impingement ◽  
Mixed Type ◽  
Surgical Intervention ◽  
Significant Risk ◽  
Hip Osteoarthritis ◽  
Hip Pain ◽  
Male Sex ◽  
Time Of Presentation

Background: Femoroacetabular impingement (FAI) is a common cause of hip pain and a known risk factor for hip osteoarthritis (OA) and total hip arthroplasty (THA) at a young age. Unfortunately, little is known about the specific factors associated with an increased risk of OA. Purpose: To (1) report the overall rate of symptomatic hip OA and/or THA in patients with FAI without surgical intervention and (2) identify radiographic features and patient characteristics associated with hip OA. Study Design: Case-control study; Level of evidence, 3. Methods: A geographic database was used to identify all patients with hip pain and radiographs between 2000 and 2016. Chart review was performed to identify patients with FAI. Patient medical records were reviewed to obtain demographic information, clinical history, physical examination findings, imaging details, and treatment details. Kaplan-Meier analysis was used to determine the rate of hip OA. Univariate and multivariate proportional hazard regression models were performed to determine risk factors for OA. Results: The study included 952 patients (649 female; 303 male; 1104 total hips) with FAI. The majority of hips had mixed type (n = 785; 71.1%), 211 (19.1%) had pincer type, and 108 (9.8%) had cam type. Mean age at time of presentation was 27.6 ± 8.7 years. Mean follow-up time was 24.7 ± 12.5 years. The rate of OA was 13.5%. THA was performed in 4% of patients. Male sex, body mass index (BMI) greater than 29, and increased age were risk factors for OA (male sex: hazard ratio [HR], 2.28; P < .01; BMI >29: HR, 2.11; P < .01; per year of increased age: HR, 1.11; P < .01.). Smoking and diabetes mellitus were not significant risk factors. No radiographic morphological features were found to be significant risk factors for OA. Conclusion: At mean follow-up of 24.7 years, 14% of hips had symptomatic OA and 4% underwent THA. BMI greater than 29, male sex, and increased age at the time of presentation with hip pain were risk factors for hip OA. The cohort consisted of a large percentage of mixed-type FAI morphologies, and no specific radiographic risk factors for OA were identified.

scholarly journals POS1002 BASELINE CALPROTECTIN AND VISFATIN LEVELS PREDICT RADIOGRAPHIC SPINAL PROGRESSION AFTER 2 YEARS IN ANKYLOSING SPONDYLITIS PATIENTS ON TNF INHIBITOR THERAPY

2021 ◽  
Vol 80 (Suppl 1) ◽  
pp. 769.2-770
Author(s):  
J. Rademacher ◽  
M. Siderius ◽  
L. Gellert ◽  
F. Wink ◽  
M. Verba ◽  
...  
Keyword(s):  
Risk Factors ◽  
Logistic Regression ◽  
Ankylosing Spondylitis ◽  
Bone Formation ◽  
Bone Turnover ◽  
Radiographic Progression ◽  
Serum Levels ◽  
Tnf Inhibitor ◽  
Research Support

