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Nadler R, Tsur AM, Lipsky AM, Benov A, Sorkin A, Glassberg E, Chen J. Trends in combat casualty care following the publication of clinical practice guidelines. J Trauma Acute Care Surg 2021; 91:S194-S200. [PMID: 34039926 DOI: 10.1097/ta.0000000000003280] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The current study explores the trends in the application of combat casualty care following the publication of clinical practice guidelines (CPGs) in five domains for 13 years. METHODS The Israel Defense Forces Trauma Registry was used to assess practice and adherence to guidelines in five domains: (a) crystalloid transfusions, (b) tranexamic acid use, (c) freeze-dried plasma use, (d) chest decompression, and (e) airway management. All patients injured between January 2006 and December 2018 were included in the analysis. Trends were analyzed and presented monthly using linear regression and were compared using the Chow test. RESULTS The mean ± SD crystalloid volume transfused decreased from 1,179 ± 653 mL in 2006 to 466 ± 202 mL in 2018 (B = 0.016, 0.006-0.044). The proportion of patients with an indication treated with tranexamic acid dropped from 8% (238 of 2,979 patients) to 2.5% (60 of 2,356 patients) following the stricter guideline's publication. Freeze-dried plasma administration in indicated casualties rose from 12.5% in 2013 to 48% in 2018 (B = 1.63, 1.3-2.05). The overall proportion of casualties undergoing chest decompression rose from 1% (61 of 6,036 casualties) to 1.5% (155 of 10,493 casualties) following the release of a new CPG in 2012 (p = 0.013). There were no significant trends in intubation ratios before (B = 0.987, 0.953-1.02) or after 2012 (B = 10.2, 0.996-1.05). CONCLUSION Some aspects demonstrate the desired trends in response to new CPGs; in others, initial improvement is achieved but followed by stagnation. In some medical care aspects, completely unexpected and undesirable trends are observed. Every change and update in CPGs should be based on reliable data. The effect of every change must be monitored carefully to ensure adequate adherence to lifesaving guidelines. LEVEL OF EVIDENCE Epidemiological study, level IV.
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Affiliation(s)
- Roy Nadler
- From the Trauma and Combat Medicine Branch (R.N., A.M.T., A.B., A.S., E.G., J.C.), Israel Defense Forces, Medical Corps; Department of General Surgery and Transplantation-Surgery B (R.N.), Chaim Sheba Medical Center; Department of Medicine 'B' (A.M.T.), Sheba Medical Center, Tel Hashomer, Ramat Gan; Department of Emergency Medicine (A.M.L.), Rambam Health Care Campus, Haifa; The Azrieli Faculty of Medicine (A.B., E.G.), Bar-Ilan University, Safad, Israel; School of Medicine, Uniformed Services University of the Health Sciences (E.G.), Bethesda, Maryland; and Central Management, Meir Medical Center (J.C.), Kfar Saba; Sackler School of Medicine (J.C.), Tel Aviv University, Tel Aviv, Israel
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Qiao XF, Liu SC, Xue Y, Ji QH. Efficacy of extracorporeal shock wave combined spinal core decompression for the treatment of patients with femoral head necrosis: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e20350. [PMID: 32481326 PMCID: PMC7249869 DOI: 10.1097/md.0000000000020350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Previous studies have reported that extracorporeal shock wave (EPSW) combined spinal core decompression (SCD) has been used for the treatment of patients with femoral head necrosis (FHN) effectively. However, their results are still inconsistent. Therefore, this study will systematically assess the efficacy and safety of EPSW and SCD for the treatment of patients with FHN. METHODS This study will systematically search the following databases from inception through March 1, 2020: MEDLINE, Web of Science, Scopus, EMBASE, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, and China National Knowledge Infrastructure. All searches will be performed without language and publication date restrictions. This study will only include randomized controlled trials investigating the efficacy and safety of EPSW and SCD for the treatment of patients with FHN. Two authors will independently assess all literatures, extract data, and appraise risk of bias. Any confusion between 2 authors will be cleared up by a third author through discussion. RevMan 5.3 software will be utilized to analyze the data and to perform a meta-analysis if necessary. RESULTS This study will summarize up-to-date evidence and provide a detailed summary related to the efficacy and safety of EPSW and SCD for the treatment of patients with FHN. CONCLUSION This study may provide helpful evidence to determine whether or not EPSW combined SCD is effective and safety for the treatment of patients with FHN. SYSTEMATIC REVIEW REGISTRATION INPLASY202040092.
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Affiliation(s)
- Xiao-feng Qiao
- First Ward of Orthopedis Department, First Affiliated Hospital of Jiamusi University
| | - Shi-chen Liu
- First Ward of Orthopedis Department, First Affiliated Hospital of Jiamusi University
| | - Yu Xue
- Department of Obstetrics and Gynecology, Second Affiliated Hospital of Jiamusi University, Jiamusi, China
| | - Qing-hui Ji
- First Ward of Orthopedis Department, First Affiliated Hospital of Jiamusi University
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Kjærvik C, Lundgreen K. Wrong can be right. Tidsskr Nor Laegeforen 2019; 139:19-0269. [PMID: 31140254 DOI: 10.4045/tidsskr.19.0269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Abstract
The aim of the study was to observe the curative effect of long intestinal tube (LT) in the treatment of phytobezoar intestinal obstruction.We performed a retrospective study of patients with phytobezoar intestinal obstruction who underwent decompression with different tube insertion method. A total of 80 patients were collected and divided into nasogastric tube (NGT) group (n = 36) and LT group (n = 44) between August 2015 and August 2018 at our hospital. Univariate analysis was used to assess the clinical efficacy of 2 groups of patients.There were no significant differences in the mean age, sex ratio, and previous surgical history between the 2 groups. There were statistically significant differences between the 2 groups in terms of improvement time of clinical indications (4.2 ± 1.4 vs 2.5 ± 0.6 days; P = .008), liquid decompression amount on the first day of catheterization (870.4 ± 400.8 vs 1738.4 ± 460.2 mL; P = .000), transit operation rate (4/36 vs 0/44; P = .023), clinical cure rate (25/36 vs 40/44; P = .014), total treatment efficiency (32/36 vs 44/44; P = .023), and total hospitalization cost (3.25 ± 0.39 vs 2.07 ± 0.41 ¥ ten thousand; P = .000).The curative effect of LT in the treatment of phytobezoar intestinal obstruction is accurate and reliable, which can effectively improve the clinical symptoms of patients, comprehensively improve the non-surgical rate of intestinal obstruction treatment, reduce the total cost of hospitalization, and is worthy of promotion in clinical application.
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Affiliation(s)
- Liang Li
- Department of Gastrointestinal Surgery
| | - Bing Xue
- Department of Internal Medicine, Zibo Central Hospital of Shandong University, Zibo, Shandong, China
| | | | | | | | - Qing Cui
- Department of Gastrointestinal Surgery
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Abstract
Aims Although there have been many studies about lumbar and cervical ablation procedures, few studies have been performed in the thoracic region. To evaluate the clinical results of a percutaneous disc decompression device in patients with radicular symptoms and/or dorsal pain due to thoracic disc herniation. Methods Eleven patients with thoracic disc herniation and/or degenerative discs (all in T10-T11, or T11-T12 levels) who did not respond to conservative treatments were undergoing ablation and compression procedures. Pain and radicular symptoms consistent with the thoracolumbar region were confirmed via abnormal magnetic resonance imaging findings after detailed anamnesis and physical examination. All patients were evaluated before and 1, 3, 6, and 12 months after treatment using the visual analog scale score. The patient satisfaction scale was used to evaluate the level of patient satisfaction at the end of the treatment at 12 months. Results The median visual analog scale score was 7.00±0.45 points before treatment and 2.73±0.65 points at 12 months post-procedure and were statistically significant (p<0.001). The results of pairwise comparisons using the Bonferroni Corrected Wilcoxon Signed-Rank test showed that there were statistically significant differences. The mean visual analog scale score at the beginning (7.00±0.45) was significantly higher than the mean score of other months. Postoperative improvement was significant with a 99% confidence interval. No complications that may cause permanent damage occurred. Conclusion Percutaneous disc decompression is an effective and safe procedure to treat pain caused by lower thoracic intervertebral disc disease, which did not respond to conservative treatments.
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Affiliation(s)
- Ayşegül Ceylan
- Department of Anesthesiology and Reanimation, University of Health Sciences, Gülhane Training and Research Hospital, Ankara, Turkey
| | - Güngör Enver Özgencil
- Department of Anesthesiology and Reanimation, Ankara University Faculty of Medicine Hospital, Ankara, Turkey
| | - Burak Erken
- Department of Anesthesiology and Reanimation, Ankara University Faculty of Medicine Hospital, Ankara, Turkey
| | - İbrahim Aşık
- Department of Anesthesiology and Reanimation, Ankara University Faculty of Medicine Hospital, Ankara, Turkey
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Hao Q, Devji T, Zeraatkar D, Wang Y, Qasim A, Siemieniuk RAC, Vandvik PO, Lähdeoja T, Carrasco-Labra A, Agoritsas T, Guyatt G. Minimal important differences for improvement in shoulder condition patient-reported outcomes: a systematic review to inform a BMJ Rapid Recommendation. BMJ Open 2019; 9:e028777. [PMID: 30787096 PMCID: PMC6398656 DOI: 10.1136/bmjopen-2018-028777] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES To identify credible anchor-based minimal important differences (MIDs) for patient-reported outcome measures (PROMs) relevant to a BMJ Rapid Recommendations addressing subacromial decompression surgery for shoulder pain. DESIGN Systematic review. OUTCOME MEASURES Estimates of anchor-based MIDs, and their credibility, for PROMs judged by the parallel BMJ Rapid Recommendations panel as important for informing their recommendation (pain, function and health-related quality of life (HRQoL)). DATA SOURCES MEDLINE, EMBASE and PsycINFO up to August 2018. STUDY SELECTION AND REVIEW METHODS We included original studies of any intervention for shoulder conditions reporting estimates of anchor-based MIDs for relevant PROMs. Two reviewers independently evaluated potentially eligible studies according to predefined selection criteria. Six reviewers, working in pairs, independently extracted data from eligible studies using a predesigned, standardised, pilot-tested extraction form and independently assessed the credibility of included studies using an MID credibility tool. RESULTS We identified 22 studies involving 5562 patients that reported 74 empirically estimated anchor-based MIDs for 10 candidate instruments to assess shoulder pain, function and HRQoL. We identified MIDs of high credibility for pain and function outcomes and of low credibility for HRQoL. We offered median estimates for the systematic review team who applied these MIDs in Grading of Recommendations Assessment, Development and Evaluation (GRADE) evidence summaries and in their interpretations of results in the linked systematic review addressing the effectiveness of surgery for shoulder pain. CONCLUSIONS Our review provides anchor-based MID estimates, as well as a rating of their credibility, for PROMs for patients with shoulder conditions. The MID estimates inform the interpretation for a linked systematic review and guideline addressing subacromial decompression surgery for shoulder pain, and could also prove useful for authors addressing other interventions for shoulder problems. PROSPERO REGISTRATION NUMBER CRD42018106531.
