Microsurgical treatment of perimedullary spinal arteriovenous fistulas

Objective: Perimedullary arteriovenous fistulas (PMAVF) are exceptional spinal vascular malformations and their best therapeutic management remains controversial. Here the authors present their experience with PMAVF to characterize the clinical, neuroimaging and treatment data of patients operated on PMAVF and to analyse both incidence of complications and resurgery in the microsurgical therapy of PMAVF. Method: Fifteen patients (13 men, 2 women, mean age 51 years) with PMAVF identified by selective spinal angiography were microsurgically treated at our institution between 1992 and 2006. The presenting symptoms (duration 3 months to 5 years) were consistent with progressive myelopathy (13) or included isolated pain syndrome (2). Lumbar PMAVF location (6) was predominant followed by the sacral (5) and thoracic (4) site including 6 PMAVF of the filum terminale and 2 PMAVF associated with a glomerular AVM and dural arteriovenous fistula, respectively. Microsurgical PMAVF obliteration and postoperative angiography were routinely performed. All patients were available for follow-up evaluation within 6 months postoperatively. Results: Surgery with complete (12) or almost complete (3) PMAVF occlusion resulted in neurological improvement (10) or stabilization (1), 4 patients deteriorated postoperatively. Whereas no complications occured, a second operation because of residual or recanalized PMAVF was indicated in one case each. Two associated dual spinal vascular malformations could be observed and subsequently obliterated. Conclusions: Microsurgical occlusion of PMAVF appears to be a secure and adequate therapeutic option that prevents progressive neurological deterioration and results in good outcome in the majority of patients. Complications associated with surgery, recurrences and reoperations are infrequent. Therefore, in the authors experience microsurgery is the preferred therapy to treat PMAVF. Despite the rarity of PMAVF the possibility of the coincidence of associated second vascular malformations should be considered.

Comparison of cost and outcome of care in patients with low back pain who are managed by physicians or physical therapists in private practice

The purpose of this study was to determine if there were differences in the cost and outcome of care in patients with low back pain who were managed by physicians or physical therapists in private practice in the state of Arizona. A secondary purpose was to describe the current status of private practice physical therapy clinicians who treat patients with low back pain.^ A Survey on Practice was mailed to 194 physical therapists who were listed by the American Physical Therapy Association as being in private practice in Arizona. Eighty-three percent of the surveys were returned after three attempts. Of those which were returned, 72 were complete and included in the analysis.^ The 72 practices were screened to determine those eligible for the second phase of the study. Those eligible for the second phase numbered 52 clinics. Twenty-six practices agreed to participate; however, only 21 did participate. Clinics which participated were sent packets of information which were to be kept on each patient seen with a complaint of low back pain during a three month period. Packets contained a patient-oriented survey on functional activity to be completed before and after the physical therapy course of treatment, as well as a log which was completed by the physical therapist on the type of care given to the patient and an assessment of the outcome of treatment. The patient was asked to fill out a satisfaction survey relative to the care received from the physical therapist and physician, if applicable.^ Although 259 patients were entered into the study, 210 patient logs were available for analysis. Results indicated that generally, there was no difference in cost or outcome as measured by the final functional score, change between the initial and final functional scores, or the therapist-rated outcome between the patients who were managed by physicians or physical therapists when controlling for age and length of time the patient was experiencing pain. Patients were more satisfied with care received from physical therapists as compared to physicians. Age and length of pain were good predictors of the type of referral patients received according to a logistic regression procedure. The initial disability score (IRS) and the time spent in the facility predicted therapist-rated outcome, a good or poor final disability score (FRS), and a good or poor change score. In addition, age predicted FRS and change scores. The time that the therapist spent in direct contact with the patient also predicted the change score.^ These findings of no difference in the cost and outcome of care were discussed as they relate to the practice of medicine and physical therapy. ^

Design and implementation of a multicriteria medical decision support system for diagnosis and treatment

