Kurt Pettersson

Percutaneous Lumbar Zygapophysial (Facet) Joint Neurotomy Using Radiofrequency Current, in the Management of Chronic Low Back Pain : A Randomized Double-Blind Trial

Study Design. A randomized controlled study of percutaneous radiofrequency neurotomy was conducted in 40 patients with chronic low back pain (20 active and 20 controls). Objective. The aim of the study was to evaluate the possible beneficial effect of percutaneous radiofrequency zygapophysial joint neurotomy in reducing pain and physical impairment in patients with pain from the lumbar zygapophysial joints, selected after repeated diagnostic blocks. Summary of Background Data. Facet or zygapophysial joint pain may be one of the causes of chronic low back pain and may be treated by a percutaneous radiofrequency denervation. Patients may possibly be identified by a positive diagnostic block. These blocks need to be repeated as false positive responses to single blocks occur. In all previous studies patients treated with radiofrequency denervation have been selected after single diagnostic blocks resulting in a varying degree of relief. Methods. All patients were examined by an orthopedic surgeon before and 6 months after the treatment (sham or active). Inclusion criteria were 3 separate positive facet blocks. Denervation was achieved by multiple lesions at each level in an effort to provide effective denervation. Results. The active treatment group showed statistically significant improvement not only in back and leg pain but also back and hip movement as well as the sacro-iliac joint test. Pre operative sensory deficit and weak or absent ankle reflex normalized (P < 0.01) and (P < 0.05), respectively. There was significant improvement in quality of life variables, global perception of improvement, and generalized pain. The improvement seen in the active group was significantly greater then that seen in the placebo group with regard to all the above-mentioned variables. None of our patients had any complication other than transient postoperative pain that was easily managed. Conclusion. Our study indicates that radiofrequency facet denervation is not a placebo and could be used in the treatment of carefully selected patients with chronic low back pain.

Disc pathology after whiplash injury. A prospective magnetic resonance imaging and clinical investigation.

STUDY DESIGN This study was used to evaluate the relationship between magnetic resonance imaging findings and clinical findings after whiplash injury. OBJECTIVES To identify initial soft-tissue damage after whiplash injury, the development of disc pathology, and the relationship of disc pathology to clinical findings. SUMMARY OF BACKGROUND DATA Although a few studies have reported pathological magnetic resonance imaging findings after whiplash injuries, there is no prospective study published to our knowledge. METHODS Thirty-nine patients, 20 women and 19 men with a mean age of 32 years, were treated for whiplash injury. Magnetic resonance imaging and clinical examination were performed in a blinded manner at a mean of 11 days after trauma. The procedure was repeated at a 2-year follow-up visit. Two patients could not be examined with the second magnetic resonance imaging because of claustrophobia and pregnancy, respectively. RESULTS The authors found 13 patients (33%) with disc herniations with medullary (six cases) or dura (seven cases) impingement over the 2-year follow-up period. At the follow-up examination all patients with medullary impingement had persistent or increased symptoms, and three of 27 patients (11%) with no or slight changes on magnetic resonance imaging had persistent symptoms. No ligament injuries were diagnosed. CONCLUSION Although disc pathology seems to be one contributing factor in the development of chronic symptoms after whiplash injury, it may be unnecessary to examine these patients in the acute phase with magnetic resonance imaging; correlating initial symptoms and signs to magnetic resonance imaging findings is difficult because of the relatively high proportion of false-positive results. Magnetic resonance imaging is indicated later in the course of treatment in patients with persistent arm pain, neurologic deficits or clinical signs of nerve root compression to diagnose disc herniations requiring surgery.

MRI and neurology in acute whiplash trauma: No correlation in prospective examination of 39 cases

39 consecutive cases of whiplash injury of the neck were examined clinically and with MRI at a mean of 11 days after trauma. 26 of these showed changes on MRI with disc lesions in 25, 10 of which were classified as disc herniations, and a muscle lesion in 1 case. All had neck pain or headache. 29 cases had neurological deficits, mostly sensibility disturbances. 22 of the 26 cases with pathologic MRI findings had neurological signs, as had 7 of the 10 cases with disc herniation. The relationship between the MRI findings and the clinical symptoms and signs was poor.

