Inferior long-term outcomes after surgery for lumbar disc herniation in patients with prior lumbar spine surgery

BACKGROUND

Previous lumbar spine surgery is a frequent exclusion criterion for studies evaluating lumbar surgery outcomes. In real-life clinical settings, this patient population is important, as a notable proportion of patients evaluated for lumbar spine surgery have undergone prior lumbar surgery already previously. Knowledge about the long-term outcomes after microdiscectomy on patients with previous lumbar surgery and how they compare to those of first-time surgery is lacking.

METHODS

The original patient cohort for screening included 615 consecutive patients who underwent surgery for lumbar disc herniation, with a median follow-up time of 18.1 years. Of these patients, 89 (19%) had undergone lumbar spine surgery prior to the index surgery. Propensity score matching (based on age, sex, and follow-up time) was utilized to match two patients without prior surgery with each patient with a previous surgery. The primary outcome measure was the need for further lumbar spine surgery during the follow-up period, and the secondary outcome measures consisted of present-time patient-reported outcome measures (Oswestry Disability Index, EuroQol-5D) and present-time ability to carry out employment.

RESULTS

Patients who received previous lumbar surgeries had a higher need for further surgery (44% vs. 28%, p = 0.009) and had a shorter time to further surgery than the propensity score-matched cohort (mean Kaplan-Meier estimate, 15.7 years vs. 19.8 years, p = 0.008). Patients with prior surgery reported inferior Oswestry Disability Index scores (13.7 vs. 8.0, p = 0.036). and EQ-5D scores (0.77 vs. 0.86, p = 0.01). In addition, they had a higher frequency of receiving lumbar spine-related disability pensions than the other patients (12% vs. 1.9%, p = 0.01).

CONCLUSIONS

Patients with previous lumbar surgery had inferior long-term outcomes compared to patients without prior surgery. However, the vast majority of these patients improved quickly after the index surgery. Furthermore, the difference in the patients' reported outcomes was small at the long-term follow-up, and they reported high satisfaction with the results of the study surgery. Hence, surgery for these patients should be considered if surgical indications are met, but special care needs must be accounted for when deliberating upon their indications for surgery.

Ultrasonography of Breast Lesions Detected in Mammography Screening

Mammography screening was carried out in 18012 women (aged 50–59) of whom 579 (3.21%) had to be recalled for clinical mammography. After completion of the clinical mammography each woman also had ultrasonography (US) with a hand-held real-time apparatus using a 7.5 MHz probe. There were 79 verified breast cancers; 32 of these were palpable and were also depicted at US, but only 29 (61.7%) of non-palpable breast cancers (n = 47) were found at US. Twenty-two of the non-palpable breast cancers were seen at US as a tumor-like lesion, 2 because of local echo-architecture distortion, and 5 only because of acoustic shadowing. The US image did not help to differentiate between malignant and benign lesions.

Androgen receptor alterations in prostate cancer relapsed during a combined androgen blockade by orchiectomy and bicalutamide

Mechanisms of prostate cancer (CaP) recurrence during a combined androgen blockade (CAB) are poorly understood. Previously, the role of androgen receptor (AR) gene mutations underlying the CAB therapy relapse has been raised. To investigate the hypothesis that AR gene aberrations are involved in CAB relapse, 11 locally recurrent CaP samples from patients treated with orchiectomy and bicalutamide were analyzed for copy number changes and DNA sequence alterations of the AR gene by fluorescence in situ hybridization and single-strand conformation polymorphism, respectively. Altogether, base changes were detected in four tumors (36%). Three of them were missense mutations (G166S, W741C, M749I) and two were silent polymorphisms. Interestingly, none of the tumors had AR amplification. These data suggest that different AR variants are developed and selected for during various types of hormonal treatments, and also, that CAB achieved by orchiectomy and bicalutamide does not act as a selective force for AR amplification.

Double reading of mammography screening films--one radiologist or two?

The effect of double reading on the number of breast cancers detected and the number of women recalled was examined in 15,457 women aged 50-59 years attending for mammographic breast screening. All the screening mammograms were interpreted independently by two radiologists without knowledge of each other's findings. All the cases selected by either radiologist were then reviewed by both radiologists and a consensus decision made on whom to recall for further studies. This method of double reading increased the number of breast cancers detected by 9% (P < 0.05) and decreased the number of women recalled by 45% (P < 0.001). Double reading of mammography screening films together with consensus decisions on the selected cases is recommended.