Health care providers face the problem of trying to make decisions with inadequate information and also with an overload of (often contradictory) information. Physicians often choose treatment long before they know which disease is present. Indeed, uncertainty is intrinsic to the practice of medicine. Decision analysis can help physicians structure and work through a medical decision problem, and can provide reassurance that decisions are rational and consistent with the beliefs and preferences of other physicians and patients. ^ The primary purpose of this research project is to develop the theory, methods, techniques and tools necessary for designing and implementing a system to support solving medical decision problems. A case study involving “abdominal pain” serves as a prototype for implementing the system. The research, however, focuses on a generic class of problems and aims at covering theoretical as well as practical aspects of the system developed. ^ The main contributions of this research are: (1) bridging the gap between the statistical approach and the knowledge-based (expert) approach to medical decision making; (2) linking a collection of methods, techniques and tools together to allow for the design of a medical decision support system, based on a framework that involves the Analytic Network Process (ANP), the generalization of the Analytic Hierarchy Process (AHP) to dependence and feedback, for problems involving diagnosis and treatment; (3) enhancing the representation and manipulation of uncertainty in the ANP framework by incorporating group consensus weights; and (4) developing a computer program to assist in the implementation of the system. ^

[Gender differences in acute and chronic pain conditions. Implications for diagnosis and therapy].

Gender differences can influence incidence and outcome of acute and chronic pain conditions. The reasons are to be found in genetic factors, hormonal effects and differences in anatomy and physiology. Furthermore differences relating to psychiatric comorbidities (i.e. depression) and psychosocial factors (roles, coping strategies) have been demonstrated. Men and women differ in the response to drugs and other treatments. They are differently affected by side effects of drugs. There is a gender bias in diagnosis and therapy. There is a need to study the influence of gender, age and race in order to optimize treatment towards a more individualized therapy. This article highlights already identified differences.

Arterial Hypertension Refractory to Renal Denervation, Abdominal Pain and Claudication: Any Coral’ations?

Coral reef aorta is a rare form of calcifying atherosclerosis typically involving the supra and juxtarenal aorta. P atients classically present with refractory hypertension, intermittent claudication and abdominal angina. The treatment is either surgical via transaortic endarterectomy or through transferal endovascular stentgraft placement. Here we describe the case of a 45yearold female patient infected with human immuno deficiency virus, with resistant hypertension, lower limb and abdominal claudication, who was successfully treated with endovascular stent placement. We f urther provide a brief overview of the disease characteristics and treatment options.

Treatment of lower extremity telangiectasias in women by foam sclerotherapy vs. Nd:YAG laser: a prospective, comparative, randomized, open-label trial.

BACKGROUND Telangiectasias of the lower extremities are very common. There are no blinded, randomized, controlled clinical trials comparing laser modalities with the gold standard sclerotherapy, while the few available studies encompass small patients cohorts. OBJECTIVE This prospective, randomized, open-label trial compares the efficacy of sclerotherapy with polidocanol vs. long-pulsed neodymium-doped yttrium aluminium garnet (Nd:YAG) laser in the treatment of leg telangiectasias. PATIENTS AND METHODS Fifty-six female patients with primary leg telangiectasias and reticular veins (C1A or S Ep AS 1 PN ) were included in the study. One leg was randomly assigned to get treatment with the multiple synchronized long-pulsed Nd:YAG laser, while the other received foam sclerotherapy with polidocanol 0.5%. The patients were treated in two sessions at intervals of 6 weeks. The patients were evaluated by the handling physician after 6 weeks and 6 months. Two investigators assessed blindly at the end of the study the photographs for clearing of the vessels using a six-point scale from 1 (no change) to 6 (100% cleared). Patients reported about pain sensation and outcome satisfaction. RESULTS According to the handling dermatologist, at the last follow-up, there was an improvement of 30-40% with a median of 3 (IQR 2) and a good improvement of 50-70% with a median of 4 (IQR 2) after laser treatment and sclerotherapy respectively. In contrast, according to the blinded investigators, there was a median of 5 (IQR 1) with a very good improvement of >70% after both therapies. Improvement was achieved more quickly by sclerotherapy, although at the last follow-up visit there was no difference in clearance between the two groups as assessed by the blinded experts (P-value 0.84). The degree of patient's satisfaction was very good and similar with both therapeutic approaches. There was a significant difference (P-value 0.003) regarding pain perception between the types of therapy. Laser was felt more painful than sclerotherapy. CONCLUSION Telangiectasias of the lower extremities can be successfully treated with either synchronized long-pulsed Nd:YAG laser or sclerotherapy. The 1064-nm long-pulsed Nd:YAG laser is associated with more pain and is suitable especially in case of needle phobia, allergy to sclerosants and in presence of small veins with telangiectatic matting, while sclerotherapy can also treat the feeder veins.