Background:Radiographic spinal progression determinates functional status and mobility in ankylosing spondylitis (AS)1.Objectives:To analyse whether biomarker of inflammation, bone turnover and adipokines at baseline or their change after 3 months or 2 years can predict spinal radiographic progression after 2 years in AS patients treated with TNF-α inhibitors (TNFi).Methods:Consecutive AS patients from the Groningen Leeuwarden Axial Spondyloarthritis (GLAS) cohort2 starting TNFi between 2004 and 2012 were included. The following serum biomarkers were measured at baseline, 3 months and 2 years of follow-up with ELISA: - Markers of inflammation: calprotectin, matrix metalloproteinase-3 (MMP-3), vascular endothelial growth factor (VEGF) - Markers of bone turnover: bone-specific alkaline phosphatase (BALP), serum C-terminal telopeptide (sCTX), osteocalcin (OC), osteoprotegerin (OPG), procollagen typ I and II N-terminal propeptide (PINP; PIINP), sclerostin. - Adipokines: high molecular weight (HMW) adiponectin, leptin, visfatinTwo independent readers assessed spinal radiographs at baseline and 2 years of follow-up according to the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS). Radiographic spinal progression was defined as mSASSS change ≥2 units or the formation of ≥1 new syndesmophyte over 2 years. Logistic regression was performed to examine the association between biomarker values at baseline, their change after 3 months and 2 years and radiographic spinal progression. Multivariable models for each biomarker were adjusted for mSASSS or syndesmophytes at baseline, elevated CRP (≥5mg/l), smoking status, male gender, symptom duration, BMI, and baseline biomarker level (the latter only in models with biomarker change).Results:Of the 137 included AS patients, 72% were male, 79% HLAB27+; mean age at baseline was 42 years (SD 10.8), ASDAScrp 3.8 (0.8) and mSASSS 10.6 (16.1). After 2 years of follow-up, 33% showed mSASSS change ≥2 units and 24% had developed ≥1 new syndesmophyte. Serum levels of biomarkers of inflammation and bone formation showed significant changes under TNFi therapy, whereas adipokine levels were not altered from baseline (Figure 1).Univariable logistic regression revealed a significant association of baseline visfatin (odds ratio OR [95% confidence interval] 1.106 [1.007-1.215]) and sclerostin serum levels (OR 1.006 [1.001-1.011]) with mSASSS progression after 2 years. Baseline sclerostin levels were also associated with syndesmophyte progression (OR 1.007 [1.001-1.013]). In multivariable logistic analysis, only baseline visfatin level remained significantly associated (OR 1.465 [1.137-1.889]) with mSASSS progression. Furthermore, baseline calprotectin showed a positive association with both, mSASSS (OR 1.195 [1.055-1.355]) and syndesmophyte progression (OR 1.107 [1.001-1.225]) when adjusting for known risk factors for radiographic progression.Univariable logistic regression showed that change of sclerostin after 3 months was associated with syndesmophytes progression (OR 1.007 [1.000-1.015), change of PINP level after 2 years was associated with mSASSS progression (OR 1.027 [1.003-1.052]) and change of visfatin after 2 years was associated with both measures of radiographic progression – mSASSS (OR 1.108 [1.004-1.224]) and syndesmophyte formation (OR 1.115; [1.002-1.24]). However, those associations were lost in multivariable analysis.Conclusion:Independent of known risk factors, baseline calprotectin and visfatin levels were associated with radiographic spinal progression after 2 years of TNFi. Although biomarkers of inflammation and bone formation showed significant changes under TNFi therapy, these changes were not significantly related to radiographic spinal progression in our cohort of AS patients.References:[1]Poddubnyy et al 2018[2]Maas et al 2019Acknowledgements:Dr. Judith Rademacher is participant in the BIH-Charité Clinician Scientist Program funded by the Charité –Universitätsmedizin Berlin and the Berlin Institute of Health.Disclosure of Interests:Judith Rademacher: None declared, Mark Siderius: None declared, Laura Gellert: None declared, Freke Wink Consultant of: AbbVie, Maryna Verba: None declared, Fiona Maas: None declared, Lorraine M Tietz: None declared, Denis Poddubnyy: None declared, Anneke Spoorenberg Consultant of: Abbvie, Pfizer, MSD, UCB, Lilly and Novartis, Grant/research support from: Abbvie, Pfizer, UCB, Novartis, Suzanne Arends Grant/research support from: Pfizer.

scholarly journals Relative Efficacy of Three of Nonsurgical Treatments for Calcific Tendinitis: Physical Therapy vs Steroid Injection vs Ultrasound-Guided Aspiration

2021 ◽  
Vol 9 (7_suppl4) ◽  
pp. 2325967121S0021
Author(s):  
Mauricio Drummond ◽  
Caroline Ayinon ◽  
Albert Lin ◽  
Robin Dunn
Keyword(s):  
Physical Therapy ◽  
Rotator Cuff ◽  
Conservative Treatment ◽  
Conservative Management ◽  
Surgical Intervention ◽  
Corticosteroid Injection ◽  
Calcific Tendinitis ◽  
Ultrasound Guided ◽  
Calcium Deposits