Ultrasonography of breast lesions detected in mammography screening

Mammography screening was carried out in 18,012 women (aged 50-59) of whom 579 (3.21%) had to be recalled for clinical mammography. After completion of the clinical mammography each woman also had ultrasonography (US) with a hand-held real-time apparatus using a 7.5 MHz probe. There were 79 verified breast cancers; 32 of these were palpable and were also depicted at US, but only 29 (61.7%) of non-palpable breast cancers (n = 47) were found at US. Twenty-two of the non-palpable breast cancers were seen at US as a tumor-like lesion, 2 because of local echo-architecture distortion, and 5 only because of acoustic shadowing. The US image did not help to differentiate between malignant and benign lesions.

Mammography screening--reasons for recall and the influence of experience on recall in the Finnish system

The reasons for recall and the influence of experience on recall were studied in 579 women (3.21%) recalled from mammography screening. The proportion of recalls for further studies was the greatest (6.30%) at the onset of screening. With increased experience, the proportion decreased by stages and in the second screening round it was only 2.04%. The proportion of cases referred for surgical biopsy in the first screening round was 0.7% and the proportion of screening-detected breast cancers was 0.52%. These change little with increasing experience. In the second screening round, however, the proportion of referrals for surgical biopsy (0.43% of those screened) and of screening-detected breast cancers, (0.30%) were both low. A tumour-like density was the commonest finding resulting in recall for further studies, and the number caused by superimposition of normal parenchymal structures decreased with experience, while the proportion of breast cancers and benign tumours increased. The proportion of cases with parenchymal distortion resulting in recall for further studies was similar in both screening rounds but the number of those referred for biopsy fell dramatically in the second screening round. The number of recalls for microcalcification also fell with experience and the proportion of breast cancers in this group increased over the two screening rounds. A high ratio of malignancies in surgical biopsies can be expected when the radiologists undertaking primary screening also perform all further studies.

Baseline screening mammography with one versus two views

Two-view baseline screening mammograms (oblique and cranial views) of 303 women recalled for further studies from among 7,245 women screened were reviewed by four experienced radiologists separately to evaluate the importance of the number of views taken for screening. As compared with the oblique view only, two views, increased the number of cancers detected and decreased the number of false-positive cancer diagnoses of two radiologists, but increased that of the other two.

Mammography screening for breast cancer: first year results from Helsinki and surroundings

11,789 women aged 50-59 years were invited for screening by the mammography screening centre of the Cancer Society of Finland in Helsinki. 9829 women (83.37%) attended and 3.85% of those were recalled for further studies. After complete examination seventy-one women (0.72%) were referred for surgical biopsy and breast cancer was histologically detected in 44 (0.45%) of those screened. The proportion of Stage I + TIS breast cancers detected was 75%, and of Stage II or more advanced, 25%. With modern mammography techniques and proper training of technicians and radiologists, with double reading of all the films, it is possible to minimise both the recall rate and the number of women who are referred for surgical biopsy, and still find cancers in their early stages.

Streptokinase and concomitant oral anticoagulants in the treatment of deep venous thrombosis

Fourty-four patients with deep venous thrombosis of the leg diagnosed by phlebography and not more than five days old were treated with streptokinase. Oral anticoagulant therapy was started at the same time. Complete lysis of thrombi was obtained in 6 cases and partial one in 25 cases. Lysis of proximal thrombi was better than that of distal ones. The age of the thrombi had no effect on the lysis. Urticaria and anaphylactic reactions occurred in 8 patients and treatment was discontinued. Haemorrhagic complications were present in 8 cases but remission was obtained by dicontinuing streptokinase infusion. Commencing oral anticoagulant therapy simultaneously with streptokinase reduces duration of treatment without increasing the risks and the results of lysis are equally good as with earlier studies. The use of streptokinase is recommended in the treatment of proximal deep venous thrombosis. This treatment offers a possibility of preventing a postthrombotic syndrome. The frequency of various complications should however be borne in mind.