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Affiliation(s)
- Qiukui Hao
- The Center of Gerontology and Geriatrics/ National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Tahira Devji
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Dena Zeraatkar
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Yuting Wang
- The Center of Gerontology and Geriatrics/ National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Anila Qasim
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Reed A C Siemieniuk
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Per Olav Vandvik
- Department of Medicine, Innlandet Hospital Trust-division, Gjøvik, Norway
- Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Tuomas Lähdeoja
- Finnish Center of Evidence Based Orthopaedics (FICEBO), University of Helsinki, Helsinki, Finland
- Department of Orthopaedics and Traumatology, HUS Helsinki University Hospital, Helsinki, Finland
| | - Alonso Carrasco-Labra
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Thomas Agoritsas
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of General Internal Medicine and Division of Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
| | - Gordon Guyatt
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Vandvik PO, Lähdeoja T, Ardern C, Buchbinder R, Moro J, Brox JI, Burgers J, Hao Q, Karjalainen T, van den Bekerom M, Noorduyn J, Lytvyn L, Siemieniuk RAC, Albin A, Shunjie SC, Fisch F, Proulx L, Guyatt G, Agoritsas T, Poolman RW. Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline. BMJ 2019; 364:l294. [PMID: 30728120 DOI: 10.1136/bmj.l294] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
CLINICAL QUESTION Do adults with atraumatic shoulder pain for more than 3 months diagnosed as subacromial pain syndrome (SAPS), also labelled as rotator cuff disease, benefit from subacromial decompression surgery? This guideline builds on to two recent high quality trials of shoulder surgery. CURRENT PRACTICE SAPS is the common diagnosis for shoulder pain with several first line treatment options, including analgesia, exercises, and injections. Surgeons frequently perform arthroscopic subacromial decompression for prolonged symptoms, with guidelines providing conflicting recommendations. RECOMMENDATION The guideline panel makes a strong recommendation against surgery. HOW THIS GUIDELINE WAS CREATED A guideline panel including patients, clinicians, and methodologists produced this recommendation in adherence with standards for trustworthy guidelines and the GRADE system. The recommendation is based on two linked systematic reviews on (a) the benefits and harms of subacromial decompression surgery and (b) the minimally important differences for patient reported outcome measures. Recommendations are made actionable for clinicians and their patients through visual overviews. These provide the relative and absolute benefits and harms of surgery in multilayered evidence summaries and decision aids available in MAGIC (www.magicapp.org) to support shared decisions and adaptation. THE EVIDENCE Surgery did not provide important improvements in pain, function, or quality of life compared with placebo surgery or other options. Frozen shoulder may be more common with surgery. UNDERSTANDING THE RECOMMENDATION The panel concluded that almost all informed patients would choose to avoid surgery because there is no benefit but there are harms and it is burdensome. Subacromial decompression surgery should not be offered to patients with SAPS. However, there is substantial uncertainty in what alternative treatment is best.
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Affiliation(s)
- Per Olav Vandvik
- Department of Medicine, Lovisenberg Diaconal Hospital, Oslo, Norway
- Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Tuomas Lähdeoja
- Finnish Center of Evidence based Orthopaedics (FICEBO), University of Helsinki, Helsinki, Finland
- Department of Orthopaedics and Traumatology, HUS Helsinki University Hospital, Helsinki, Finland
| | - Clare Ardern
- Division of Physiotherapy, Linköping University, Linköping, Sweden
- School of Allied Health, La Trobe University, Melbourne, Australia
| | - Rachelle Buchbinder
- Monash Department of Clinical Epidemiology, Cabrini Institute and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University
| | - Jaydeep Moro
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Jens Ivar Brox
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital and Faculty of Medicine, University of Oslo, Norway
| | - Jako Burgers
- Dutch College of General Practitioners, Utrecht, The Netherlands
- Care and Public Health Research Institute, Department Family Medicine, Maastricht, The Netherlands
| | - Qiukui Hao
- Center of Gerontology and Geriatrics (National Clinical Research Center for Geriatrics), West China Hospital, Sichuan University, Chengdu, China
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Teemu Karjalainen
- Monash Department of Clinical Epidemiology, Cabrini Institute and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University
| | - Michel van den Bekerom
- Department of Orthopaedic Surgery and Traumatology, Joint Research, OLVG, Amsterdam, The Netherlands
| | - Julia Noorduyn
- Department of Orthopaedic Surgery and Traumatology, Joint Research, OLVG, Amsterdam, The Netherlands
| | - Lyubov Lytvyn
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Reed A C Siemieniuk
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | | | | | | | | | - Gordon Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Thomas Agoritsas
- Division General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
| | - Rudolf W Poolman
- Department of Orthopaedic Surgery and Traumatology, Joint Research, OLVG, Amsterdam, The Netherlands
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Van Damme L, De Waele JJ. Effect of decompressive laparotomy on organ function in patients with abdominal compartment syndrome: a systematic review and meta-analysis. Crit Care 2018; 22:179. [PMID: 30045753 PMCID: PMC6060511 DOI: 10.1186/s13054-018-2103-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 06/20/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Decompressive laparotomy has been advised as potential treatment for abdominal compartment syndrome (ACS) when medical management fails; yet, the effect on parameters of organ function differs markedly in the published literature. In this study, we sought to investigate the effect of decompressive laparotomy on intra-abdominal pressure and organ function in critically ill adult and pediatric patients with ACS, specifically focusing on hemodynamic, respiratory, and kidney function and outcome. METHODS A systematic review and meta-analysis of the literature was performed. Articles reporting data on intra-abdominal pressure (IAP), hemodynamic (mean arterial pressures [MAP], central venous pressure [CVP], cardiac index [CI], heart rate [HR], systemic vascular resistance index [SVRI] and/or pulmonary capillary wedge pressure [PCWP]), respiratory (positive end-expiratory pressure [PEEP], peak inspiratory pressure [PIP] and/or ratio of partial pressure arterial oxygen and fraction of inspired oxygen [P/F ratio]), and/or urinary output (UO) following decompressive laparotomy were analyzed. RESULTS A total of 15 articles were included; 3 included children only (aged 18 years or younger). Of the 286 patients who were included, 49.7% had primary ACS. The baseline mean IAP in adults decreased with an average of 18.2 ± 6.5 mmHg following decompression, from 31.7 ± 6.4 mmHg to 13.5 ± 3.0 mmHg. There was a decrease in HR (12.2 ± 9.5 beats/min; p = 0.04), CVP (4.6 ± 2.3 mmHg; p = 0.022), PCWP (5.8 ± 2.3 mmHg; p = 0.029), and PIP (10.1 ± 3.9 cmH2O; p < 0.001) and a mean increase in P/F ratio (70.4 ± 49.4; p < 0.001) and UO (95.3 ± 105.3 ml/h; p < 0.001). In children, there was a significant increase in MAP (20.0 ± 2.3 mmHg; p = 0.006), P/F ratio (238.2; p < 0.001), and UO (2.88 ± 0.64 ml/kg/h; p < 0.001) and a decrease in CVP (7 mmHg; p = 0.016) and PIP (9.9 cmH2O; p = 0.002). The overall mortality rate was 49.7% in adults and 60.8% in children following decompressive laparotomy. CONCLUSIONS Decompressive laparotomy resulted in a significantly lower IAP and had beneficial effects on hemodynamic, respiratory, and renal parameters. Mortality after decompressive laparotomy remains high in both adults and children.
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Affiliation(s)
- Lana Van Damme
- Faculty of Medicine and Health Sciences, Ghent University, C. Heymanslaan 10, 9000 Ghent, Belgium
| | - Jan J. De Waele
- Department of Critical Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000 Ghent, Belgium
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Schoenfeld AJ, Sturgeon DJ, Burns CB, Hunt TJ, Bono CM. Establishing benchmarks for the volume-outcome relationship for common lumbar spine surgical procedures. Spine J 2018; 18:22-28. [PMID: 28887272 DOI: 10.1016/j.spinee.2017.08.263] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 08/29/2017] [Accepted: 08/29/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The importance of surgeon volume as a quality measure has been defined for a number of surgical specialties. Meaningful procedural volume benchmarks have not been established, however, particularly with respect to lumbar spine surgery. PURPOSE We aimed to establish surgeon volume benchmarks for the performance of four common lumbar spine surgical procedures (discectomy, decompression, lumbar interbody fusion, and lumbar posterolateral fusion). STUDY DESIGN A retrospective review of data in the Florida Statewide Inpatient Dataset (2011-2014) was carried out. PATIENT SAMPLE Patients who underwent one of the four lumbar spine surgical procedures under study comprised the study sample. OUTCOME MEASURE The development of a complication or hospital readmission within 90 days of the surgical procedure was the surgical outcome. METHODS For each specific procedure, individual surgeon volume was separately plotted against the number of complications and readmissions in a spline analysis that adjusted for co-variates. Spline cut-points were used to create a categorical variable of procedure volume for each individual procedure. Log-binomial regression analysis was then separately performed using the categorical volume-outcome metric for each individual procedure and for the outcomes of 90-day complications and 90-day readmissions. RESULTS In all, 187,185 spine surgical procedures met inclusion criteria, performed by 5,514 different surgeons at 178 hospitals. Spline analysis determined that the procedure volume cut-point was 25 for decompressions, 40 for discectomy, 43 for interbody fusion, and 35 for posterolateral fusions. For surgeons who failed to meet the volume metric, there was a 63% increase in the risk of complications following decompressions, a 56% increase in the risk of complications following discectomy, a 15% increase in the risk of complications following lumbar interbody fusions, and a 47% increase in the risk of complications following posterolateral fusions. Findings were similar for readmission measures. CONCLUSIONS The results of this work allow us to identify meaningful volume-based benchmarks for the performance of common lumbar spine surgical procedures including decompression, discectomy, and fusion-based procedures. Based on our determinations, readily achievable goals for individual surgeons would approximate an average of four discectomy and lumbar interbody fusion procedures per month, three posterolateral lumbar fusions per month, and at least one decompression surgery every other week.