Objectives: Calcific tendinitis of the shoulder is a painful condition characterized by the presence of calcium deposits within the tendons of the rotator cuff (RTC) that accounts for up to 7% of cases of shoulder pain1. The most common conservative treatments typically include physical therapy (PT), corticosteroid injection (CSI), or ultrasound-guided aspiration (USA). When conservative management fails, the patient may require arthroscopic surgery to remove the calcium with concomitant rotator cuff repair. The purpose of this study was to characterize the failure rates, defined as the need for surgery, of each of these three methods of conservative treatment, as well as to compare post-operative improvement in patient-reported outcomes (PROs) – including subjective shoulder values (SSV) and visual analog scale (VAS) pain scores – based on the type of pre-operative conservative intervention provided. A secondary aim was to compare post-operative range of motion (ROM) outcomes between groups that failed conservative management. We hypothesized that all preoperative conservative treatments would have equivalent success rates, PROs, and ROM. Bosworth B. Calcium deposits in the shoulder and subacromial bursitis: a survey of 12122 shoulders. JAMA. 1941;116(22):2477-2489. Methods: A retrospective review of all patients who were diagnosed with calcific tendinitis at our institution treated among 3 fellowship trained orthopedic surgeons between 2009 and 2019 was performed. VAS, SSV, and ROM in forward flexion (FF) and external rotation (ER) was abstracted from the medical records. Scores were recorded at the initial presentation as well as final post-operative follow-up visit for those who underwent surgery. The conservative treatment method utilized by each patient was recorded and included PT, CSI, or USA. Failure of conservative management was defined as eventual progression to surgical intervention. Statistical analysis included chi-square, independent t test and ANOVA. Descriptive statistics were used to report data. A p<0.05 was considered to be statistically significant. Results: 239 patients diagnosed with calcific tendinitis were identified in the study period with mean age of 54 years and follow up of at least 6 months. In all, 206 (86.2%) patients underwent a method of conservative treatment. Of these patients, 71/239 (29.7%) underwent PT, 67/239 (28%) attempted CSI, and 68/239 (28.5%) underwent USA. The overall failure rate across all treatment groups was 29.1%, with injections yielding the highest success rate of 54/67 (80.6%). Physical therapy saw the highest failure rate, with 26/71 (36.7%) proceeding to surgical intervention. Patients undergoing physical therapy were statistically more likely to require surgery compared to those undergoing corticosteroid injection (RR 1.88, p= 0.024). Of all 93 patients who underwent surgery, VAS, SSV, ROM improved significantly in all groups. On average, VAS decreased by 4.02 points (6.3 to 2.3), SSV increased by 33 points (51 to 84), FF improved by 13.8º, and ER improved 8.4º between the pre- and post-operative visits (p<0.05). The 33 patients who did not attempt a conservative pre-operative treatment demonstrated the largest post-operative improvement in VAS (-6.00), which was significantly greater than those who previously attempted PT (-3.33, p<0.05). There was a trend towards greater improvement in SSV in the pre-operative PT group (45 to 81) compared to others, but this did not reach statistical significance (p=0.47). Range of motion was not significantly affected by the method of pre-operative conservative intervention. Conclusions: Conservative treatment in the form of physical therapy, corticosteroid injection, and ultrasound-guided aspiration is largely successful in managing calcific tendinitis of the shoulder. Of these, PT demonstrated the highest rate of failure in terms of requiring surgical management. PRO improvement varied among the conservative modalities used, however patients who did not attempt conservative management experienced the greatest improvements following surgery. If surgery is necessary following failed conservative treatment, excellent outcomes can be expected with significant improvements in ROM and PROs. This information should be considered by the surgeon when deciding whether to recommend conservative treatment for the management of calcific tendinitis, as well as which specific method to employ.

