Neurosurgery
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Surgery for spinal metastases remains the mainstay treatment for pain, instability, and neurological deterioration due to tumor infiltration of the spine. However, several new therapies are emerging which may improve outcomes further, and in some cases even replace the need for surgery. We now have a better understanding of which factors influence survival and quality of life after surgery, and this underpins the development and application of new treatments, and assessment of outcome. ⋯ New surgical techniques allow smaller, quicker, and safer operations with less blood loss, pain, and quicker recovery after surgery. Radiation treatments have also leapt forward with the greater accuracy and higher doses possible from intensity-modulated photon radiation, stereotactic body radiation treatment, proton beam therapy, or carbon ion treatment. Combined with more advanced materials for vertebral body stabilization, computer navigation systems, and robotics, more can be done at earlier or later stages of the spinal disease than was previously possible, resulting in more options and improved outcomes for patients.
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Spine surgery is complicated by an incidence of 1% to 9% of surgical site infection (SSI). The most common organisms are gram-positive bacteria and are endogenous, that is are brought to the hospital by the patient. Efforts to improve safety have been focused on reducing SSI using a bundle approach. The bundle approach applies many quality improvement efforts and has been shown to reduce SSI in other surgical procedures. ⋯ Significant reduction of SSIs is possible, but requires a systems approach involving all stakeholders. There are many simple and low-cost components that can be adjusted to reduce SSIs. Systematic efforts including understanding of pathophysiology, prevention strategies, and system-wide quality improvement programs demonstrate significant reduction of SSI.
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Over the last several decades, significant advances have occurred in the assessment and management of spinal deformity. ⋯ It is ultimately through the reviewed and other recent and ongoing advances that care for patients with spinal deformity will continue to evolve, enabling better informed treatment decisions, more meaningful patient counseling, reduced complications, and achievement of desired clinical outcomes.
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Spinal osteobiologics have evolved substantially in this century after the development of many product categories such as growth factors, allograft, and stem cells. The indications for the use of novel biologics within spine surgery are rapidly expanding as the mechanism of each is elucidated. While the knowledge base of bone morphogenetic protein increases with each subsequent year, the application of new nanotechnology and cell-based strategies are being reported. This review will discuss the most recent data in novel osteobiologics, and where we could use future study.
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Review
The Advancing Role of Neuromodulation for the Management of Chronic Treatment-Refractory Pain.
Neuropathic pain is a common cause of disability and health care utilization. While judicious pharmacotherapy and management of comorbid psychological distress can provide for improved quality of life, some patients with treatment-refractory disease require more invasive therapies. Spinal cord stimulation can provide for improvement in pain and decrease in medication utilization, with level 1 evidence supporting its use across various pain etiologies including persistent postoperative neuropathic pain, complex regional pain syndrome, chronic inoperable limb ischemia, treatment refractory angina, and painful diabetic neuropathy. ⋯ Technological innovation in lead design, implantable pulse generator capability, and stimulation algorithms and parameters may further enhance the success of this therapy. Neuromodulation of distal targets such as dorsal root ganglion may permit greater anatomic specificity of the therapy, whereas subthreshold stimulation with high-frequency or burst energy delivery may eliminate noxious and off-target paresthesiae. Such new technologies should be subject to rigorous evaluation as their mechanisms of action and long-term outcomes remain hitherto undefined.