High-dose methylprednisolone prevents extensive sick leave after whiplash injury. A prospective, randomized, double-blind study

Study Design. A prospective, randomized, double‐blind study comparing high‐dose methylprednisolone with placebo. Objectives. To evaluate the efficacy of high‐dose methylprednisolone when administered within 8 hours after whiplash injury. Summary of Background Data. Whiplash injury often results in chronic symptoms. The management of whiplash injuries is controversial, and pharmacologic therapy has received little evaluation. In recent reports, dysfunction of the central nervous system has been indicated in several cases. Methylprednisolone administered within 8 hours after the injury to patients with acute spinal cord injury has been demonstrated to improve the outcome. This procedure was also adopted in a randomized study of cases of whiplash injury in car accidents. Methods. Forty patients, 22 men and 18 women with a mean age of 35 years (range, 19‐65), were included in the study, 20 in each of two groups. They were treated for whiplash injury, which they had sustained in car accidents. The patients were enrolled if their diagnoses were complete and treatment had begun within 8 hours after injury. Disabling symptoms severe enough to prevent the patient from returning to work, number of sick days before and after injury, and sick‐leave profile after injury were used as parameters for the evaluation of the effects of the treatment. Baseline demographic data were controlled for when statistical analysis had been performed. Results. At the follow‐up examination 6 months after initial treatment, there was a significant difference in disabling symptoms between the actively treated patients and the placebo group (P = 0.047), total number of sick days (P = 0.01), and sick‐leave profile (P = 0.003). Conclusions. The results of this study indicate that acute treatment with high‐dose methylprednisolone may be beneficial in preventing extensive sick leave after whiplash injury. However, the number of patients studied was small, and therefore further prospective, controlled studies are needed.

Decreased Width of the Spinal Canal in Patients With Chronic Symptoms After Whiplash Injury

Study Design The sagittal diameter of the cervical spinal canal was measured on standard lateral radiographs of 48 consecutive patients with acute whiplash injury. A follow-up was done 12 months after injury. Objectives The purpose of this study was to evaluate the relationship between spinal canal width and chronic symptoms after whiplash injury. Summary of Background Data A narrow sagittal diameter of the cervical spinal canal has been correlated with neurologic deficits in degenerative conditions and after fractures. The authors are not aware of previous studies on whiplash patients related to this area. Methods Forty-eight consecutive patients were evaluated for whiplash trauma after car accidents. Twentyfour patients (12 men and 12 women; mean age, 37 years) had persistent symptoms after 12 months, while 24 patients (12 men and 12 women; mean age, 34 years) were asymptomatic. All measurements were done from standard lateral radiographs with a graphic digitizer connected to a microcomputer. Three anteroposterior and one obliaque measurement of the canal were reconstructed for each vertebrae from C2-C6. Multivariate analysis of variance was used to evaluate any association between gender, remaining symptoms at follow-up, and the recorded values of the spinal canal width. Results The spinal canal was significantly smaller in the patients with persistent symptoms than in the asymptomatic group. A significant difference also was found between men and women. Conclusion Narrow diameter of the cervical spinal canal is unfavorable in patients with whiplash.

Sensory recovery after hand reimplantation: a clinical, morphological, and neurophysiological study in humans.

Despite fairly good return of motor function, patients who have amputated hands reimplanted demonstrate poor sensory recovery and severe cold intolerance, two variables that are difficult to quantify reliably. In this study we wanted to find out if there is a correlation between morphological findings of sensory and sympathetic reinnervation and clinical and neurophysiological variables. Skin was biopsied from the reimplanted and corresponding area in the normal hands of eight patients who had sustained a hand amputation and subsequent reimplantation. The sections were immunostained using markers for both sensory and sympathetic nerve fibres. Comparison between the reimplanted and normal sides in each individual showed a mean loss of sensory immunoreactive nerve fibres of 30%, and for sympathetic immunoreactivity the loss was 60%. There was measurable two-point discrimination in the injured hand only in patients below the age of 40 years, corresponding to the better recovery of mechanical thresholds evaluated neurophysiologically for this age group. These results confirm the extensive loss of sensory nerve fibres after nerve injury, probably correlated to loss of sensory neurons. We have also shown that it is possible to correlate the results of clinical and neurophysiological evaluation with morphological results of skin reinnervation specific to the repaired nerve, and so improve the possibility for the quantification of sensory recovery.