scholarly journals MEAN 6 YEAR CLINICAL OUTCOMES, SURVIVORSHIP, AND RETURN TO SPORTS AFTER ARTHROSCOPIC CAPSULAR REPAIR WITH SUTURE ANCHORS FOR ADOLESCENT MULTIDIRECTIONAL SHOULDER INSTABILITY

2021 ◽  
Vol 9 (7_suppl3) ◽  
pp. 2325967121S0002
Author(s):  
Brendon C. Mitchell ◽  
Matthew Y. Siow ◽  
Alyssa Carrol ◽  
Andrew T. Pennock ◽  
Eric W. Edmonds
Keyword(s):  
Risk Factors ◽  
Surgical Treatment ◽  
Shoulder Instability ◽  
Surgical Intervention ◽  
Operation Time ◽  
Demographic Variables ◽  
Return To Sports ◽  
Suture Anchors ◽  
Surgical Failure

Background: Multidirectional shoulder instability (MDI) refractory to rehabilitation can be treated with arthroscopic capsulolabral reconstruction with suture anchors. No studies have reported on outcomes or examined the risk factors that may contribute to poor outcomes in adolescent athletes. Hypothesis/Purpose: To identify risk factors for surgical failure by comparing anatomic, clinical, and demographic variables in adolescents who underwent surgical intervention for MDI. Methods: All patients undergoing arthroscopic shoulder surgery at one institution between January 2009 and April 2017 were reviewed. Patients >20 years old at presentation were excluded. Multidirectional instability was defined by positive drive-through sign on arthroscopy plus positive sulcus sign and/or multidirectional laxity on anterior and posterior drawer testing while under anesthesia. Two-year minimum follow-up was required, but those whose treatment failed earlier were included for reporting purposes. Demographics and intraoperative findings were recorded, as were Single Assessment Numeric Evaluation (SANE) scoring, Pediatric and Adolescent Shoulder Survey (PASS), and the short version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) results. Results: Eighty adolescents (88 shoulders) were identified for having undergone surgical treatment of MDI. Of these 80 patients, 42 (50 shoulders; 31 female, 19 male) were available at a minimum of 2-year follow-up. Mean follow-up was 6.3 years (range, 2.8-10.2 years). Thirteen (26.0%) shoulders experienced surgical failure defined by recurrence of subluxation and instability, all of which underwent re-operation. Time to re-operation occurred at a mean of 1.9 years (range, 0.8-3.2). Our cohort had an overall survivorship of 96% at 1 year after surgery and 76% at 3 years. None of the anatomic, clinical, or demographic variables tested, or the presence of generalized ligamentous laxity, were correlated with subjective outcomes or re-operation. Number of anchors used was not different between those that failed and those that did not fail. Patients reported a mean SANE score of 83.3, PASS score of 85.0, and QuickDASH score of 6.8. Return to prior level of sport (RTS) occurred in 56% of patients. Conclusion: Multidirectional shoulder instability is a complex disorder that can be challenging to treat. Adolescent MDI that is refractory to non-surgical management appears to have long-term outcomes after surgical intervention that are comparable to adolescent patients with unidirectional instability. In patients who do experience failure of capsulorraphy, we show that failure will most likely occur within 3 years of the index surgical treatment. [Table: see text][Figure: see text]

A propensity-adjusted comparison of middle meningeal artery embolization versus conventional therapy for chronic subdural hematomas

2021 ◽  
pp. 1-6
Author(s):  
Joshua S. Catapano ◽  
Andrew F. Ducruet ◽  
Candice L. Nguyen ◽  
Tyler S. Cole ◽  
Jacob F. Baranoski ◽  
...  
Keyword(s):  
Treatment Failure ◽  
Conservative Management ◽  
Conventional Therapy ◽  
Surgical Intervention ◽  
Middle Meningeal Artery ◽  
Adjusted Analysis ◽  
Subdural Hematomas ◽  
Tertiary Center ◽  
Meningeal Artery

