Holger Joswig

The timed up and go test for lumbar degenerative disc disease

We report on the use and performance of an objective measure of functional impairment, the timed up and go (TUG) test, in clinical practice for patients with lumbar degenerative disc disease (DDD). We illustrate nine representative patients with lumbar DDD, who were selected from an ongoing prospective study, to report our clinical experience with the TUG test. In addition, a preliminary sample of 30 non-selected consecutive patients is presented. The following parameters were assessed preoperatively, and 3 days and 6 weeks postoperatively: back and leg pain using the visual analogue scale (VAS); functional impairment using the Oswestry disability index (ODI) and Roland-Morris disability index (RMDI); health-related quality of life using the EuroQol 5D (EQ5D) and Short-Form 12 (SF-12). The TUG test results improved by 2.6 and 5.4s after 3 days and 6 weeks compared to the baseline assessment. The mean VAS for back and leg pain decreased by 2.3 and 5.3, respectively, after 3 days, and by 2.7 and 4.6 after 6 weeks. The mean RMDI and ODI decreased by 3.4 and 23.3, respectively, after 3 days, and by 7.0 and 28.0 after 6 weeks. The mean EQ5D increased by 0.38 after 3 days and 0.358 after 6 weeks. The mean SF-12 mental component scale decreased by 0.2 after 3 days and increased by 5.6 after 6 weeks, whereas the mean SF-12 physical component scale increased by 6.4 after 3 days and by 9.8 after 6 weeks. The TUG test proved to be a useful, easy to use tool that could add a new, objective dimension to the armamentarium of clinical tests for the diagnosis and management of DDD. From our preliminary experience, we conclude that the TUG test accurately reflects a patients objective functional impairment before and after surgery.

Sex differences in subjective and objective measures of pain, functional impairment, and health-related quality of life in patients with lumbar degenerative disc disease.

Abstract Sex differences in pain perception are known to exist; however, the exact pathomechanism remains unclear. This work aims to elucidate sex differences in subjective and objective measures of pain, functional impairment, and health-related quality of life (HRQoL) in patients with lumbar degenerative disc disease. In a prospective 2-center study, back and leg pain (visual analogue scale [VAS]), functional disability (Oswestry Disability Index and Roland–Morris Disability Index), and HRQoL (EuroQol-5D and Short Form [SF12]) were collected for consecutive patients undergoing lumbar spine surgery. Objective functional impairment (OFI) was estimated using age-adjusted and sex-adjusted cutoff values for the timed-up-and-go (TUG) test. A healthy cohort of n = 110 subjects served as the control group. Univariate and multivariate analyses were performed to test the association between sex and pain, subjective and OFIs, and HRQoL. The study comprised n = 305 patients (41.6% females). Female patients had more VAS back pain (P = 0.002) and leg pain (P = 0.014). They were more likely to report higher functional impairment in terms of Oswestry Disability Index (P = 0.005). Similarly, HRQoL measured with the EuroQol-5D index (P = 0.012) and SF12 physical composite score (P = 0.005) was lower in female patients. Female patients reported higher VAS back and leg pain, functional impairment, and reduced HRQoL than male patients. However, there were no sex differences with respect to the presence and degree of OFI measured by the TUG test using age-adjusted and sex-adjusted cutoff values. As such, the TUG may be a good test to overcome sex bias for the clinical assessment of patients with degenerative disc disease.

