European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society
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Comparative Study
A retrospective study of surgical and conservative treatment for spinal extradural abscess.
The management of spinal extradural abscess (SEA), particularly the choice between surgical and conservative treatment, is controversial. We therefore undertook a retrospective study of patients admitted with this diagnosis: Details of presentation, treatment and outcome were obtained by review of inpatient notes and radiology. Twenty-five individuals with SEA aged 10-79 years were admitted between 1989 and 1995. ⋯ Four patients treated conservatively (44%) and seven treated surgically (43%) were capable of return to work or school, whilst a further seven patients (three treated conservatively and four treated surgically) were able to lead independent lives. No significant difference in outcome was demonstrated between patients treated non-operatively and those treated surgically. We conclude that certain carefully selected patients can be treated conservatively, but that surgery should remain the mainstay of management.
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Both endoscopic lumbar spinal surgery and the non-standardized and unstable retractor systems for the lumbar spine presently on the market have disadvantages and limitations in relation to the minimally invasive surgical concept, which have been gradually recognized in the last few years. In an attempt to resolve some of these issues, we have developed a highly versatile retractor system, which allows access to and surgery at the lumbar, thoracic and even cervical spine. This retractor system - Synframe - is based on a ring concept allowing 360 degrees access to a surgical opening in anterior as well as posterior surgery. ⋯ This ring also functions as a carrier for fiberoptic illumination devices and different sizes of endoscopes, used to transmit the surgical procedure out of the depth of the surgical exposure for both teaching purposes and for the surgical team when it has no longer direct visual access to the procedure. The ring is stable, being fixed onto the operating table, allowing precise minimally open approaches and surgical procedures under direct vision with optimal illumination. This ring system also opens perspectives for an integrated minimally open surgical concept, where the ring may be used as a reference platform in computer-navigated surgery.
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The coincidental development of minimal intervention techniques for carrying out anterior lumbar spinal fusion and the introduction of cages to provide mechanical support of introduced bone graft led to the development of a type of cage suitable for both minimal intervention use (laparoscopic) and for the standard open procedure (the BAK cage). Reported results concentrated in the main on feasibility, safety and fusion rate achieved, rather than clinical outcome. ⋯ There was no long-term benefit from the laparoscopic procedure. Laparoscopic insertion at the L4/5 level was attended by a greater incidence of complications, and had a longer learning curve.
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Multicenter Study Clinical Trial
Posterior endoscopic discectomy (and other procedures).
Percutaneous approaches to lumbar discectomy were somewhat controversial, because of their limited indications. They have not proven to be as effective as standard open lumbar disc surgery, because of longer operating times and some technical problems in addressing all the different aspects of lumbar disc herniations. ⋯ MED, and METR'x which evolved from it,. allow the surgeon to address not only contained lumbar disc herniations, but also free-fragment disc pathology and symptomatic lateral recess stenosis secondary to bony hypertrophy. The surgical technique is summarized and some preliminary clinical results of a prospective multicenter study with 13 months' mean follow-up are presented.