Replacement of proximal interphalangeal joints with new ceramic arthroplasty: a prospective series of 20 proximal interphalangeal joint replacements.

A prospective consecutive series of 20 proximal interphalangeal (PIP) joints replaced with a new ceramic unconstrained prosthesis (MOJE) included 13 patients with osteoarthrosis, five with rheumatoid arthritis, and one each with post-traumatic infection and traumatic arthrosis. All patients were assessed preoperatively and postoperatively at one year by an independent physiotherapist and an occupational therapist who evaluated grip strength, range of motion, activities of daily living (ADL) and occupational scores (COPM Canadian Occupational Performance Measure). The mean range of motion of the PIP joint improved from 43° to 60° (p=0.001), and the mean grip strength from 169–199 N (p=0.002). The patients’ self-perception of occupational performance, assessed by the COPM, improved significantly from 3.6–6.6 (p<0.001) for satisfaction, and 3.8–6.3 (p<0.001) for performance. The MOJE PIP joint replacement provides significant pain relief, improved strength and range of motion, and short-term satisfaction. Further long-term studies are therefore advocated.

Surgery for chronic symptoms after whiplash injury Follow-up of 20 cases

20 patients operated on with discectomy and anterior cervical fusion because of chronic symptoms after whiplash injury were examined 4 years after surgery. The commonest indications for surgery were disabling headache and neck pain and radiographically verified disc protrusion. At follow-up, 11 patients had reduced headache and neck pain, while paresthesia and radicular pain were diminished in 9 patients. Based on Robinssons criteria for the evaluation of surgical results, 2 patients had good, 9 had fair and 9 had poor results.

MRI in acute phase of whiplash injury

A prospective MRI study of 39 whiplash patients was performed and results were compared with the clinical findings. The inclusion criteria were: (1) automobile accident, (2) noncontact cervical spine trauma, (3) no skull injury, (4) conscious patient, (5) no previously known cervical pain before the accident, (6) plain X-ray of the cervical spine without fracture and (7) MRI within 15 days after trauma. All MR images were obtained blinded with no previous knowledge of the patients symptoms or findings. The MRI parameters included disc bulging either with impingment on the anterior epidural space or with medullary compression, foraminal stenosis, dorsal ligament thickening, osteophyte extension and intramedullary or paravertebral soft tissue injury. All changes were graded visually on a four-point scale (no, some, moderate or extensive changes). After the MRI evaluation was made the clinical findings were analysed by two orthopaedic surgeons using a specially designed protocol. With MRI 29 patients (74%) showed no or only slight changes, and were thus regarded as normal variations. Of these, 10 of 29 patients (34%) had as the only symptom pain in the head or in the neck, 19 of 29 patients (66%) showed neurological changes, either paresthesias, sensory deficits or weakness of upper extremities. In 10 (26%) patients with moderate or extensive MRI changes, 3 of 10 (33%) had only head or neck pain, or both, and 7 of 10 (66%) had neurological changes. Use of MRI in whiplash injury is helpful, but it is not the first-choice radiological examination method. Despite neurological changes, the frequency of true traumatic lesions is low. There is no clear correlation between the patients subjective symptoms or clinical signs and the findings with MRI. However, MRI can be used to find patients with disk herniation that can be treated surgically.

Discuspathologie na een whiplash–letsel. Een prospectief onderzoek met behulp van magnetische resonantiebeelden en klinisch onderzoek

Met behulp van dit onderzoek werd de relatie tussen bevindingen uit magnetische resonantiebeelden (mri) en klinische bevindingen na whiplash–letsel geevalueerd.