Acupuncture for post anaesthetic recovery and postoperative pain: study protocol for a randomised controlled trial.

BACKGROUND We report on the design and implementation of a study protocol entitled Acupuncture randomised trial for post anaesthetic recovery and postoperative pain - a pilot study (ACUARP) designed to investigate the effectiveness of acupuncture therapy performed in the perioperative period on post anaesthetic recovery and postoperative pain. METHODS/DESIGN The study is designed as a randomised controlled pilot trial with three arms and partial double blinding. We will compare (a) press needle acupuncture, (b) no treatment and (c) press plaster acupressure in a standardised anaesthetic setting. Seventy-five patients scheduled for laparoscopic surgery to the uterus or ovaries will be allocated randomly to one of the three trial arms. The total observation period will begin one day before surgery and end on the second postoperative day. Twelve press needles and press plasters are to be administered preoperatively at seven acupuncture points. The primary outcome measure will be time from extubation to 'ready for discharge' from the post anaesthesia care unit (in minutes). The 'ready for discharge' end point will be assessed using three different scores: the Aldrete score, the Post Anaesthetic Discharge Scoring System and an In-House score. Secondary outcome measures will comprise pre-, intra- and postoperative variables (which are anxiety, pain, nausea and vomiting, concomitant medication). DISCUSSION The results of this study will provide information on whether acupuncture may improve patient post anaesthetic recovery. Comparing acupuncture with acupressure will provide insight into potential therapeutic differences between invasive and non-invasive acupuncture techniques. TRIAL REGISTRATION NCT01816386 (First received: 28 October 2012).

The modified coronally advanced tunnel combined with an enamel matrix derivative and subepithelial connective tissue graft for the treatment of isolated mandibular Miller Class I and II gingival recessions: a report of 16 cases.

OBJECTIVES To clinically evaluate the healing of mandibular Miller Class I and II isolated gingival recessions treated with the modified coronally advanced tunnel (MCAT) in conjunction with an enamel matrix derivative (EMD) and subepithelial connective tissue graft (SCTG). METHOD AND MATERIALS Sixteen healthy patients (13 women and 3 men) exhibiting one isolated mandibular Miller Class I and II gingival recessions of a depth of ≥ 3 mm, were consecutively treated with the MCAT in conjunction with EMD and SCTG. Treatment outcomes were assessed at baseline and at 12 months postoperatively. The primary outcome variable was complete root coverage (CRC) (eg, 100% root coverage). RESULTS Postoperative pain and discomfort were low and no complications such as postoperative bleeding, allergic reactions, abscesses, or loss of SCTG were observed. At 12 months, statistically significant (P < .0001) root coverage was obtained in all 16 defects. CRC was measured in 12 out of the 16 cases (75%) while in the remaining 4 defects root coverage amounted to 90% (in two cases) and 80% (in two cases), respectively. Mean root coverage was 96.25%. Mean keratinized tissue width increased from 1.98 ± 0.8 mm at baseline to 2.5 ± 0.9 mm (P < .0001) at 12 months, while mean probing depth did not show any statistically significant changes (ie, 1.9 ± 0.3 mm at baseline vs 1.8 ± 0.2 mm at 12 months). CONCLUSION Within their limits, the present results indicate that the described treatment approach may lead to predictable root coverage of isolated mandibular Miller Class I and II gingival recessions.

Nerve stimulator-guided sciatic-femoral nerve block in raptors undergoing surgical treatment of pododermatitis.