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Affiliation(s)
- Andrew J Schoenfeld
- Center for Surgery and Public Health, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA.
| | - Daniel J Sturgeon
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | - Camden B Burns
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | - Tyler J Hunt
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Christopher M Bono
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
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Guha D, Jakubovic R, Gupta S, Alotaibi NM, Cadotte D, da Costa LB, George R, Heyn C, Howard P, Kapadia A, Klostranec JM, Phan N, Tan G, Mainprize TG, Yee A, Yang VXD. Spinal intraoperative three-dimensional navigation: correlation between clinical and absolute engineering accuracy. Spine J 2017; 17:489-498. [PMID: 27777052 DOI: 10.1016/j.spinee.2016.10.020] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 10/19/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Spinal intraoperative computer-assisted navigation (CAN) may guide pedicle screw placement. Computer-assisted navigation techniques have been reported to reduce pedicle screw breach rates across all spinal levels. However, definitions of screw breach vary widely across studies, if reported at all. The absolute quantitative error of spinal navigation systems is theoretically a more precise and generalizable metric of navigation accuracy. It has also been computed variably and reported in less than a quarter of clinical studies of CAN-guided pedicle screw accuracy. PURPOSE This study aimed to characterize the correlation between clinical pedicle screw accuracy, based on postoperative imaging, and absolute quantitative navigation accuracy. DESIGN/SETTING This is a retrospective review of a prospectively collected cohort. PATIENT SAMPLE We recruited 30 patients undergoing first-time posterior cervical-thoracic-lumbar-sacral instrumented fusion±decompression, guided by intraoperative three-dimensional CAN. OUTCOME MEASURES Clinical or radiographic screw accuracy (Heary and 2 mm classifications) and absolute quantitative navigation accuracy (translational and angular error in axial and sagittal planes). METHODS We reviewed a prospectively collected series of 209 pedicle screws placed with CAN guidance. Each screw was graded clinically by multiple independent raters using the Heary and 2 mm classifications. Clinical grades were dichotomized per convention. The absolute accuracy of each screw was quantified by the translational and angular error in each of the axial and sagittal planes. RESULTS Acceptable screw accuracy was achieved for significantly fewer screws based on 2 mm grade versus Heary grade (92.6% vs. 95.1%, p=.036), particularly in the lumbar spine. Inter-rater agreement was good for the Heary classification and moderate for the 2 mm grade, significantly greater among radiologists than surgeon raters. Mean absolute translational-angular accuracies were 1.75 mm-3.13° and 1.20 mm-3.64° in the axial and sagittal planes, respectively. There was no correlation between clinical and absolute navigation accuracy. CONCLUSIONS Radiographic classifications of pedicle screw accuracy vary in sensitivity across spinal levels, as well as in inter-rater reliability. Correlation between clinical screw grade and absolute navigation accuracy is poor, as surgeons appear to compensate for navigation registration error. Future studies of navigation accuracy should report absolute translational and angular errors. Clinical screw grades based on postoperative imaging may be more reliable if performed in multiple by radiologist raters.
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Affiliation(s)
- Daipayan Guha
- Division of Neurosurgery, Department of Surgery, University of Toronto, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada; Institute of Medical Science, School of Graduate Studies, University of Toronto, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada; Biophotonics and Bioengineering Laboratory, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Raphael Jakubovic
- Biophotonics and Bioengineering Laboratory, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada; Department of Biomedical Physics, Ryerson University, 350 Victoria St., Toronto, ON, M5B 2K3, Canada
| | - Shaurya Gupta
- Biophotonics and Bioengineering Laboratory, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Naif M Alotaibi
- Division of Neurosurgery, Department of Surgery, University of Toronto, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada; Institute of Medical Science, School of Graduate Studies, University of Toronto, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada
| | - David Cadotte
- Division of Neurosurgery, Department of Surgery, University of Toronto, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada
| | - Leodante B da Costa
- Division of Neurosurgery, Department of Surgery, University of Toronto, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada
| | - Rajeesh George
- JurongHealth, Ng Teng Fong General Hospital, 1 Jurong East Street, Singapore, 609606, Singapore
| | - Chris Heyn
- Division of Neuroradiology, Department of Medical Imaging, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Peter Howard
- Division of Neuroradiology, Department of Medical Imaging, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Anish Kapadia
- Department of Medical Imaging, University of Toronto, 263 McCaul St., Toronto, ON, M5T 1W7, Canada
| | - Jesse M Klostranec
- Department of Medical Imaging, University of Toronto, 263 McCaul St., Toronto, ON, M5T 1W7, Canada
| | - Nicolas Phan
- Division of Neurosurgery, Department of Surgery, University of Toronto, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada
| | - Gamaliel Tan
- JurongHealth, Ng Teng Fong General Hospital, 1 Jurong East Street, Singapore, 609606, Singapore
| | - Todd G Mainprize
- Division of Neurosurgery, Department of Surgery, University of Toronto, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada
| | - Albert Yee
- Division of Orthopedic Surgery, Department of Surgery, University of Toronto, 149 College St., Toronto, ON, M5T 1P5, Canada
| | - Victor X D Yang
- Division of Neurosurgery, Department of Surgery, University of Toronto, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada; Institute of Medical Science, School of Graduate Studies, University of Toronto, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada; Biophotonics and Bioengineering Laboratory, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada; Department of Electrical and Computer Engineering, Ryerson University, 350 Victoria St., Toronto, ON, M5B 2K3, Canada.
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Joswig H, Hock C, Hildebrandt G, Schaller K, Stienen MN. Microscopic lumbar spinal stenosis decompression: is surgical education safe? Acta Neurochir (Wien) 2016; 158:357-66. [PMID: 26687377 DOI: 10.1007/s00701-015-2667-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 12/08/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Acquiring operative skills in the course of a structured neurosurgery residency training program is vital to safely operating on patients autonomously upon board certification. We tested the hypothesis that the complication rates and outcome of microscopic lumbar spinal stenosis (LSS) decompression done by supervised residents are not inferior to those of board-certified faculty neurosurgeons (BCFNs). METHODS Retrospective single-center study performed at a Swiss teaching hospital comparing consecutive patients undergoing surgery for LSS by a supervised neurosurgery resident (teaching cases) to a consecutive series of patients operated on by a BCFN (non-teaching cases). The primary endpoint was occurrence of complications during surgery. Secondary endpoints were patients' clinical outcomes 4 weeks after surgery, categorized into a binary responder and non-responder variable, occurrence of postoperative complications, need for re-do surgery, and clinical outcome until the last follow-up (FU). RESULTS In a total of n = 471 operations, n = 194 (41.2 %) were teaching cases and n = 277 (58.8 %) non-teaching cases. A longer operation time (single-level procedures: mean 100.0 vs. 83.2 min, p < 0.001) was recorded for teaching cases, while estimated blood loss was equal (single-level procedures: mean 109.9 vs. 117.0 ml, p = 0.409). In multivariate analysis, supervised residents were as likely as BCFNs to have an intraoperative complication (OR 0.92, 95 % CI 0.41-2.04, p = 0.835). They were as likely as BCFNs to achieve a favorable 4-week response to surgery (OR 1.82, 95 % CI 0.79-4.15, p = 0.155). Until final FU, the likelihood for patients in the teaching group to suffer from postoperative complications (OR 1.07, 95 % CI 0.46-2.49, p = 0.864) or require re-do surgery (OR 0.68, 95 % CI 0.31-1.52, p = 0.358) was similar to that of the non-teaching group. CONCLUSIONS Complication rates and short- and mid-term outcomes following LSS decompression were comparable for patients operated on by supervised neurosurgery residents and senior neurosurgeons. Our data thus indicate that a structured neurosurgical hands-on training including LSS decompression is safe for patients.
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Affiliation(s)
- Holger Joswig
- Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Carolin Hock
- Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Gerhard Hildebrandt
- Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Karl Schaller
- Department of Neurosurgery and Faculty of Medicine, University Hospital Geneva, Geneva, Switzerland
| | - Martin N Stienen
- Department of Neurosurgery and Faculty of Medicine, University Hospital Geneva, Geneva, Switzerland.
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Moon BJ, Lee HY, Kim KN, Yi S, Ha Y, Yoon DH, Shin DA. Experimental Evaluation of Percutaneous Lumbar Laser Disc Decompression Using a 1414 nm Nd:YAG Laser. Pain Physician 2015; 18:E1091-E1099. [PMID: 26606022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND Laser ablation under an epiduroscopic view allows for the vaporization of a small amount of the nucleus pulposus, causing a reduction in intradiscal pressure and relief of radicular pain. Currently, Ho:YAG and Nd:YAG lasers are commonly used for spinal diseases. However, the use of the Nd:YAG laser for intra-spinal procedures can be limited because of thermal injury and low efficacy. OBJECTIVE To investigate the efficacy and safety of epiduroscopic laser ablation using a 1414 nm Nd:YAG laser, we examined that laser ablation was able to penetrate nucleus pulposus without heating surrounding tissues and without mechanical damage to surrounding tissue. STUDY DESIGN Our experiment involved live and cadaveric animal studies and a human cadaveric study. SETTING University in Korea. METHODS Two live pigs, 3 porcine cadavers, and 2 human cadavers were used. For the in vitro study, intradiscal and epidural pressure and temperature were compared in vertebral columns obtained from 3 porcine cadavers before and after laser ablation. For the in vivo study, 2 pigs were used to simulate percutaneous epiduroscopic laser ablation. They were observed for behavioral changes and neurological deficits for one month after the laser ablation procedure. Two human cadavers were used for placing the laser fiber and epiduroscope in the correct target site through the sacral hiatus. Histological analysis was also performed to observe any damage around the ablated lesion. RESULTS Both intradiscal and epidural pressure were markedly reduced immediately after laser ablation as compared with the pre-ablative state. The amount of the pressure decrease in the intradiscal space was significantly greater than that in the epidural space (45.8 ± 15.0 psi vs. 30.0 ± 9.6 psi, P = 0.000). The temperature beneath the ipsilateral spinal nerve, which was the nearest site to the laser probe, never exceeded 40° C. Histology revealed no evidence of thermal damage to surrounding structures, including the spinal nerves, end plates, and vertebrae, after laser ablation. All live pigs showed normal behavior without any sign of pain. In the human cadaveric study, there was no case of targeting failure or dural laceration. The mean time to reach the target region was less than 5 minutes. LIMITATIONS The pressure measurements were performed on cadavers and not in vivo. Cadaver models cannot account for intradiscal pressure changes that occur during live muscle contraction and different positions, which may affect results. Moreover, although we controlled temperatures with heat baths, vascular and cerebrospinal fluid circulations were not simulated. Those circulations may change the temperature results in vivo. CONCLUSIONS The 1414 nm Nd:YAG laser can be used effectively and safely under the guidance of a spinal epiduroscope in an in vivo porcine model and in a human cadaveric model. STUDY APPROVAL: Approval for the current study was granted by the Institutional Review Board of our institute (approval number: 1-2014-0049).
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Affiliation(s)
- Bong Ju Moon
- Yonsei University College of Medicine, Seoul, Korea
| | | | | | - Seong Yi
- Yonsei University College of Medicine, Seoul, Korea
| | - Yoon Ha
- Yonsei University College of Medicine, Seoul, Korea
| | - Do Heum Yoon
- Yonsei University College of Medicine, Seoul, Korea
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Horiuchi A, Tanaka N. Improving quality measures in colonoscopy and its therapeutic intervention. World J Gastroenterol 2014; 20:13027-13034. [PMID: 25278696 PMCID: PMC4177481 DOI: 10.3748/wjg.v20.i36.13027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Revised: 01/13/2014] [Accepted: 05/05/2014] [Indexed: 02/06/2023] Open
Abstract
Colonoscopy with polypectomy has been shown to reduce the risk of colon cancer. The critical element in the quality of colonoscopy in terms of polyp detection and removal continues to be the performance of the endoscopist, independent of patient-related factors. Improved results in terms of polyp detection and complete removal have implications regarding the development of screening and surveillance intervals and the reduction of interval cancers after negative colonoscopy. Advances in colonoscopy techniques such as high-definition colonoscopy, hood-assisted colonoscopy and dye-based chromoendoscopy have improved the detection of small and flat-type colorectal polyps. Virtual chromoendoscopy has not proven to improve polyp detection but may be useful to predict polyp pathology. The majority of polyps can be removed endoscopically. Available polypectomy techniques include cold forceps polypectomy, cold snare polypectomy, conventional polypectomy, endoscopic mucosal resection and endoscopic submucosal dissection. The preferred choice depends on the polyp size and characteristics. Other useful techniques include colonoscopic hemostasis for acute colonic diverticular bleeding, endoscopic decompression using colonoscopic stenting, and transanal tube placement for colorectal obstruction. Here we review the current knowledge concerning the improvement of quality measures in colonoscopy and colonoscopy-related therapeutic interventions.
