Persistent knee pain after uncomplicated total knee arthroplasty secondary to undiagnosed spondylotic myelopathy: a case report

Persistent pain following total knee arthroplasty: The role of underlying diseases

Background

With increasing age and joint-destructive diseases, the need for novel surgeries such as total knee arthroplasty (TKA) has increased. Complications such as pain exacerbation and persistent pain after surgery may occur which increases rehabilitation programs. Factors such as body mass index (BMI), psychiatric disorders, spine diseases, and comorbidities diseases can affect outcomes. Our study was conducted to evaluate the effect of BMI, psychiatric disorders, spine diseases, and underlying diseases on persistent and annoying pain after TKA.

Materials and Methods

This is a case-control study that was conducted on patients who underwent TKA in Kashani Hospital in Isfahan City in 2020-2022. Demographic data of patients including age and BMI, diabetes mellitus (DM), history of psychiatric disorders, spine disorders such as spondylolisthesis or disc herniation, and other underlying diseases were obtained. Patients were assigned to case or control groups based on pain complaints after surgery. All patients were evaluated 6 months after the initial surgery. After collecting the study data, they were entered into SPSS software (version 25, IBM Corporation, Armonk, NY, USA) and analyzed.

Results

We enrolled 35 patients in the case group and 39 patients in the control group between June 2020 and September 2022, based on the severity of pain measured using a Visual Analog Scale score. Our results show that BMI and DM had a meaningful relationship with pain after surgery (P ≤ 0.01). Other factors did not show a significant difference between groups.

Conclusion

Underlying diseases, psychiatric diseases, and spine disorders did not significantly affect the pain after TKA. Patients with DM and higher BMI experienced more persistent pain after TKA.

Knee Pain Following Total Knee Arthroplasty Secondary to Cervical Spondylotic Myelopathy

We report the case of a 78-year-old woman who presented with a 14-month history of progressive bilateral knee spasms and pain and reduced quality of life. The patient had undergone bilateral total knee arthroplasty after a diagnosis of osteoarthritis and failure of conservative treatment. Symptoms reappeared 8 months postoperatively, and the patient was diagnosed with cervical spondylotic myelopathy. Consequently, she was successfully treated with chiropractic rehabilitation which involved scraping therapy, spinal manipulation, and intermittent motorized traction to relieve cervical nerve pressure. Thus, cervical spondylotic myelopathy should be considered in the differential diagnosis of cases of persistent knee pain.

A Retrospective Pilot Study for Preoperative Screening to Prevent Iatrogenic Cervical Spinal Cord Injury

PURPOSE

The preoperative medical clearance process is well established to screen for medical comorbidities and therefore must be thorough. However, screening for potential cervical spine disease is often overlooked. In older surgical candidates, the presence of cervical spondylosis can increase risk of iatrogenic cervical spine injury during prolonged neck extension in non-spinal surgeries. We present a standard protocol for cervical spine clearance and a novel sustained neck extension maneuver through a retrospective case series.

METHODS

Sixty-three consecutive cases that underwent preoperative cervical clearance between April 2012 and December 2019 were reviewed. Referral for clearance occurred through the department of anesthesiology after concerning radiographic or physical exam findings were noted. A standard preoperative screening protocol with a sustained one-minute neck extension maneuver was implemented. Recommendations were made for standard neck precautions with or without neuromonitoring or for cervical spine decompression surgery prior to the planned procedure.

RESULTS

There were 25 patients with symptoms of myelopathy, 11 with radiculopathy and 13 with neck pain at baseline. Cervical spondylosis was observed in 51 patients, cervical canal stenosis in 29 and cervical myelomalacia in six. Fifty-seven patients underwent neck extension exam and 25 exhibited new or worsening symptoms. Myelopathic symptoms and radicular pain at baseline and positive Hoffman's and Spurling's sign, independently, were significantly associated with a positive neck extension exam (p<0.05). Fourteen patients were recommended for cervical decompression prior to planned procedure.

CONCLUSIONS

Our preoperative cervical spine clearance protocol is safe and may aid in identifying patients susceptible to iatrogenic cervical spine injury.