OBJECTIVEMiddle meningeal artery (MMA) embolization is a promising treatment strategy for chronic subdural hematomas (cSDHs). However, studies comparing MMA embolization and conventional therapy (surgical intervention and conservative management) are limited. The authors aimed to compare MMA embolization versus conventional therapy for cSDHs using a propensity-adjusted analysis.METHODSA retrospective study of all patients with cSDH who presented to a large tertiary center over a 2-year period was performed. MMA embolization was compared with surgical intervention and conservative management. Neurological outcome was assessed using the modified Rankin Scale (mRS). A propensity-adjusted analysis compared MMA embolization versus surgery and conservative management for all individual cSDHs. Primary outcomes included change in hematoma diameter, treatment failure, and complete resolution at last follow-up.RESULTSA total of 231 patients with cSDH met the inclusion criteria. Of these, 35 (15%) were treated using MMA embolization, and 196 (85%) were treated with conventional treatment. On the latest follow-up, there were no statistically significant differences between groups in the percentage of patients with worsening mRS scores. Of the 323 total cSDHs found in 231 patients, 41 (13%) were treated with MMA embolization, 159 (49%) were treated conservatively, and 123 (38%) were treated with surgical evacuation. After propensity adjustment, both surgery (OR 12, 95% CI 1.5–90; p = 0.02) and conservative therapy (OR 13, 95% CI 1.7–99; p = 0.01) were predictors of treatment failure and incomplete resolution on follow-up imaging (OR 6.1, 95% CI 2.8–13; p < 0.001 and OR 5.4, 95% CI 2.5–12; p < 0.001, respectively) when compared with MMA embolization. Additionally, MMA embolization was associated with a significant decrease in cSDH diameter on follow-up relative to conservative management (mean −8.3 mm, 95% CI −10.4 to −6.3 mm, p < 0.001).CONCLUSIONSThis propensity-adjusted analysis suggests that MMA embolization for cSDH is associated with a greater extent of hematoma volume reduction with fewer treatment failures than conventional therapy.

scholarly journals Periprosthetic Ankle Fractures

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0007
Author(s):  
Alexander Lazarides ◽  
Tyler Vovos ◽  
James DeOrio ◽  
Mark Easley ◽  
James Nunley ◽  
...  
Keyword(s):  
Periprosthetic Fracture ◽  
Surgical Intervention ◽  
Nonoperative Management ◽  
High Rate ◽  
Periprosthetic Fractures ◽  
Medial Malleolus ◽  
Operative Fixation ◽  
Time To Fracture ◽  
Univariate Analyses

Category: Ankle Introduction/Purpose: Total ankle replacements (TAR) are an increasingly popular option for the management of tibiotalar arthritis. Periprosthetic fracture is an uncommon but challenging complication of patients undergoing arthroplasty. Evidence on the management of and outcomes from periprosthetic fractures about a TAR are limited. The purpose of this study was to evaluate patients with postoperative periprosthetic fractures about a TAR and determine clinical outcomes of these patients following operative fixation. Additionally, we propose an algorithm for the management of these patients. Methods: We retrospectively analyzed 400 patients who underwent TAR from 2007 through 2017. Charts were reviewed and patients with postoperative fractures were selected for inclusion. Patients with a fracture >4 weeks from index surgery were considered candidates for inclusion. Patients with intraoperative fractures were excluded. Univariate analyses were used to identify differences in outcomes. Results: 32 patients were identified with a postoperative periprosthetic fracture about a TAR. Average age was 65.3 years. Average time to fracture was 39.5 months while average follow up from fracture was 26 months. Fractures were primarily located about the medial malleolus (60.6%). 76.8% of fractures were deemed to be stable (Table 1); 75% of these fractures were managed with ORIF or IMN, while 21% of these fractures were treated with immobilization. 80% of patients with stable fractures treated with immobilization ultimately required surgical intervention. 24.2% of fractures were deemed to be unstable. Fractures about the talus were always unstable and always required revision TAR surgery (100%, p= 0.0002). Conclusion: This retrospective review demonstrates that the majority of periprosthetic fractures about a TAR involve the medial malleolus. Additionally, the majority of stable fractures about a TAR required operative fixation. Despite attempts at nonoperative management, management with immobilization is fraught with a high rate of subsequent surgical intervention. Fractures about the talus should be treated with revision TAR surgery or arthrodesis. Based on these findings, we propose an algorithm for the management of patients with a periprosthetic fracture about a TAR.