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García-Ureña MÁ, López-Monclús J, Robín Á. [«Surgical» analysis of the new clinical practice guide on compartmental syndrome]. Med Intensiva 2013; 38:170-2. [PMID: 24315131 DOI: 10.1016/j.medin.2013.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 09/26/2013] [Indexed: 12/16/2022]
Abstract
The new published guidelines of compartment syndrome are supposed to be a helpful tool in order to make decisions in patients with abdominal hypertension. From a surgical perspective of view, an important effort has been made in order to reach consensus in different phases in which there is no clear answer in evidence-based medicine. It is mandatory the use of a universal classification of open abdomen and there are three main concepts that must be observed: make a decompressive laparotomy when conservative measures have failed, attempt to closure the abdomen as soon as possible and the use of negative-pressure treatments that facilitates the management of an open abdomen. Although most of recommendations that have been delivered are not high grades, the present guide is an important assistant for the management of intra-abdominal hypertension and several lines of investigation are opened in order to answer the doubts that have been addressed.
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Affiliation(s)
| | - Javier López-Monclús
- Hospital Universitario del Henares, Universidad Francisco de Vitoria, Coslada, España
| | - Álvaro Robín
- Hospital Universitario del Henares, Universidad Francisco de Vitoria, Coslada, España
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Gardner A, Gardner E, Morley T. Cauda equina syndrome: a review of the current clinical and medico-legal position. Eur Spine J 2011; 20:690-7. [PMID: 21193933 PMCID: PMC3082683 DOI: 10.1007/s00586-010-1668-3] [Citation(s) in RCA: 157] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2009] [Revised: 11/22/2010] [Accepted: 12/15/2010] [Indexed: 11/29/2022]
Abstract
Cauda equina syndrome (CES) is a rare condition with a disproportionately high medico-legal profile. It occurs most frequently following a large central lumbar disc herniation, prolapse or sequestration. Review of the literature indicates that around 50-70% of patients have urinary retention (CES-R) on presentation with 30-50% having an incomplete syndrome (CES-I). The latter group, especially if the history is less than a few days, usually requires emergency MRI to confirm the diagnosis followed by prompt decompression by a suitably experienced surgeon. Every effort should be made to avoid CES-I with its more favourable prognosis becoming CES-R while under medical supervision either before or after admission to hospital. The degree of urgency of early surgery in CES-R is still not in clear focus but it cannot be doubted that earliest decompression removes the mechanical and perhaps chemical factors which are the causes of progressive neurological damage. A full explanation and consent procedure prior to surgery is essential in order to reduce the likelihood of misunderstanding and litigation in the event of a persistent neurological deficit.
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Affiliation(s)
- Alan Gardner
- South Essex University Hospitals and The Essex Spine Centre, Brentwood, UK.
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Abstract
Colonic stents traditionally have been used for the management of colorectal cancer, either as a palliative treatment or as a bridge to surgery. More recently, colonic stents have also been advocated as part of the therapy of benign strictures. A number of colonic stents are available worldwide, four of which are made in the USA. These stents are classified as covered or uncovered, with similar clinical applications. Technical and clinical success rates are similar among these different stents, as well as the rate of complications, which mainly consist of obstruction and migration. The deployment systems utilize fluoroscopy, endoscopy, or both. More recently, stents became available that are deployed "through the scope" (TTS) making the procedure faster. However, this advance does not exclude the use of fluoroscopy, particularly in those cases where the direct visualization of the proximal end of the stricture is absent. The increasing experience in the management of colorectal cancer with colonic stents decreases the morbidity and mortality, as well as cost, in comparison with surgical intervention for acute colonic obstruction. Management with colonic stents can also rule out proximal synchronous lesions after initial decompression prior to definitive surgery. Benign conditions may also be treated with stents. A multidisciplinary approach for the use of colonic stents during assessment and management of acute colonic obstruction is necessary in order to achieve a satisfactory outcome, whether that be better quality of life or improved survival.
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Affiliation(s)
- Leandro Feo
- Hahnemann University Hospital, Drexel University School of Medicine, Philadelphia, PA, USA
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Cırpar M, Arı M, Türker M, Ekşioğlu MF, Cetik O. [The efficacy and safety of limited incision technique in carpal tunnel release]. Eklem Hastalik Cerrahisi 2011; 22:33-38. [PMID: 21417984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
OBJECTIVES This study aims to determine the safety and symptomatic and functional efficacy of median nerve decompression with 3 cm limited incision in carpal tunnel syndrome surgery. PATIENTS AND METHODS Carpal tunnel release with a 3 cm limited palmar incision was performed on 91 hands in 83 patients. Patients were evaluated with Boston Carpal Tunnel Questionnaire, grip strength and pinch strength measurements, Semmes-Weinstein Monofilament test and two-point discrimination tests preoperatively, and at postoperative 3rd and 6th months. The pre- and postoperative mean values for these assessment criteria were statistically analyzed by paired samples t-test. The symptoms, physical findings, electroneuromyography carpal tunnel syndrome severity scores of the patients were evaluated using descriptive statistical analyses. RESULTS At postoperative evaluation, there was a statistically significant increase in Boston Carpal Tunnel Questionnaire scores, grip and pinch strengths, and sensory tests results of the patients when compared with preoperative values. No complications other than pillar pain were encountered. CONCLUSION Carpal tunnel release with a 3 cm limited incision technique appears to be effective when compared with classical open, endoscopic and mini incision techniques. The rate of complications is lower than that of these techniques. In conclusion, a 3 cm limited incision is both effective and safe in carpal tunnel release.
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Affiliation(s)
- Meriç Cırpar
- Department of Orthopedics and Traumatology, Medicine Faculty of Kırıkkale University, Kırıkkale, Turkey.
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Tsibirov AA, Svistov DV, Kandyba DV, Savello AV, Kravtsov MN, Landik SA. [Initial experience of using XperCT in neurosurgery]. Vestn Khir Im I I Grek 2011; 170:84-90. [PMID: 21848246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Modern angiographic complexes allow performing emulation of computed tomography (CT). Comparison of the resolving power of XperCT and CT indicated sufficient sensitivity of the new technology in detection of focal lesions of the brain, the possibility of its application in interventional neuroradiology. The application of XperGuide allows control the position of the instrument during operation directly without using additional equipment of moving the patient. The application of XperGuide decreases the risk of intra- and early postoperative complications.
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Tadepalli SC, Gandhi AA, Fredericks DC, Grosland NM, Smucker J. Cervical laminoplasty construct stability: an experimental and finite element investigation. Iowa Orthop J 2011; 31:207-214. [PMID: 22096443 PMCID: PMC3215137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
STUDY DESIGN Experimental and finite element investigation of cervical laminoplasty. OBJECTIVE To determine the stability of the construct post cervical laminoplasty. SUMMARY OF BACKGROUND DATA Cervical laminoplasty is a widely used technique to widen the spinal canal dimensions without permanently removing the dorsal elements of the cervical spine. Although various laminoplasty procedures have been developed recently, the use of mini-plates to hold the lamina open and prevent restenosis of the spinal cord is a fairly new method and has not been thoroughly investigated. METHODS Biomechanical compression tests and finite element analyses were performed in this study. Sixteen cervical vertebrae (C3 - C6) were isolated from six cadaveric cervical spines (age at death 68 to 91 years; mean 85 years) and were used for compression tests. Out of the 16 vertebrae, four were without any surgical intervention and the remaining 12 were implanted with one of the two laminoplasty plates: open door (OD) graft. Each vertebra was randomly assigned to one of the three groups: OD plate (6), graft plate (6) or intact vertebrae (4). The intact and implanted vertebrae were potted and loaded to failure. Cross-head displacements and the corresponding reaction force throughout the test were recorded to determine the failure loads. A finite element model of the C5 cervical vertebra was created to accommodate the laminoplasty implants. Experimental loading and boundary conditions were simulated and the stress distribution in the lamina was predicted in response to the compressive loads. RESULTS A substantial increase in the sagittal canal diameter (27%-33%) and the spinal canal area (31.2%-47%) was observed at all levels. The strength of the implanted specimens was considerably decreased (by six to eight times) as compared to the intact specimens. CONCLUSION Experimentally obtained data can be combined with mathematical models, such as finite element models, to accurately predict the biomechanical behavior (stresses and strains) of implants and the posterior bone which may not be possible by the use of any other method.
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Shamil N, Quraishi S, Riaz S, Channa A, Maher M. Is nasogastric decompression necessary in elective enteric anastomosis? J Ayub Med Coll Abbottabad 2010; 22:23-26. [PMID: 22455254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND Placement of nasogastric tube is common surgical practice after bowel anastomosis. What is to be achieved by this prophylaxis is gastric decompression, a decreased likelihood of nausea and vomiting, decreased distension, less chance of pulmonary aspiration and pneumonia, less risk of wound separation and infection, less chance of fascial dehiscence and hernia, earlier return of bowel function and earlier discharge from hospital. We conducted a prospective observational study in Surgical Ward 2, Jinnah Postgraduate Medical Centre, Karachi from January 2008 to December 2009 to assess whether routine use of nasogastric decompression in elective enteric anastomosis can be safely omitted. METHOD Patients who underwent elective enteric anastomosis were included in this study. These patients were managed prospectively without nasogastric decompression. Outcome were measured in terms of time of passing flatus, nausea, vomiting, abdominal distension, pulmonary complications, wound infection, wound dehiscence, anastomotic leak, length of hospital stay and mortality. RESULTS Except for incidence of minor symptoms like nausea or vomiting, omission of NG tube did not lead to any serious complication like anastomotic leak, pulmonary complications wound dehiscence or death. CONCLUSION Nasogastric decompression can safely be omitted from a routine part of postoperative care after elective enteric anastomosis.
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Affiliation(s)
- Nadia Shamil
- Department of Surgery, Jinnah Postgraduate Medical Centre, Karachi, Pakistan.