Awake Craniotomy: First-Year Experiences and Patient Perception

BACKGROUND Awake craniotomy for brain lesions in or near eloquent brain regions enables neurosurgeons to assess neurologic functions of patients intraoperatively, reducing the risk of permanent neurologic deficits and increasing the extent of resection. METHODS A retrospective review was performed of a consecutive series of patients with awake craniotomies in the first year of their introduction to our tertiary non-university-affiliated neurosurgery department. Operation time, complications, and neurologic outcome were assessed, and patient perception of awake craniotomy was surveyed using a mailed questionnaire. RESULTS There were 24 awake craniotomies performed in 22 patients for low-grade/high-grade gliomas, cavernomas, and metastases (average 2 cases per month). Mean operation time was 205 minutes. Failure of awake craniotomy because of intraoperative seizures with subsequent postictal impaired testing or limited cooperation occurred in 2 patients. Transient neurologic deficits occurred in 29% of patients; 1 patient sustained a permanent neurologic deficit. Of the 18 patients (82%) who returned the questionnaire, only 2 patients recalled significant fear during surgery. CONCLUSIONS Introducing awake craniotomy to a tertiary non-university-affiliated neurosurgery department is feasible and resulted in reasonable operation times and complication rates and high patient satisfaction.

Short- and long-term effects of smoking on pain and health-related quality of life after non-instrumented lumbar spine surgery.

OBJECTIVES A myriad of negative bodily health effects related to tobacco smoking is known while its detrimental effects on the spine in particular are less defined. The goal of the current study is to compare long-term outcome between smokers and non-smokers after non-instrumented lumbar spine surgery. PATIENTS AND METHODS Prospective observational study on n=172 consecutive patients undergoing non-instrumented spine surgery for lumbar disc herniation (LDH) or lumbar spinal stenosis (LSS) with a follow-up (FU) of 4.5 years. Patients were dichotomized according to their smoking status at the time of surgery. Back pain and health-related quality of life (HRQoL) were assessed using the visual analogue scale (VAS) and the Short-Form (SF)-12. Any subsequent lumbar spine surgeries since the index surgery were registered. Logistic regression analysis was used to estimate the effect size of the relationship between smoking and the responder status to surgery in terms of pain and HRQoL-metrics. RESULTS Complete FU data was available for n=29 (55%) smokers and n=75 (63%) non-smokers. At discharge, 1 month, 1 year and 4.5 years, smokers were as likely as non-smokers to achieve a favourable response to surgery in terms of VAS back pain and the SF-12 mental and physical component scale metric. A subgroup analysis on active smokers throughout the entire study interval did not find an inferior responder rate than in never-smokers. A trend for additional lumbar spine surgery performed in 17.2% of the smoking and 8.2% of the non-smoking patients during FU was observed (OR 2.39, 95% CI 0.67-8.57, p=0.179). CONCLUSION Up to 4.5 years following non-instrumented lumbar spine surgery, there was no difference in the pain or HRQoL-responder status of smokers and non-smokers. Smokers may be more likely to undergo re-do surgery in the long term, but more data is needed to confirm this statistical trend.

Influence of age on pain intensity, functional impairment and health-related quality of life before and after surgery for lumbar degenerative disc disease

BACKGROUND Demographic changes will lead to an increase of elderly people in our population and consecutively to a higher prevalence of patients suffering from degenerative disc disease (DDD). The goal of this study was to investigate age-related differences in pain intensity, subjective and objective functional impairment and health-related quality of life (HRQoL) in patients with lumbar DDD. METHODS In a prospective two-center study, back and leg pain intensity (visual analogue scale (VAS)), functional impairment (Oswestry Disability Index (ODI), Roland-Morris Disability Index (RMDI)) and HRQoL (EuroQol-5D (EQ-5D), Short-Form (SF12)) were collected for consecutive patients undergoing lumbar spine surgery. Objective functional impairment (OFI) was measured using the Timed Up and Go (TUG) test. Adjusted partial correlation was used to correlate age to each scale preoperatively, as well as to the postoperative improvement at six weeks. RESULTS A total of n=377 patients (161 females, 42.7%) with a mean age of 58.5 years (SD 15.7, range 18.0-93.7) were included. Unadjusted TUG test raw times naturally increased with age, whereas the age-effect on standardized OFI T-scores was close to zero in patients with a lumbar disc herniation (LDH; r=-0.0666, p=0.367) or lumbar spinal stenosis (LSS; r=-0.0134, p=0.879). There was a weak correlation between age and higher ODI (LDH: r=0.1289, p=0.089; LSS: r=0.1975; p=0.027), lower EQ-5D (LSS: r=-0.1824, p=0.042) and higher RMDI by trend (LSS: r=0.1679, p=0.061). The correlation between age and postoperative improvement was negative on the VAS for back pain (LDH: r=-0.3189, p=0.026), VAS for leg pain (LDH: r=-0.3656, p=0.009) and RMDI by trend (LSS: r=-0.2004, p=0.069), as well as positive on the EQ-5D index (r=0.2412, p=0.011), indicating that younger patients showed better improvement. Due to in-group heterogeneity, no age-effect could be calculated for patients scheduled for surgical fusion. CONCLUSIONS The influence of age on subjective and objective measures of pain, functional impairment and HRQoL is limited for patients with LDH and LSS, but suggests an age-dependent increase of functional disability. Younger patients generally showed greater postoperative improvement at six weeks than older patients.