OBJECTIVE To describe the nerve stimulator-guided sciatic-femoral nerve block in raptors undergoing surgical treatment of pododermatitis. STUDY DESIGN Prospective clinical trial. ANIMALS Five captive raptors (Falco peregrinus) aged 6.7 ± 1.3 years. METHODS Anaesthesia was induced and maintained with isoflurane in oxygen. The sciatic-femoral nerve block was performed with 2% lidocaine (0.05 mL kg(-1) per nerve) as the sole intra-operative analgesic treatment. Intraoperative physiological variables were recorded every 10 minutes from endotracheal intubation until the end of anaesthesia. Assessment of intraoperative nociception was based on changes in physiological variables above baseline values, while evaluation of postoperative pain relied on species-specific behavioural indicators. RESULTS The sciatic-femoral nerve block was feasible in raptors and the motor responses following electrical stimulation of both nerves were consistent with those reported in mammalian species. During surgery no rescue analgesia was required. The anaesthesia plane was stable and cardiorespiratory variables did not increase significantly in response to surgical stimulation. Iatrogenic complications, namely nerve damage and local anaesthetic toxicity, did not occur. Recovery was smooth and uneventful. The duration (mean ± SD) of the analgesic effect provided by the nerve block was 130 ± 20 minutes. CONCLUSION AND CLINICAL RELEVANCE The sciatic-femoral nerve block as described in dogs and rabbits can be performed in raptors as well. Further clinical trials with a control groups are required to better investigate the analgesic efficacy and the safety of this technique in raptors.

Sono-Electro-Magnetic Therapy for Treating Chronic Pelvic Pain Syndrome in Men: A Randomized, Placebo-Controlled, Double-Blind Trial.

OBJECTIVE To assess the efficacy and safety of sono-electro-magnetic therapy compared to placebo in men with refractory CPPS. PATIENTS AND METHODS In a randomized, placebo-controlled, double-blind single center trial, we assessed the effect of sono-electro-magnetic therapy in men with treatment refractory CPPS. Sixty male patients were randomly assigned to treatment with either sono-electro-magnetic (n = 30) or placebo therapy (n = 30) for 12 weeks. The primary outcome was a change in the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) from baseline to 12 weeks. RESULTS The 12-week difference between sono-electro-magnetic and placebo therapy in changes of the NIH-CPSI total score was -3.1 points (95% CI -6.8 to 0.6, p = 0.11). In secondary comparisons of NIH-CPSI sub-scores, we found differences between groups most pronounced for the quality-of-life sub-score (difference at 12 weeks -1.6, 95% CI -2.8 to -0.4, p = 0.015). In stratified analyses, the benefit of sono-electro-magnetic therapy appeared more pronounced among patients who had a symptom duration of 12 months or less (difference in NIH-CPSI total score -8.3, 95% CI -14.5 to 2.6) than in patients with a longer symptom duration (-0.8, 95% CI -4.6 to 3.1; p for interaction = 0.023). CONCLUSIONS Sono-electro-magnetic therapy did not result in a significant improvement of symptoms in the overall cohort of treatment refractory CPPS patients compared to placebo treatment. Subgroup analysis indicates, however, that patients with a symptom-duration of 12 months or less may benefit from sono-electro-magnetic therapy, warranting larger randomized controlled trials in this subpopulation. TRIAL REGISTRATION ClinicalTrials.gov NCT00688506.

Head Reduction Osteotomy With Additional Containment Surgery Improves Sphericity and Containment and Reduces Pain in Legg-Calvé-Perthes Disease.