scholarly journals Non-operative Management of Posterior Shoulder Instability: An Assessment of Survival and Predictors for Conversion to Surgery at 1 to 13 Years After Diagnosis

2018 ◽  
Vol 6 (7_suppl4) ◽  
pp. 2325967118S0009
Author(s):  
Jarret Murray Woodmass ◽  
Julia Lee ◽  
Nick R. Johnson ◽  
Christopher L. Camp ◽  
Diane L. Dahm ◽  
...  
Keyword(s):  
Shoulder Instability ◽  
Radiographic Progression ◽  
Surgical Intervention ◽  
Cox Proportional Hazards ◽  
Posterior Shoulder Instability ◽  
Late Failure ◽  
Posterior Shoulder ◽  
Increased Risk ◽  
History Of

Objectives: Among patients treated non-operatively for 1 year following a diagnosis of posterior shoulder instability (PSI), little is known about the the incidence of surgery between 1-13 years after injury. The purpose of this study is to define the frequency and evaluate the factors predictive for late surgical intervention of symptomatic PSI. Methods: This study included a population-based cohort of 115 patients (14 females, 101 males) diagnosed with PSI between January 1994 and July 2012 with a minimum 5-years follow-up (mean:13.9 years; range: 5-23 years). Landmark survival analysis was performed to evaluate incidence of surgery after 1 year. Survival was estimated using Kaplan Meier method and predictors of late surgical intervention were analyzed using Cox proportional hazards regression. Results: A total of 61/115 (53%) patients were treated non-operatively for 1 year following diagnosis of PSI. Of these, 24/61 (39%) converted to surgery for symptomatic PSI. The overall survival free of surgery at 1 and 5 years was 53.0% (95% CI 434.7-63.0) and 37.1% (95% CI 29.1-47.1), respectively. BMI >35 (p=0.04, HR 3.3) was predictive for late conversion to surgery. Age, gender, occupation, or history of glenohumeral dislocation were not significant. Assessing surgery as a time dependent covariate, a patient undergoing surgery was at an increased risk for radiographic progression of osteoarthritis (p=0.02, HR=4.0, 95% CI 1.2-13.2). Conclusion: Conservative management was performed for at least one year in over half of patients diagnosed with PSI. However, long-term follow-up demonstrates that nearly 40% of these patients eventually require surgery. Increased BMI was predictive for late failure of while age, gender, history of dislocation and occupation did not show an effect. Patients who underwent surgery were at an increased risk of radiographic progression of arthritis.

scholarly journals An analysis of tumor-related potential spinal column instability (Spine Instability Neoplastic Scores 7–12) eventually requiring surgery with a 1-year follow-up

2021 ◽  
Vol 50 (5) ◽  
pp. E6
Author(s):  
Enrique Vargas ◽  
Dennis T. Lockney ◽  
Praveen V. Mummaneni ◽  
Alexander F. Haddad ◽  
Joshua Rivera ◽  
...  
Keyword(s):  
Logistic Regression ◽  
San Francisco ◽  
Surgical Intervention ◽  
Nonoperative Management ◽  
Multivariable Analysis ◽  
Spinal Instability ◽  
Karnofsky Performance Scale ◽  
Surgery Group ◽  
Increased Risk