Sex differences in lumbar degenerative disc disease.

OBJECTIVES A growing number of studies focus on sex differences in the pre- and postoperative setting in patients with degenerative disc disease (DDD). The exact pathomechanism behind this phenomenon, however, remains unclear. The objective of this study was to investigate pre- and postoperative sex differences in patients with lumbar DDD. PATIENTS AND METHODS In a prospective two-center study, back and leg pain (Visual Analogue Scale (VAS)), functional disability (Oswestry Disability Index (ODI) and Roland-Morris Disability Index) and health-related quality of life (HRQoL) (EuroQol 5D and Short-Form (SF12)) were collected for patients scheduled for lumbar spine surgery. In addition to the subjective functional impairment (SFI), objective functional impairment (OFI) was estimated using age- and sex-adjusted cut-off values for the timed-up-and-go (TUG) test. The 6-week responder status was defined using minimally clinically important differences of the ODI, SF12 PCS, VAS back and leg pain in all patients. Six months and one year follow-up (FU) was available in n=127 and n=87 patients, respectively. RESULTS The patient cohort comprised of n=214 patients (41.6% females). Preoperatively, female patients scored significantly worse on VAS back and leg pain, ODI and SF12 PCS (p<0.033), while OFI was similar (p=0.334). At the 6 week FU, sex-related differences had resolved for SFI and OFI was similar as well (p=0.333). There were no sex differences in the mean improvement after 6 weeks for all measures of pain intensity, functional impairment and HRQoL (p>0.182). Male and female patients profited equally on measures of SFI and HRQoL up to six months and one year after surgery (p>0.091). CONCLUSION Preoperatively, female patients scored worse in terms of SFI, while OFI was similar. Consecutively, OFI appears to be less prone to sex bias and may thus serve as a valuable surrogate-marker of disability. The disadvantageous preoperative SFI-status did not translate into worse postoperative results, as no sex differences were present at the 6-week, 6-months and 1-year follow-up.

Influence of the mental health status on a new measure of objective functional impairment in lumbar degenerative disc disease