BACKGROUND Severe femoral head deformities in the frontal plane such as hips with Legg-Calvé-Perthes disease (LCPD) are not contained by the acetabulum and result in hinged abduction and impingement. These rare deformities cannot be addressed by resection, which would endanger head vascularity. Femoral head reduction osteotomy allows for reshaping of the femoral head with the goal of improving head sphericity, containment, and hip function. QUESTIONS/PURPOSES Among hips with severe asphericity of the femoral head, does femoral head reduction osteotomy result in (1) improved head sphericity and containment; (2) pain relief and improved hip function; and (3) subsequent reoperations or complications? METHODS Over a 10-year period, we performed femoral head reduction osteotomies in 11 patients (11 hips) with severe head asphericities resulting from LCPD (10 hips) or disturbance of epiphyseal perfusion after conservative treatment of developmental dysplasia (one hip). Five of 11 hips had concomitant acetabular containment surgery including two triple osteotomies, two periacetabular osteotomies (PAOs), and one Colonna procedure. Patients were reviewed at a mean of 5 years (range, 1-10 years), and none was lost to followup. Mean patient age at the time of head reduction osteotomy was 13 years (range, 7-23 years). We obtained the sphericity index (defined as the ratio of the minor to the major axis of the ellipse drawn to best fit the femoral head articular surface on conventional anteroposterior pelvic radiographs) to assess head sphericity. Containment was assessed evaluating the proportion of patients with an intact Shenton's line, the extrusion index, and the lateral center-edge (LCE) angle. Merle d'Aubigné-Postel score and range of motion (flexion, internal/external rotation in 90° of flexion) were assessed to measure pain and function. Complications and reoperations were identified by chart review. RESULTS At latest followup, femoral head sphericity (72%; range, 64%-81% preoperatively versus 85%; range, 73%-96% postoperatively; p = 0.004), extrusion index (47%; range, 25%-60% versus 20%; range, 3%-58%; p = 0.006), and LCE angle (1°; range, -10° to 16° versus 26°; range, 4°-40°; p = 0.0064) were improved compared with preoperatively. With the limited number of hips available, the proportion of an intact Shenton's line (64% versus 100%; p = 0.087) and the overall Merle d'Aubigné-Postel score (14.5; range, 12-16 versus 15.7; range, 12-18; p = 0.072) remained unchanged at latest followup. The Merle d'Aubigné-Postel pain subscore improved (3.5; range, 1-5 versus 5.0; range, 3-6; p = 0.026). Range of motion was not observed to have improved with the numbers available (p ranging from 0.513 to 0.778). In addition to hardware removal in two hips, subsequent surgery was performed in five of 11 hips to improve containment after a mean interval of 2.3 years (range, 0.2-7.5 years). Of those, two hips had triple osteotomy, one hip a combined triple and valgus intertrochanteric osteotomy, one hip an intertrochanteric varus osteotomy, and one hip a PAO with a separate valgus intertrochanteric osteotomy. No avascular necrosis of the femoral head occurred. CONCLUSIONS Femoral head reduction osteotomy can improve femoral head sphericity. Improved head containment in these hips with an often dysplastic acetabulum requires additional acetabular containment surgery, ideally performed concomitantly. This can result in reduced pain and avascular necrosis seems to be rare. With the number of patients available, function did not improve. Therefore, future studies should use more precise instruments to evaluate clinical outcome and include longer followup to confirm joint preservation. LEVEL OF EVIDENCE Level IV, therapeutic study.

Surgical hip dislocation for treatment of femoroacetabular impingement: factors predicting 5-year survivorship.

BACKGROUND Patients with femoroacetabular impingement (FAI) often develop pain, impaired function, and progression of osteoarthritis (OA); this is commonly treated using surgical hip dislocation, femoral neck and acetabular rim osteoplasty, and labral reattachment. However, results with these approaches, in particular risk factors for OA progression and conversion to THA, have varied. QUESTIONS/PURPOSES We asked if patients undergoing surgical hip dislocation with labral reattachment to treat FAI experienced (1) improved hip pain and function; and (2) prevention of OA progression; we then determined (3) the survival of the hip at 5-year followup with the end points defined as the need for conversion to THA, progression of OA by at least one Tönnis grade, and/or a Merle d'Aubigné-Postel score less than 15; and calculated (4) factors predicting these end points. METHODS Between July 2001 and March 2003, we performed 146 of these procedures in 121 patients. After excluding 35 patients (37 hips) who had prior open surgery and 11 patients (12 hips) who had a diagnosis of Perthes disease, this study evaluated the 75 patients (97 hips, 66% of the procedures we performed during that time) who had a mean followup of 6 years (range, 5-7 years). We used the anterior impingement test to assess pain, the Merle d'Aubigné-Postel score to assess function, and the Tönnis grade to assess OA. Survival and predictive factors were calculated using the method of Kaplan and Meier and Cox regression, respectively. RESULTS The proportion of patients with anterior impingement decreased from 95% to 17% (p < 0.001); the Merle d'Aubigné-Postel score improved from a mean of 15 to 17 (p < 0.001). Seven hips (7%) showed progression of OA and another seven hips (7%) converted to THA Survival free from any end point (THA, progression of OA, or a Merle d'Aubigné-Postel < 15) of well-functioning joints at 5 years was 91%; and excessive acetabular rim trimming, preoperative OA, increased age at operation, and weight were predictive factors for the end points. CONCLUSIONS At 5-year followup, 91% of patients with FAI treated with surgical hip dislocation, osteoplasty, and labral reattachment showed no THA, progression of OA, or an insufficient clinical result, but excessive acetabular trimming, OA, increased age, and weight were associated with early failure. To prevent early deterioration of the joint, excessive rim trimming or trimming of borderline dysplastic hips has to be avoided.