OBJECTIVE Within the Spine Instability Neoplastic Score (SINS) classification, tumor-related potential spinal instability (SINS 7–12) may not have a clear treatment approach. The authors aimed to examine the proportion of patients in this indeterminate zone who later required surgical stabilization after initial nonoperative management. By studying this patient population, they sought to determine if a clear SINS cutoff existed whereby the spine is potentially unstable due to a lesion and would be more likely to require stabilization. METHODS Records from patients treated at the University of California, San Francisco, for metastatic spine disease from 2005 to 2019 were retrospectively reviewed. Seventy-five patients with tumor-related potential spinal instability (SINS 7–12) who were initially treated nonoperatively were included. All patients had at least a 1-year follow-up with complete medical records. A univariate chi-square test and Student t-test were used to compare categorical and continuous outcomes, respectively, between patients who ultimately underwent surgery and those who did not. A backward likelihood multivariate binary logistic regression model was used to investigate the relationship between clinical characteristics and surgical intervention. Recursive partitioning analysis (RPA) and single-variable logistic regression were performed as a function of SINS. RESULTS Seventy-five patients with a total of 292 spinal metastatic sites were included in this study; 26 (34.7%) patients underwent surgical intervention, and 49 (65.3%) did not. There was no difference in age, sex, comorbidities, or lesion location between the groups. However, there were more patients with a SINS of 12 in the surgery group (55.2%) than in the no surgery group (44.8%) (p = 0.003). On multivariate analysis, SINS > 11 (OR 8.09, CI 1.96–33.4, p = 0.004) and Karnofsky Performance Scale (KPS) score < 60 (OR 0.94, CI 0.89–0.98, p = 0.008) were associated with an increased risk of surgery. KPS score was not correlated with SINS (p = 0.4). RPA by each spinal lesion identified an optimal cutoff value of SINS > 10, which were associated with an increased risk of surgical intervention. Patients with a surgical intervention had a higher incidence of complications on multivariable analysis (OR 2.96, CI 1.01–8.71, p = 0.048). CONCLUSIONS Patients with a mean SINS of 11 or greater may be at increased risk of mechanical instability requiring surgery after initial nonoperative management. RPA showed that patients with a KPS score of 60 or lower and a SINS of greater than 10 had increased surgery rates.

scholarly journals Conservative management of early uncomplicated appendicitis in children

2017 ◽  
Vol 4 (3) ◽  
pp. 1024 ◽  
Author(s):  
Sunil Kumar Maini ◽  
Neeraj Kumar Jain ◽  
Manjari Goel Jain ◽  
Vicky Khobragade
Keyword(s):  
Abdominal Pain ◽  
Acute Appendicitis ◽  
Conservative Management ◽  
Medical Management ◽  
Surgical Intervention ◽  
Lower Abdominal Pain ◽  
Primary Treatment ◽  
Research Centre ◽  
Uncomplicated Appendicitis

Background: Right lower abdominal pain management in children is a challenging task for the surgeon. Most of the time right lower abdominal pain ends up in acute appendicitis. For long time appendicetomy was the treatment of choice. However surgical intervention has its own disadvantages such as pain, scarring, adhesions, hernia development and venous thrombosis disease. Anxiety and fear of surgery were also two difficulties in obtaining consent for surgery. Parents often request and insist for medical management. Their unwillingness for surgical intervention was the most important reason for medical management of uncomplicated acute appendicitis.Methods: Our prospective observational study was conducted in the Department of General Surgery, R.K.D.F. Medical College and Research Centre, Bhopal, Madhya Pradesh, India during period of January 2014 to January 2016 and follow up was done till December 2016. Our target group was children under 16 years. A total of 92 children with complaint of right lower abdominal pain attended the hospital for treatment. Routine investigations including ultrasonography of abdomen were performed for all the patients. Out of 92 patients diagnosis of acute appendicitis was made in 74 patients, Surgery was performed in 32 patients, while remaining 42 patients were treated conservatively and the results were analyzed.Results: In this study of 92 patients of pain in right iliac fossa below 16 years, 74 (80.43%) were diagnosed as acute appendicitis. 32 (43.24%) Patients were operated earlier. 42 (56.75%) Patient were treated conservatively. Out of 42 patients, 12 (16.21%) patients were operated within 1 year, 30 (40.54%) Patients didn’t require any surgical intervention during 1 year follow up. In present study, significant role of antibiotic was found in conservative management of acute appendicitis in children. So it can be concluded that conservative management of acute appendicitis in children can be attempted under observation.Conclusions: Antibiotics are both effective and safe as primary treatment for patients with uncomplicated acute appendicitis. Initial antibiotic treatment merits consideration as a primary treatment option for early uncomplicated appendicitis. Appendicectomy should be done but conservative management of acute appendicitis in children can be attempted under observation.