BACKGROUND CONTEXT The Timed Up and Go (TUG) test has recently been proposed as a simple and standardized measure for objective functional impairment (OFI) in patients with lumbar degenerative disc disease (DDD). PURPOSE The study aimed to explore the relationship between a patients mental health status and both patient-reported outcome measures (PROMs) and TUG test results. STUDY DESIGN/SETTING This is a prospective institutional review board-approved two-center study. PATIENT SAMPLE The sample was composed of 375 consecutive patients scheduled for lumbar spine surgery and a healthy cohort of 110 control subjects. OUTCOME MEASURES Patients and control subjects were assessed with the TUG test and a comprehensive panel of subjective PROMs of pain intensity (visual analog scale [VAS]), functional impairment (Roland-Morris Disability Index [RMDI]), Oswestry Disability Index [ODI]), as well as health-related quality of life (hrQoL; Euro-Qol [EQ]-5D). METHODS Standardized age- and sex-adjusted TUG test T-scores were calculated. The dependent variable was the short-form (SF)-12 mental component summary (MCS) quartiles, and the independent variables were the TUG T-scores and PROMs. Direct and adjusted analyses of covariance were performed to estimate the interaction between the SF-12 MCS quartiles and the independent variables. RESULTS In patients, there was a significant decrease in the subjective PROMs, notably the VAS back pain (p=.001) and VAS leg pain (p=.035), as well as significant increase in the RMDI (p<.001), ODI (p<.001), and the EQ-5D index (p<.001) with every increase in the quartile of the SF-12 MCS. There were no significant group differences of OFI as measured by the TUG T-scores across the SF-12 MCS quartiles (p=.462). In the healthy control group, a significant decrease in VAS leg pain (p=.028), RMDI (p=.013), and ODI (p<.001), as well as a significant increase in the EQ-5D index (p<.001), was seen across the SF-12 MCS quartiles, whereas TUG T-scores remained stable (p=.897). CONCLUSIONS There are significant influences of mental hrQoL on subjective measures of pain, functional impairment, and hrQoL that might lead to bias when evaluating patients with lumbar DDD who suffer from reduced mental hrQoL. The TUG test appears to be a stable instrument and especially helpful in the evaluation of patients with lumbar DDD and mental health problems.

Residents' Learning Curve of Lumbar Transforaminal Epidural Steroid Injections

Background and Study Aims There is a paucity of literature on beginners’ training and on its connection with patient safety for transforaminal epidural steroid injections (TFESIs). This study retrospectively assessed the learning curves and associated complications of neurosurgery residents never previously exposed to TFESI and compared them with experienced board‐certified faculty neurosurgeons (BCFNs). Material and Methods Procedure time in minutes, dose‐area product (DAP) in cGy*cm2, periprocedural observations, and complications in 354 TFESIs for radicular pain secondary to lumbar disk herniation or lumbar spinal stenosis were extracted from operative notes and the electronic infiltration logbook in the per‐injection format. Learning curves for 238 residents and 116 BCFN TFESIs in terms of procedure time and DAP were estimated using monotone regression. Results Residents’ TFESI procedure time and DAP reached BCFN level (4.7 minutes and 140.2 Gy*cm2) after 67 and 68 cases, respectively. Residents’ TFESIs were unsuccessful in 1.7%, mostly for severe obesity and hypertrophied facet joints, but no severe complications were noted. Obesity, however, did not result in increased procedure times or radiation exposure in general. Residents were faster and required less fluoroscopy in TFESI of the upper lumbar nerve roots than for L5 or S1 in particular. Conclusion The residents’ learning curve for TFESIs in terms of procedure time and radiation exposure can be overcome safely after < 70 TFESIs. An outcome analysis correlating to the interventionalists training level would be worth investigating in future studies.

Sentinel Headache: A Warning Sign Preceding Every Fourth Aneurysmal Subarachnoid Hemorrhage

With great interest, we read the recent retrospective study of Oda et al[1][1] in the American Journal of Neuroradiology reporting a 33.9% incidence of minor leaks preceding aneurysmal subarachnoid hemorrhage (aSAH) confirmed by neuroradiologic methods, in which the authors found a much lower

Reversible pure word deafness due to inferior colliculi compression by a pineal germinoma in a young adult

We report a clinical case of a 19-year-old male patient who developed pure word deafness due to the local compressive effect of a pineal germinoma on the inferior colliculi of the quadrigeminal plate. After percutaneous radiation therapy the size of the tumor decreased significantly, while audiometry demonstrated a complete regression of the auditory deficit. Since pure word deafness is commonly attributed to temporal lesions, the inferior colliculi represent an exceptional site for these symptoms. The pathophysiological background and the scarce literature on pure word deafness, especially the one related to neoplasms of the tectal region, are briefly discussed.