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23
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Nodera H, Kaji R. Ulnar neuropathy at the elbow: not simply a compressive neuropathy? Clin Neurophysiol 2010; 122:1-2. [PMID: 20580310 DOI: 10.1016/j.clinph.2010.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2010] [Revised: 05/31/2010] [Accepted: 06/01/2010] [Indexed: 11/27/2022]
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Turgut AT, Turgut M. Intradural extramedullary primary hydatid cyst of the spine in a child: a very rare presentation. Eur Spine J 2009; 18:1234-5; author reply 1236. [PMID: 19396476 DOI: 10.1007/s00586-009-1006-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2008] [Accepted: 04/08/2009] [Indexed: 11/29/2022]
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Oe K, Doita M, Miyamoto H, Kanda F, Kurosaka M, Sumi M. Is extensive cervical laminoplasty an effective treatment for spinal cord sarcoidosis combined with cervical spondylosis? Eur Spine J 2009; 18:570-6. [PMID: 19214600 DOI: 10.1007/s00586-009-0891-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2008] [Accepted: 01/18/2009] [Indexed: 11/30/2022]
Abstract
Patients with neurosarcoidosis are usually initially treated with steroid administration even when they have concomitant cord compression on magnetic resonance imaging (MRI). Operative intervention may be indicated in patients with spinal cord sarcoidosis requiring either tissue biopsy for diagnosis or associated with progressive neurologic symptoms. However, there have been no previous reports describing clinical outcomes of laminoplasty for spinal cord sarcoidosis. The objectives of this study are to investigate whether extensive cervical laminoplasty is an effective treatment for spinal cord sarcoidosis combined with spondylotic changes and/or cervical spinal canal stenosis. Open-door laminoplasty was performed in three patients with spinal cord sarcoidosis. All patients received intensive corticosteroid therapy after the operation MRI imaging was performed in all patients before and after the operation. Operative outcomes were not satisfactory and the clinical courses of the patients fluctuated after corticosteroid therapy. Daily life activities were not significantly improved after treatments in any of the three patients, and in the long-term follow-up period the clinical course of one patient was one of inexorable deterioration to a state of quadriplegia. The possibility of spinal cord sarcoidosis should be included in the differential diagnosis, when a distinct high signal intensity area is observed within the spinal cord on T2-weighted MR images in patients with spondylotic changes. Laminoplasty is not an effective intervention for the treatment of spinal cord sarcoidosis even when patients have spondylotic changes and/or a constitutionally narrowing cervical spinal canal. Patients with neurosarcoidosis should be treated first with steroid administration even when they have concomitant cord compression on MRI.
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Affiliation(s)
- Keisuke Oe
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-Ku, Kobe 650-0017, Japan
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Bapat MR, Chaudhary K, Sharma A, Laheri V. Surgical approach to cervical spondylotic myelopathy on the basis of radiological patterns of compression: prospective analysis of 129 cases. Eur Spine J 2008; 17:1651-63. [PMID: 18946692 DOI: 10.1007/s00586-008-0792-9] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/09/2008] [Revised: 07/30/2008] [Accepted: 09/14/2008] [Indexed: 11/26/2022]
Abstract
This is a prospective analysis of 129 patients operated for cervical spondylotic myelopathy (CSM). Paucity of prospective data on surgical management of CSM, especially multilevel CSM (MCM), makes surgical decision making difficult. The objectives of the study were (1) to identify radiological patterns of cord compression (POC), and (2) to propose a surgical protocol based on POC and determine its efficacy. Average follow-up period was 2.8 years. Following POCs were identified: POC I: one or two levels of anterior cord compression. POC II: one or two levels of anterior and posterior compression. POC III: three levels of anterior compression. POC III variant: similar to POC III, associated with significant medical morbidity. POC IV: three or more levels of anterior compression in a developmentally narrow canal or with multiple posterior compressions. POC IV variant: similar to POC IV with one or two levels, being more significant than the others. POC V: three or more levels of compression in a kyphotic spine. Anterior decompression and reconstruction was chosen for POC I, II and III. Posterior decompression was chosen in POC III variant because they had more incidences of preoperative morbidity, in spite of being radiologically similar to POC III. Posterior surgery was also performed for POC IV and IV variant. For POC IV variant a targeted anterior decompression was considered after posterior decompression. The difference in the mJOA score before and after surgery for patients in each POC group was statistically significant. Anterior surgery in MCM had better result (mJOA = 15.9) versus posterior surgery (mJOA = 14.96), the difference being statistically significant. No major graft-related complications occurred in multilevel groups. The better surgical outcome of anterior surgery in MCM may make a significant difference in surgical outcome in younger and fitter patients like those of POC III whose expectations out of surgery are more. Judicious choice of anterior or posterior approach should be made after individualizing each case.
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Affiliation(s)
- Mihir R Bapat
- King Edward Memorial Hospital, Parel, Mumbai, 400 014, India.
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Park JS, Kong DS, Lee JA, Park K. Hemifacial spasm: neurovascular compressive patterns and surgical significance. Acta Neurochir (Wien) 2008; 150:235-41; discussion 241. [PMID: 18297233 DOI: 10.1007/s00701-007-1457-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2007] [Accepted: 10/11/2007] [Indexed: 11/25/2022]
Abstract
BACKGROUND The aim of this study was to report further investigation of neurovascular compression as a cause of hemifacial spasm (HFS) and to provide useful surgical guidelines by describing the compression patterns. MATERIAL AND METHODS From January 2004 to February 2006, 236 consecutive patients with HFS underwent microvascular decompression (MVD) in a single centre. Based on the operation and medical records, the intraoperative findings and post-operative outcomes were obtained and analysed. RESULTS We found that 95.3% of lesions had accompanying causative factors that made the neurovascular compression inevitable. Based on the contributing factors, compression patterns were categorised into six different types including: loop (n = 11: 4.6%), arachnoid (n = 66: 27.9%), perforator (n = 58: 24.6%), branch (n = 18: 7.6%), sandwich (n = 28: 11.9%), and tandem (n = 52: 22.0%). The compression patterns were significantly correlated with the compressing vessels involved. Thirty-two (86.5%) of 37 lesions where the vertebral artery was the compressing vessel involved the tandem type. Anterior inferior cerebellar artery was the compressing vessel involved in 49 (84.5%) of 58 perforator type compressions, while posterior inferior cerebellar artery was the compressing vessel involved in 8 (72.7%) of 11 loop type compressions. CONCLUSIONS Once the compressing vessel responsible for the neurovascular compression are identified, the probable pattern of compression can be anticipated; this knowledge could facilitate the application of the appropriate operative procedures and minimise post-operative complications.
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Affiliation(s)
- J S Park
- Samsung Medical Center, Department of Neurosurgery, School of Medicine, Sungkyunkwan University, Seoul, South Korea
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Qureshi A, Sell P. Cauda equina syndrome treated by surgical decompression: the influence of timing on surgical outcome. Eur Spine J 2007; 16:2143-51. [PMID: 17828560 PMCID: PMC2140120 DOI: 10.1007/s00586-007-0491-y] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2007] [Revised: 08/07/2007] [Accepted: 08/19/2007] [Indexed: 11/29/2022]
Abstract
A prospective longitudinal inception cohort study of 33 patients undergoing surgery for cauda equina syndrome (CES) due to a herniated lumbar disc. To determine what factors influence spine and urinary outcome measures at 3 months and 1 year in CES specifically with regard to the timing of onset of symptoms and the timing of surgical decompression. CES consists of signs and symptoms caused by compression of lumbar and sacral nerve roots. Controversy exists regarding the relative importance of timing of surgery as a prognostic factor influencing outcome. Post-operative outcome was assessed at 3 months and 1 year using the Oswestry Disability Index (ODI), Visual Analogue Scale (VAS) scores for leg and back pain and an incontinence questionnaire. Statistical analysis was used to determine the association between pre-operative variables and these post-operative outcomes with a specific emphasis on the timing of surgery. Surgery was performed on 12 (36%) patients within 48 h of the onset of symptoms including seven patients (21%) who underwent surgery within 24 h. Follow up was achieved in 27 (82%) and 25 (76%) patients at 3 and 12 months, respectively. There was no statistically significant difference in outcome between three groups of patients with respect to length of time from symptom onset to surgery- <24, 24-48 and >48 h. A significantly better outcome was found in patients who were continent of urine at presentation compared with those who were incontinent. The duration of symptoms prior to surgery does not appear to influence the outcome. This finding has significant implications for the medico-legal sequelae of this condition. The data suggests that the severity of bladder dysfunction at the time of surgery is the dominant factor in recovery of bladder function.
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Affiliation(s)
- Assad Qureshi
- Department of Orthopaedics, University Hospitals of Leicester, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4PW UK
| | - Philip Sell
- Department of Orthopaedics, University Hospitals of Leicester, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4PW UK
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30
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Abstract
BACKGROUND Spinal subdural hematoma (SSDH) is an exceedingly uncommon and potentially neurologically devastating condition. Recognition of blood products in magnetic resonance imaging is a very important clue for the diagnosis of SSDH. It is generally agreed that prompt surgical evacuation should be performed before irreversible damage to the spinal cord occurs. However, conservative treatment still plays a role in the management of SSDH. OBJECTIVES To describe the clinical presentation, characteristic MRI findings, and treatment of traumatic SSDH. METHODS A case of traumatic SSDH at the thoraco-lumbar junction. RESULTS Magnetic resonance imaging findings of high signal intensity lesion in both T1 and T2 sequences suggest the possibility of subdural hematoma although it may be mistaken for tumorlike cystic lesion of the cord. Although there is a place for conservative treatment of subdural hematoma, we believe that rapid surgical drainage of the subdural hematoma will be associated with the best prognosis especially in the cervical, thoracic, and thoraco-lumbar junctions of the spinal cord. CONCLUSIONS Rapid surgical drainage of traumatic SSDH affecting the thoraco-lumbar junction of the cord will be associated in most of the cases with rapid neurologic recovery.
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Affiliation(s)
- Ralph Greiner-Perth
- Department of Spine surgery, Orthopedic Surgery and Neurosurgery, SRH, Wald Klinikum Gera GmbH, Gera, Germany
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31
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Abstract
Neurovascular compression has been postulated as a probable mechanism for a large number of cranial nerve syndromes, with trigeminal neuralgia (TGN) as the prime example. Microvascular decompression (MVD) is often cited as the procedure of choice for treatment of medically refractory TGN. Arguments against these assumptions are: MRA studies indicate that vascular contact with the trigeminal nerve is present in most healthy individuals. Treatment results of MVD in multiple sclerosis patients with TGN are almost as good (at least in the short term) as in idiopathic cases. MVD is reported to provide pain relief even in TGN patients without visible neurovascular contact . In other syndromes of cranial nerve'hyperactive dysfunction'--vertigo, tinnitus and neurogenic hypertension--the documentation is even weaker.
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Affiliation(s)
- P Monstad
- Spesialistsenteret AS, Tollbodgt Kristiansand, Norway.
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32
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Bach CM. Comment on the paper "Contralateral radiculopathy after transforaminal lumbar interbody fusion" (Travis Hunt et al.). Eur Spine J 2007; 16 Suppl 3:315. [PMID: 17520300 PMCID: PMC2148096 DOI: 10.1007/s00586-007-0389-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/19/2007] [Indexed: 10/23/2022]
Affiliation(s)
- Christian M Bach
- Department of Orthopedic Surgery, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria.