Radiological and clinical outcomes of pituitary apoplexy: comparison of conservative management versus early surgical intervention

2021 ◽  
pp. 1-9
Author(s):  
Matthew J. Shepard ◽  
M. Harrison Snyder ◽  
Sauson Soldozy ◽  
Leonel L. Ampie ◽  
Saul F. Morales-Valero ◽  
...  
Keyword(s):  
Clinical Outcomes ◽  
Median Time ◽  
Conservative Management ◽  
Pituitary Apoplexy ◽  
Surgical Intervention ◽  
Early Surgery ◽  
High Dose ◽  
Visual Outcomes ◽  
Early Surgical Intervention

OBJECTIVE Early surgical intervention for patients with pituitary apoplexy (PA) is thought to improve visual outcomes and decrease mortality. However, some patients may have good clinical outcomes without surgery. The authors sought to compare the radiological and clinical outcomes of patients with PA who were managed conservatively versus those who underwent early surgery. METHODS Patients with symptomatic PA were identified. Radiological, endocrinological, and ophthalmological data were reviewed. Patients with progressive visual deterioration or ophthalmoplegia were candidates for early surgery (within 7 days). Patients without visual symptoms or whose symptoms improved on high-dose steroids were treated conservatively. Log-rank and univariate analysis compared clinical and radiological outcomes between those receiving early surgery and those who underwent intended conservative management. RESULTS Sixty-four patients with PA were identified: 47 (73.4%) underwent intended conservative management, while 17 (26.6%) had early surgery. Patients receiving early surgery had increased rates of impaired visual acuity (VA; 64.7% vs 27.7%, p = 0.009); visual field (VF) deficits (64.7% vs 19.2%, p = 0.002); and cranial neuropathies (58.8% vs 29.8%, p < 0.05) at presentation. Tumor volumes were greater in the early surgical cohort (15.1 ± 14.8 cm3 vs 4.5 ± 10.3 cm3, p < 0.001). The median clinical and radiological follow-up visits were longer in the early surgical cohort (70.0 and 64.4 months vs 26.0 and 24.7 months, respectively; p < 0.001). Among those with VA/VF deficits, visual outcomes were similar between both groups (p > 0.9). The median time to VA improvement (2.0 vs 3.0 months, p = 0.9; HR 0.9, 95% CI 0.3–3.5) and the median time to VF improvement (2.0 vs 1.5 months; HR 0.8, 95% CI 0.3–2.6, p = 0.8) were similar across both cohorts. Cranial neuropathy improvement was more common in conservatively managed patients (HR 4.8, 95% CI 1.5–15.4, p < 0.01). Conservative management failed in 7 patients (14.9%) and required surgery. PA volumes spontaneously regressed in 95.0% of patients (38/40) with successful conservative management, with a 6-month regression rate of 66.2%. Twenty-seven patients (19 in the conservative and 8 in the early surgical cohorts) responded to a prospectively administered Visual Function Questionnaire-25 (VFQ-25). VFQ-25 scores were similar across both cohorts (conservative 95.5 ± 3.8, surgery 93.2 ± 5.1, p = 0.3). Younger age, female sex, and patients with VF deficits or chiasmal compression were more likely to experience unsuccessful conservative management. Surgical outcomes were similar for patients receiving early versus delayed surgery. CONCLUSIONS These data suggest that a majority of patients with PA can be successfully managed without surgical intervention assuming close neurosurgical, radiological, and ophthalmological follow-up is available.

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