Is thermochemotherapy with the Synergo system a viable treatment option in patients with recurrent non-muscle-invasive bladder cancer?

OBJECTIVES To prospectively evaluate the outcome of combined microwave-induced bladder wall hyperthermia and intravesical mitomycin C instillation (thermochemotherapy) in patients with recurrent non-muscle-invasive bladder cancer. METHODS Between 2003 and 2009, 21 patients (median age 70 years, range 35-95 years) with recurrent non-muscle-invasive bladder cancer (pTaG1-2 n = 9; pTaG3 n = 3; pT1 n = 9; concurrent pTis n = 8) were prospectively enrolled. Of 21 patients, 15 (71%) had received previous intravesical instillations with bacillus Calmette-Guérin, mitomycin C and/or farmorubicin. Thermochemotherapy using the Synergo system was carried out in 11 of 21 patients (52%) with curative intent, and in 10 of 21 patients (48%) as prophylaxis against recurrence. RESULTS The median number of thermochemotherapy cycles per patient was six (range 1-12). Adverse effects were frequent and severe: urinary urgency/frequency in 11 of 21 patients (52%), pain in eight of 21 patients (38%) and gross hematuria in five of 21 patients (24%). In eight of 21 patients (38%), thermochemotherapy had to be abandoned because of the severity of the adverse effects (pain in 3/8, severe bladder spasms in 2/8, allergic reaction in 2/8, urethral perforation in 1/8). Overall, six of 21 patients (29%) remained free of tumor after a median follow up of 50 months (range 1-120), six of 21 patients (29%) had to undergo cystectomy because of multifocal recurrences or cancer progression and seven of 21 patients (33%) died (2/7 of metastatic disease, 5/7 of non-cancer related causes). CONCLUSIONS Given the high rate of severe side-effects leading to treatment discontinuation, as well as the limited tumor response, thermochemotherapy should be offered only in highly selected cases of recurrent non-muscle-invasive bladder cancer.

p.L1612P, a Novel Voltage-gated Sodium Channel Nav1.7 Mutation Inducing a Cold Sensitive Paroxysmal Extreme Pain Disorder

BACKGROUND Mutations in the SCN9A gene cause chronic pain and pain insensitivity syndromes. We aimed to study clinical, genetic, and electrophysiological features of paroxysmal extreme pain disorder (PEPD) caused by a novel SCN9A mutation. METHODS Description of a 4-generation family suffering from PEPD with clinical, genetic and electrophysiological studies including patch clamp experiments assessing response to drug and temperature. RESULTS The family was clinically comparable to those reported previously with the exception of a favorable effect of cold exposure and a lack of drug efficacy including with carbamazepine, a proposed treatment for PEPD. A novel p.L1612P mutation in the Nav1.7 voltage-gated sodium channel was found in the four affected family members tested. Electrophysiologically the mutation substantially depolarized the steady-state inactivation curve (V1/2 from -61.8 ± 4.5 mV to -30.9 ± 2.2 mV, n = 4 and 7, P < 0.001), significantly increased ramp current (from 1.8% to 3.4%, n = 10 and 12) and shortened recovery from inactivation (from 7.2 ± 5.6 ms to 2.2 ± 1.5 ms, n = 11 and 10). However, there was no persistent current. Cold exposure reduced peak current and prolonged recovery from inactivation in wild-type and mutated channels. Amitriptyline only slightly corrected the steady-state inactivation shift of the mutated channel, which is consistent with the lack of clinical benefit. CONCLUSIONS The novel p.L1612P Nav1.7 mutation expands the PEPD spectrum with a unique combination of clinical symptoms and electrophysiological properties. Symptoms are partially responsive to temperature but not to drug therapy. In vitro trials of sodium channel blockers or temperature dependence might help predict treatment efficacy in PEPD.

Operation bei asymptomatischer Inguinalhernie – unnötig?

Until recently, the repair of asymptomatic groin hernia has been advocated as a prophylaxis for incarceration. However, incarcerations of inguinal hernias are rare events and can be treated adequately if the patient presents himself early after onset of symptoms. Randomized controlled trials showed, that watchful waiting is not associated with increased incarcerations and can be offered as a save alternative. However, within seven years after randomization 50 % to 70 % of the patients in the watchful waiting groups required surgery, mainly because of new onset or increasing symptoms.