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Abstract
PURPOSE Although many authors have reported on cervical range of motion after laminoplasty, they have focused on flexion and extension based on lateral radiographs, not on axial rotation. In this study, we assessed cervical rotation from C1 to T1 after laminoplasty using computed tomography. PATIENTS AND METHODS Eighteen consecutive patients with cervical myelopathy who had undergone laminoplasty were observed. Patient was placed in the supine position on the computed tomography scan table. After the scans in this neutral position were completed, the patient actively rotated his neck as far as possible taking care that the shoulders remained in the horizontal plane. We measured the C1 to T1, C1 to C2, and C2 to T1 rotation angles preoperatively, and at 2 weeks and 6 months after surgery. RESULTS The average C1 to T1 rotation angles preoperatively were 46 degrees on the right and 45 degrees on the left. The percentage of C1 to C2 rotation during global cervical rotation (C1 to T1) was 62%. C1 to T1 rotation angle significantly decreased at two weeks after surgery but recovered to almost preoperative levels (11% decreases) by 6 months after surgery with no difference between right and left motion. The average C2 to T1 subaxial rotation angles did not significantly decreased after surgery. CONCLUSIONS Rotation angle after laminoplasty decreased slightly at 2 weeks after surgery but recovered almost to preoperative levels by 6 months. Subaxial rotation (C2 to T1) angles did not significantly decreased after surgery.
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Affiliation(s)
- Yoshihisa Sugimoto
- Okayama University Hospital of Medicine and Dentistry, Okayama city, Japan.
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34
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Iplikcioglu C, Bikmaz K, Gokduman CA, Bek S. Cerebellopontine angle lipoma with extracranial extension. J Clin Neurosci 2006; 13:1045-7. [PMID: 17113988 DOI: 10.1016/j.jocn.2006.01.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2005] [Accepted: 01/16/2006] [Indexed: 10/23/2022]
Abstract
Lipomas of the cerebellopontine angle (CPA) are rare. A recent literature review identified only 98 reported cases of CPA lipoma. We present here a case of CPA lipoma in a 28-year-old woman who was admitted to our hospital with hearing loss in her left ear. Computed tomography scan and magnetic resonance imaging revealed a CPA mass lesion with extracranial extension around the left internal carotiol artery. The patient was operated on in the sitting position via a right suboccipital craniectomy. The intracranial part of the mass was partially removed. Histopathological examination resulted in a diagnosis of lipoma. Surgical treatment of CPA lipomas is rarely indicated, and the aim of surgery must be decompression of neural structures.
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Affiliation(s)
- Celal Iplikcioglu
- Neurosurgery Clinic, Social Security Okmeydani Teaching Hospital, Istanbul, Turkey
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35
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Mouchaty H, Conti P, Conti R, Aito S, D'Andrea M, Marinelli C, Di Lorenzo N. Assessment of three year experience of a strategy for patient selection and timing of operation in the management of acute thoracic and lumbar spine fractures: a prospective study. Acta Neurochir (Wien) 2006; 148:1181-7; discussion 1187. [PMID: 16960661 DOI: 10.1007/s00701-006-0883-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2006] [Accepted: 07/28/2006] [Indexed: 11/30/2022]
Abstract
BACKGROUND The purpose of this article is to report experience gained over three years of the use of a protocol for patient selection and timing of operation for acute thoracic and lumbar fractures. METHOD At admission, all patients underwent neurological and imaging exams. All patients with a spinal cord lesion scored as ASIA A at any level inferior to T10 and as ASIA B, C or D at any level, were categorized as emergency and operated on within eight hours from trauma. ASIA A cases in the T1-T10 tract and ASIA E cases at any level were treated in the ordinary operative work schedule. FINDINGS Ninety-four patients with surgically treated lumbar or thoracic fractures took part in this study. On the imaging studies, 12 patients were classified as A, 50 as B and 32 as C following the AO classification. At the neurological exam, 39 patients were scored as ASIA A, nine as B, six as C, two as D and 38 as E. At follow-up, of the 39 patients scored as ASIA A, 13 (33%) improved at least one grade and of the 17 scored as ASIA B, C or D, 11 (64.7%) improved. None of the 38 patients scored as ASIA E deteriorated. CONCLUSIONS The findings show that the strategy in the protocol was safe and followed by satisfactory rates of neurological outcome. Larger prospective studies, preferably randomized, are needed to establish definitively its place in the management of patients with spinal injury.
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Affiliation(s)
- H Mouchaty
- Department of Neurosurgery, University of Florence, Florence, Italy.
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Abstract
OBJECTIVE Cadaveric dissections were performed to review the intracranial and extracranial course of the hypoglossal nerve. The neurological significance of a newly defined "triple cross" of the hypoglossal nerve is discussed. MATERIALS AND METHODS 10 cadaveric heads (left and right; 20 sides) were dissected using microsurgical techniques. RESULTS In the cisternal segment of hypoglossal nerve, the diameter of the rostral trunk amounted to 155-680 microm (mean 435 microm), and the caudal trunk to 210-820 microm (mean 482 microm). The roots formed three trunks in 20% of the hypoglossal nerves and two trunks in the rest. As a first cross, the anterior medullary segment of the vertebral artery crossed the hypoglossal nerve roots in 14 of 20 sides (70%). As a rare variation, the vertebral artery extended medial to the nerve (25%) or between its roots (5%). The second cross was found between the descendens hypoglossus and the occipital artery (75%), sternocleidomastoid artery and vein complex (15%) and external carotid artery (10%). The third cross was shown in the submandibular triangle between the lingual hypoglossus and its drainage vein; vena committans nervus hypoglossus. CONCLUSION Throughout its way, the hypoglossal nerve passes over vascular structures in three crossing points which may serve as a probable cause of hypoglossal nerve entrapment disorders.
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Affiliation(s)
- G Bademci
- Department of Neurosurgery, University of Kirikkale, Kirikkale, Turkey.
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37
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Kassam AB, Mintz AH, Gardner PA, Horowitz MB, Carrau RL, Snyderman CH. The expanded endonasal approach for an endoscopic transnasal clipping and aneurysmorrhaphy of a large vertebral artery aneurysm: technical case report. Neurosurgery 2006; 59:ONSE162-5; discussion ONSE162-5. [PMID: 16888561 DOI: 10.1227/01.neu.0000220047.25001.f8] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Aneurysms of the vertebral artery are rare, comprising less than 5% of all aneurysms. They can present with subarachnoid hemorrhage, medullary compression, and cranial neuropathies. In consideration of their surrounding regional anatomy, they present a formidable surgical challenge to the neurosurgeon using traditional techniques. Recent advances in endoscopic transnasal surgery have provided an additional approach for the treatment of these difficult lesions. CLINICAL PRESENTATION We present a case of a large vertebral artery aneurysm causing mass effect on the medulla. Initial treatment consisted of endovascular trapping of the aneurysm; however, because of concerns that the remaining aneurysm and intraluminal thrombus was causing mass effect and continued brainstem compression, a decompressive procedure was required. INTERVENTION After the endovascular trapping, the patient underwent a completely endoscopic transnasal surgical clipping and aneurysmorrhaphy. After exposure of the aneurysm, distal and proximal clips were applied transnasal, and the aneurysmorrhaphy completed using suction and ultrasonic aspiration. CONCLUSION In consideration of their surrounding regional anatomy, aneurysms of the vertebral artery present a formidable surgical challenge to the neurosurgeon. Although endovascular techniques have proven to be extremely valuable for the treatment of these lesions, they are limited when patients have significant mass effect with brainstem compression or cranial neuropathy. Advances in endoscopic transnasal surgery have provided an additional approach for the treatment of these difficult lesions. This case report represents, to our knowledge, the first literature report of a transnasal endoscopic aneurysm clipping and thrombectomy.
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MESH Headings
- Atlanto-Occipital Joint/anatomy & histology
- Atlanto-Occipital Joint/diagnostic imaging
- Atlanto-Occipital Joint/surgery
- Cerebral Angiography
- Cerebral Arterial Diseases/physiopathology
- Cerebral Arterial Diseases/surgery
- Cervical Atlas/anatomy & histology
- Cervical Atlas/surgery
- Cranial Fossa, Posterior/anatomy & histology
- Cranial Fossa, Posterior/pathology
- Cranial Fossa, Posterior/surgery
- Cranial Sinuses/anatomy & histology
- Cranial Sinuses/surgery
- Craniotomy/instrumentation
- Craniotomy/methods
- Craniotomy/standards
- Decompression, Surgical/instrumentation
- Decompression, Surgical/methods
- Decompression, Surgical/standards
- Embolization, Therapeutic/instrumentation
- Embolization, Therapeutic/methods
- Embolization, Therapeutic/standards
- Endoscopy/methods
- Female
- Humans
- Hypoglossal Nerve/anatomy & histology
- Hypoglossal Nerve/surgery
- Intracranial Aneurysm/physiopathology
- Intracranial Aneurysm/surgery
- Intraoperative Complications/etiology
- Intraoperative Complications/physiopathology
- Intraoperative Complications/prevention & control
- Medulla Oblongata/blood supply
- Medulla Oblongata/physiopathology
- Medulla Oblongata/surgery
- Middle Aged
- Nasal Cavity/anatomy & histology
- Nasal Cavity/surgery
- Occipital Bone/anatomy & histology
- Occipital Bone/diagnostic imaging
- Occipital Bone/surgery
- Postoperative Hemorrhage/etiology
- Postoperative Hemorrhage/physiopathology
- Postoperative Hemorrhage/prevention & control
- Preoperative Care/methods
- Surgical Instruments/standards
- Tomography, X-Ray Computed
- Treatment Outcome
- Vertebral Artery/anatomy & histology
- Vertebral Artery/pathology
- Vertebral Artery/surgery
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Affiliation(s)
- Amin B Kassam
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA.
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38
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Mukherjee KK, Mohindra S, Gupta SK, Gupta R, Khosla VK. True hemicranial decompression for severe pediatric cranial trauma: a short series of 4 cases and literature review. ACTA ACUST UNITED AC 2006; 66:305-10; discussion 310. [PMID: 16935641 DOI: 10.1016/j.surneu.2005.12.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2005] [Accepted: 12/08/2005] [Indexed: 11/29/2022]
Abstract
BACKGROUND Traumatic acute SDH in pediatric patients is a life-threatening situation. There is a severe increase in ICP caused by acute SDH or diffuse brain swelling or secondary to ischemic brain damage. In certain situations, conventional measures may fail to control such a rapid increase in ICP. CASE DESCRIPTION The cases of 4 pediatric patients with cranial trauma with raised ICP, in whom hemicranial decompression was performed, are described. All patients had acute SDH with diffuse brain injury; in addition, 2 of them had associated massive infarcts. Three of them survived and had a favorable outcome. CONCLUSIONS In certain situations, pediatric patients with cranial trauma may be offered hemicranial decompression as a surgical option. These children may have a better long-term outcome despite massive infarcts.
