Spine
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The cost of chronic benign spinal pain is large and growing. The costs of interventional treatment for spinal pain were at a minimum of $13 billion (U. S. dollars) in 1990, and the costs are growing at least 7% per year. ⋯ Cost-minimization versus cost-effectiveness approaches are described. Spinal cord stimulation and intraspinal drug infusion systems are alternatives that can be justified on a cost basis. Cost minimization analysis suggests that epidural injections under fluoroscopy may not be justified by the current literature.
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A literature review was conducted. ⋯ The ultimate efficacy of spinal cord stimulation remains to be determined, primarily because of limitations associated with the published literature. However, on the basis of the current evidence, it may represent a valuable treatment option, particularly for patients with chronic pain of predominantly neuropathic origin and topographical distribution involving the extremities. The potential treatment of other pain topographies and etiologies by spinal cord stimulation continues to be studied.
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A cross-sectional study was conducted. ⋯ The inner transverse diameter of the lumbar pedicle, particularly in young children, is smaller than previously reported. Insertion of screws currently available commercially screws seems to be safe in the L4-L5 pedicles of children ages 5 to 8 years, and in the L3-L5 pedicles of older children. Custom-made screws might be considered for upper levels for safe application.
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A literature review and synthesis were performed. ⋯ Some clinical or experimental support can be found in the literature for 10 specific mechanisms or proposed mechanisms of spinal cord stimulation.
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An anatomic study of pedicle dimensions and orientation was performed for upper thoracic vertebrae from elderly human subjects. ⋯ Even the largest patients had some pedicles that could not accommodate the smallest standard pedicle screw, and more than one half of the pedicles average patients were too small. Transpedicular screw placement is not safe in these patients. Proper placement must avoid penetration of the medial pedicle wall.