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Affiliation(s)
- Kanchan Kumar Mukherjee
- Depatrment of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigash, India
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39
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Simsek S, Yigitkanli K, Belen D, Bavbek M. Halo traction in basilar invagination: technical case report. ACTA ACUST UNITED AC 2006; 66:311-4; discussion 314. [PMID: 16935643 DOI: 10.1016/j.surneu.2005.12.029] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2005] [Accepted: 12/19/2005] [Indexed: 11/26/2022]
Abstract
BACKGROUND In the management of basilar invagination, traction therapy may help by pulling down the odontoid process away from the brain stem that may result in clinical and radiological improvement. We aimed to discuss the role of the halo vest apparatus traction on the reduction of severe anterior compression pathologies in basilar invagination. CASE DESCRIPTION We describe a simple and safe cervical traction method by the halo vest apparatus that is followed by rigid posterior occipitocervical fixation and foramen magnum decompression in a patient who presented with basilar invagination and symptoms of severe brain stem compression. An MR-suitable halo vest apparatus was used for reduction of the deformity. The reduction of the basilar invagination was achieved gradually by distracting the halo crown in stages. CONCLUSION The halo vest apparatus can be safely used in complex craniocervical junction anomalies. An effective cervical traction can be performed in basilar invagination, and reduction of the deformity may be achieved without the risk of overdistraction. In some cases, even partial reduction of the deformity may facilitate brain stem and spinal cord relief without any need of posterior decompression. Patients may benefit from ambulatory functions because bed rest is eliminated in this procedure. Neurovascular structures and the degree of the reduction can be observed on MRIs when an MR-suitable device is used.
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Affiliation(s)
- Serkan Simsek
- Neurosurgery Department, Ministry of Health, Diskapi Educational and Research Hospital, Ankara 06110, Turkey
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40
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Abstract
STUDY DESIGN Case studies, literature review. OBJECTIVES The goal of this review is to raise awareness and stimulate contributions on this topic. SUMMARY OF BACKGROUND DATA Surgical management of adult patients presenting with intractable back and leg pain in conjunction with spinal deformity often raises the question of need for curve arthrodesis. Meticulous patient assessment is essential in determining if the deformity underlies patient symptoms. If so, then the deformity must be stabilized according to criteria established in the literature. However, when patient evaluation suggests that the deformity is not the source of symptoms, other surgical options may be considered. These include limited decompression without fusion or decompression with short fusion limited only to the site of pathology. MATERIALS AND METHODS Three cases are presented illustrating situations where decompression alone or decompression with short fusion was indicated. RESULTS When an adult spinal deformity is stable and is not the source of symptoms, symptomatic relief may be provided through limited decompression within the curve but without curve arthrodesis. Similarly, symptomatic pathology arising from levels adjacent to or remote from the deformity may be addressed with short-segment decompression and fusion. CONCLUSIONS This brief and limited communication reviews some of the pertinent issues and provides several examples of selective surgical treatment options without curve arthrodesis in patients with deformity. These options are typically much smaller surgical undertakings, particularly in adult patients who generally have complicating comorbidities. Little has been published to guide surgical management for these conditions.
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Affiliation(s)
- Mark Weidenbaum
- Department of Orthopaedic Surgery, New York Presbyterian Hospital, Columbia University, New York, NY 10032, USA.
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41
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Abstract
Abstract
OBJECTIVE:
The visual outcome in patients with tuberculum and diaphragm sellae meningiomas treated with microsurgery was evaluated. Prognostic and diagnostic values of short- and long-term postoperative visual outcome and etiology for postoperative visual deterioration are discussed with special attention.
METHODS:
Clinical data for 30 surgically treated patients with tuberculum and diaphragm sellae meningiomas were reviewed retrospectively. The mean duration of the follow-up period was 75.9 months (range, 12–151 mo). Mean tumor diameter and volume was 25.9 mm (range, 16.3–63.3 mm) and 12.4 cm3 (range, 2.3–125.6 cm3). A visual impairment score was used to assess the short-term (≤2 wk after surgery) and the long-term (>6 mo after surgery) postoperative visual outcome. Various predictive factors for visual outcome were tested statistically.
RESULTS:
Complete resection was achieved in 23 out of 30 (76.7%) patients. Average preoperative, short- and long-term visual impairment scores were 48.2, 43.4, and 40.9, respectively. Favorable visual outcome was achieved in 80% of patients in the short term and 70% in the long term. Short-term postoperative aggravation of visual function was an ominous sign of further aggravation or at least of little hope for recovery, whereas there was a tendency to improve in the long term if short-term postoperative visual function showed favorable outcome. Recurrence or regrowth of tumor fully was responsible for late deterioration of visual function. No significant prognostic factor for visual outcome could be found.
CONCLUSION:
Short-term postoperative visual outcome was a strong indicator of permanent visual outcome after surgery for tuberculum sellae and diaphragm sellae meningiomas.
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MESH Headings
- Adult
- Aged
- Carotid Artery, Internal/pathology
- Carotid Artery, Internal/surgery
- Decompression, Surgical/adverse effects
- Decompression, Surgical/methods
- Decompression, Surgical/standards
- Disease Progression
- Female
- Humans
- Male
- Meningioma/blood supply
- Meningioma/physiopathology
- Meningioma/surgery
- Microcirculation/pathology
- Microcirculation/surgery
- Microsurgery/adverse effects
- Microsurgery/methods
- Microsurgery/standards
- Middle Aged
- Neoplasm Recurrence, Local/complications
- Neoplasm Recurrence, Local/physiopathology
- Neoplasm Recurrence, Local/prevention & control
- Neurosurgical Procedures/adverse effects
- Neurosurgical Procedures/methods
- Neurosurgical Procedures/standards
- Optic Nerve/blood supply
- Optic Nerve/pathology
- Optic Nerve/surgery
- Optic Nerve Injuries/etiology
- Optic Nerve Injuries/physiopathology
- Optic Nerve Injuries/prevention & control
- Postoperative Complications/etiology
- Postoperative Complications/physiopathology
- Postoperative Complications/prevention & control
- Prognosis
- Sella Turcica/pathology
- Sella Turcica/surgery
- Skull Base Neoplasms/blood supply
- Skull Base Neoplasms/physiopathology
- Skull Base Neoplasms/surgery
- Treatment Outcome
- Vision Tests/standards
- Vision, Low/etiology
- Vision, Low/physiopathology
- Vision, Low/prevention & control
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Affiliation(s)
- Chul-Kee Park
- Department of Neurosurgery, Seoul National University College of Medicine, Clinical Research Institute, Seoul National University Hospital, Seoul, Korea
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42
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Abstract
The present study is aimed to clarify the postoperative outcome of endoscopic carpal tunnel release in elderly patients with carpal tunnel syndrome. Endoscopic carpal tunnel release was performed on 37 hands of 27 patients (2 men, 25 women) who were aged 70 years or older and clinically and electrophysiologically diagnosed with carpal tunnel syndrome. Mean age at the time of surgery was 74.5 years (range: 70-85 years). Mean postoperative follow-up was 35.5 months (range: 12-114 months). Pain was present preoperatively in 20 hands, but quickly resolved postoperatively in all cases. Numbness completely disappeared in 13 of 37 hands (35.1%), but some degree of numbness remained in the remaining cases. Preoperative severity of thenar muscle atrophy was none in 4 hands, mild in 7 hands, moderate in 12 hands and severe in 14 hands. Postoperative severity of thenar muscle atrophy at final follow-up was none in 13 hands, mild in 16 hands, moderate in 2 hands and severe in 6 hands, confirming that thenar muscle atrophy improves even in elderly patients. However, moderate or severe thenar muscle atrophy remained in 8 hands (21.6%). Endoscopic carpal tunnel release should be considered in the elderly, even though clinical symptoms may not improve substantially in advanced cases.
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Affiliation(s)
- M Nagaoka
- Orthopaedic Department, Surugadai Nihon University Hospital, Tokyo, Japan.
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43
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Hosono N, Sakaura H, Mukai Y, Fujii R, Yoshikawa H. C3-6 laminoplasty takes over C3-7 laminoplasty with significantly lower incidence of axial neck pain. Eur Spine J 2006; 15:1375-9. [PMID: 16547754 PMCID: PMC2438573 DOI: 10.1007/s00586-006-0089-9] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2005] [Revised: 11/22/2005] [Accepted: 02/10/2006] [Indexed: 11/30/2022]
Abstract
Five-lamina (C3-7) procedure is the most popular cervical laminoplasty and there have been no studies on the most appropriate number of laminae to be opened. We prospectively reduced the range of laminoplasty from C3-7 to C3-6 in 2002 and compared the outcome of C3-6 laminoplasty (n=37) to that of C3-7 laminoplasty (n=28). In both groups, neurological gain was satisfactory, radiographic changes were minimal, and postoperative MRI indicated sufficient expansion of the dura and the spinal cord. Average operating period was significantly shorter, and length of the operative wound was significantly less in the C3-6 group than in the C3-7 group. Postoperative axial neck pain was significantly rarer after C3-6 laminoplasty than after C3-7 laminoplasty (5.4% vs. 29%, P=0.015). Due to its simplicity and various benefits, C3-6 laminoplasty is a promising alternative to conventional C3-7 laminoplasty for treatment of multisegmental compression myelopathy.
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Affiliation(s)
- N Hosono
- Department of Spine Surgery, Osaka Kosei-Nenkin Hospital, Osaka, Japan.
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44
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Liu JT, Tyan YS, Lee YK, Wang JT. Emergency management of epidural haematoma through burr hole evacuation and drainage. A preliminary report. Acta Neurochir (Wien) 2006; 148:313-7; discussion 317. [PMID: 16437186 DOI: 10.1007/s00701-005-0723-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2005] [Accepted: 11/24/2005] [Indexed: 11/24/2022]
Abstract
BACKGROUND Blood clot evacuation through an osteoplastic craniotomy, a procedure requiring neurosurgical expertise and modern medical facilities, is the accepted method for treatment of a pure traumatic epidural haematoma following closed head injury. In certain emergency situations and/or in less sophisticated settings, however, use of this procedure may not be feasible. The present study was undertaken to ascertain whether placement of a burr hole and drainage under negative pressure constituted a rapid, effective and safe approach to manage patients with simple epidural haematomas. METHODS Thirteen patients suffering from a traumatic epidural haematoma were treated from January, 1999 to October, 2002. Twelve patients presented with skull fracture but no fracture was depressed. Placement of flexible tubes through a burr hole, followed by continuous suction under negative pressure, enabled aspiration of the clot and drainage of the cavity. In 8 cases, the procedure was performed under local anaesthesia with 2% Xylocaine and with intravenous sedation with propofol as needed. The operative procedure was accomplished within 30 min, and the drainage tube was left in place for 3-5 days. CT scans were performed daily from days 1 to 5. RESULTS In 11 of 13 cases, clots were evacuated successfully and patients regained consciousness within 2 hours. Recoveries occurred without significant sequelae. In the remaining 2 cases, the drainage tube was found to be obstructed by a blood clot such that the haematoma was unaffected. A traditional craniotomy was performed within 8-12 hours, and these 2 patients recovered consciousness within the subsequent 6 hours. CONCLUSION Burr hole evacuation followed by drainage under negative pressure is a safe and effective method for emergency management of a pure traumatic epidural haematoma. To assure safety patients given this procedure should be monitored by daily CT scans. Decompressive craniotomy should be performed if consciousness does not improve within several hours.
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MESH Headings
- Adult
- Brain/diagnostic imaging
- Brain/pathology
- Cranial Sinuses/injuries
- Cranial Sinuses/physiopathology
- Cranial Sinuses/surgery
- Craniotomy/instrumentation
- Craniotomy/methods
- Craniotomy/standards
- Decompression, Surgical/instrumentation
- Decompression, Surgical/methods
- Decompression, Surgical/standards
- Dura Mater/blood supply
- Dura Mater/pathology
- Dura Mater/surgery
- Emergency Medical Services/methods
- Emergency Medical Services/standards
- Epidural Space/pathology
- Epidural Space/surgery
- Female
- Head Injuries, Closed/complications
- Hematoma, Epidural, Cranial/physiopathology
- Hematoma, Epidural, Cranial/surgery
- Humans
- Male
- Meningeal Arteries/injuries
- Meningeal Arteries/physiopathology
- Meningeal Arteries/surgery
- Middle Aged
- Monitoring, Physiologic/standards
- Patient Selection
- Postoperative Hemorrhage/prevention & control
- Skull/diagnostic imaging
- Skull/injuries
- Skull/surgery
- Skull Fractures/complications
- Skull Fractures/physiopathology
- Suction/instrumentation
- Suction/methods
- Suction/standards
- Time Factors
- Tomography, X-Ray Computed
- Treatment Outcome
- Unconsciousness/etiology
- Unconsciousness/physiopathology
- Unconsciousness/surgery
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Affiliation(s)
- J T Liu
- Department of Neurosurgery, Chung-Shan Medical University Hospital, Taichung, Taiwan
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45
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Singh A, Gnanalingham KK, Casey AT, Crockard A. Use of quantitative assessment scales in cervical spondylotic myelopathy--survey of clinician's attitudes. Acta Neurochir (Wien) 2005; 147:1235-8; discussion 1238. [PMID: 16205864 DOI: 10.1007/s00701-005-0639-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND There is considerable uncertainty regarding the selection criteria of patients and timing of surgery for cervical spondylotic myelopathy (CSM). Attempts have been made to quantify CSM severity using various assessment scales to provide an adjunct to clinical decision-making. The aim of the present study was to determine, by means of a 7-item questionnaire the attitudes of clinicians regarding the importance of quantitative assessment scales in the management of CSM, their actual use in clinical practice and how current scales fall short of the ideal. FINDINGS Clinical history, examination, radiological imaging and quantitative functional assessment were regarded by 117 clinicians as being almost equally important in the management of CSM. However, only 22 (19%) of clinicians admitted to using an assessment scale in clinical practice and 4 (3%) believed there was a 'gold-standard' assessment scale. These clinicians also considered 'ease of use' to be the most important attribute of an ideal assessment scale, followed by 'reproducibility', 'sensitivity to change' and 'validity'. CONCLUSIONS The discrepancy between the importance attached to quantitative measurement and its actual use suggests that current scales are under-utilised or unsuitable for clinical practice. A new easy-to use scale may be required that better reflects clinical requirements.
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Affiliation(s)
- A Singh
- Department of Surgical Neurology, National Hospital for Neurology and Neurosurgery, London, UK.
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MESH Headings
- Basilar Artery/pathology
- Basilar Artery/physiopathology
- Cervical Vertebrae/pathology
- Cervical Vertebrae/physiopathology
- Decompression, Surgical/standards
- Diagnosis, Differential
- Ear, Inner/blood supply
- Ear, Inner/physiopathology
- Head Movements/physiology
- Humans
- Ischemic Attack, Transient/diagnosis
- Ischemic Attack, Transient/etiology
- Ischemic Attack, Transient/physiopathology
- Labyrinth Diseases/etiology
- Labyrinth Diseases/physiopathology
- Labyrinth Diseases/surgery
- Nystagmus, Pathologic/diagnosis
- Nystagmus, Pathologic/etiology
- Nystagmus, Pathologic/physiopathology
- Rotation/adverse effects
- Syndrome
- Vertebral Artery/abnormalities
- Vertebral Artery/pathology
- Vertebral Artery/physiopathology
- Vertebrobasilar Insufficiency/pathology
- Vertebrobasilar Insufficiency/physiopathology
- Vertebrobasilar Insufficiency/surgery
- Vertigo/diagnosis
- Vertigo/etiology
- Vertigo/physiopathology
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47
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Zakrzewska JM, Lopez BC, Kim SE, Varian EA, Coakham HB. Patient satisfaction after surgery for trigeminal neuralgia--development of a questionnaire. Acta Neurochir (Wien) 2005; 147:925-32. [PMID: 16079960 DOI: 10.1007/s00701-005-0575-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2004] [Accepted: 06/03/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE This project aimed to prepare a self complete patient satisfaction survey for patients who have undergone surgery for trigeminal neuralgia and then assess its reproducibility, validity and acceptability in one centre. METHODS The questionnaire, for initial use in patients who had undergone posterior fossa surgery for trigeminal neuralgia, was designed after a systematic review of the surgical literature had been performed and discussions held at the US and UK Trigeminal Neuralgia Support group meetings. It underwent several changes after input from neurosurgeons, patients, copywriter and statistician and finally contained 44 questions, the SF12, Hospital Anxiety and Depression Scale (HAD), Brief Pain Inventory (BPI) and McGill Pain questionnaire (MPQ). From the total number of 413 patients in the database of one centre the questionnaire was sent with a covering letter to 305 patients, the rest had died (25), were lost to follow up (26) or did not meet the inclusion criteria (56). One patient had bilateral PSR. The completed questionnaires were evaluated by an independent physician, neurosurgeon and patient. A repeat questionnaire was sent to 10% of the patients to check reproducibility. RESULTS The questionnaires were well completed with a final response rate of 92%. It appeared to be highly acceptable and reproducible but needed adjustment to improve its validity before being used in other centres and for all surgical procedures. A new questionnaire is proposed which could be used on an annual basis. CONCLUSIONS A questionnaire has been developed for use in patients who have undergone surgical management for trigeminal neuralgia and which is acceptable to patients.
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Affiliation(s)
- J M Zakrzewska
- Oral Medicine, Barts and the London, Queen Mary's School of Medicine and Dentistry, UK.
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Reithmeier T, Löhr M, Pakos P, Ketter G, Ernestus RI. Relevance of ICP and ptiO2 for indication and timing of decompressive craniectomy in patients with malignant brain edema. Acta Neurochir (Wien) 2005; 147:947-51; discussion 952. [PMID: 15912256 DOI: 10.1007/s00701-005-0543-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2004] [Accepted: 03/31/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND The exact effects of decompressive craniectomy on intracranial pressure (ICP) and cerebral tissue oxygenation (ptiO2) are still unclear. Therefore, we have monitored ICP and ptiO2 intra-operatively and correlated these values to different operative steps during craniectomy. METHODS ICP and ptiO2 values have been monitored both, simultaneously and continuously, in 15 patients with cerebral edema due to posttraumatic or postischemic brain swelling. Indications for craniectomy were an increase in ICP above 25 mmHg or a decrease in ptiO2 below 10 mmHg resistant to conservative treatment (e.g. mannitol, hyperventilation, adequate arterial blood oxygenation, etc.). In all cases, we performed a fronto-temporo-parietal craniectomy (15 x 12 cm) and dura enlargement with galea-periosteum. During craniectomy, monitoring of ICP and ptiO2 in the affected hemisphere was continued. Values were recorded and correlated with the different operative steps. FINDINGS We performed craniectomy according to our treatment protocol in 5 patients. Prior to surgery, mean ICP values were 25.6 mmHg (range: 23-29 mmHg), mean ptiO2 values were 5.9 mmHg (range: 2.4-9.5 mmHg), and mean CPP values were 66 mmHg (range: 60-70 mmHg). After removing the bone flap, ICP values dropped to physiological values (mean: 7.4 mmHg), whereas ptiO2 values increased only slightly (mean: 11 mmHg). Opening of the dura resulted in a further decrease of ICP (mean 4.8 mmHg) and an increase of ptiO2 to normal limits (mean: 18.8 mmHg). After skin closure, mean ICP was 6.8 mmHg and mean ptiO2 was 21.7 mmHg, respectively. We found a significant decrease of ICP after craniectomy (p<0.042) and after dura enlargement (p<0.039) as well as a statistically significant increase in ptiO2 after craniectomy (p<0.043) and after dura enlargement (p<0.041). CONCLUSION As a large bone flap in decompressive craniectomy is essential for adequate ICP reduction, the results of the presented cases suggest that dura enlargement is the crucial step to restore adequate brain tissue oxygenation and that ptiO2 monitoring could be an important tool for timing craniectomy in the future.
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Affiliation(s)
- T Reithmeier
- Department of Neurosurgery, University of Cologne, Cologne, Germany.
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49
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50
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Peng B, Hou S, Wu W, Zhang C, Yang Y. The pathogenesis and clinical significance of a high-intensity zone (HIZ) of lumbar intervertebral disc on MR imaging in the patient with discogenic low back pain. Eur Spine J 2005; 15:583-7. [PMID: 16047210 PMCID: PMC3489329 DOI: 10.1007/s00586-005-0892-8] [Citation(s) in RCA: 123] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2004] [Revised: 12/01/2004] [Accepted: 01/25/2005] [Indexed: 01/19/2023]
Abstract
Recently, the presence of a high-intensity zone (HIZ) within the posterior annulus seen on T2-weighted MRI has aroused great interest and even controversy among many investigators, particularly on whether the HIZ was closely associated with a concordant pain response on awake discography. The study attempted to interpret the correlation between the presence of the HIZ on MRI and awake discography, as well as its characteristic pathology. Fifty two patients with low back pain without disc herniation underwent MRI and discography successively. Each disc with HIZ was correlated for an association between the presence of a HIZ and the grading of annular disruption and a concordant pain response. Eleven specimens of lumbar intervertebral discs which contain HIZ in the posterior annulus from 11 patients with discogenic low back pain were harvested for histologic examination to interpret the histologic basis of a nociceptive response during posterior lumbar interbody fusion (PLIF). The study found that in all of 142 discograms in 52 patients, 17 presented HIZ. All 17 discs with HIZ showed painful reproduction and abnormal morphology with annular tears extending either well into or through the outer third of the annulus fibrosus. The consecutive sagittal slices through the HIZ lesion showed that a notable histologic feature of the formation of vascularized granulation tissue in the outer region of the annulus fibrosus. The current study suggests that the HIZ of the lumbar disc on MRI in the patient with low back pain could be considered as a reliable marker of painful outer anular disruption.
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Affiliation(s)
- Baogan Peng
- Department of Orthopaedics, 304th hospital, Medical Postgraduate College of PLA, 100037 Beijing, People's Republic of China.
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