Neurosurg Focus
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Historical Article
The "tract" of history in the treatment of lumbar degenerative disc disease.
In this paper past, present, and future treatments of degenerative disc disease (DDD) of the lumbar spine are outlined in a straight forward manner. This is done to review previous knowledge of the disease, define current treatment procedures, and discuss future perspectives. ⋯ In this paper, the authors attempt to outline the history of DDD of the lumbar spine in an unbiased and scientific fashion. Physiological, diagnostic, and therapeutic implications will all be addressed in this study.
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Historical Article
Evolution of the lateral extracavitary approach to the spine.
The development of alternative approaches to spine disorders marked an evolutionary change in the methods by which surgeons address diseases that affect the ventral portion of the spine. From the advent of spinal surgery until quite recently, physicians used posterior approaches almost exclusively for the treatment of all pathological processes. Surgeons subsequently became frustrated and disenchanted with outcomes of patients with anterior vertebral body disease when these procedures were applied. ⋯ In this paper, the authors chart the development of an influential approach to the spine that is designed to address these issues: the lateral extracavitary approach. They trace its origins to early precursor procedures and follow its use in current practice for the treatment of a variety of spinal disorders. They also examine its applications, role, and continued importance in the age of minimally invasive surgery.
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Review Case Reports
Is there an upper limit of intracranial pressure in patients with severe head injury if cerebral perfusion pressure is maintained?
Authors of recent studies have championed the importance of maintaining cerebral perfusion pressure (CPP) to prevent secondary brain injury following traumatic head injury. Data from these studies have provided little information regarding outcome following severe head injury in patients with an intracranial pressure (ICP) greater than 40 mm Hg, however, in July 1997 the authors instituted a protocol for the management of severe head injury in patients with a Glasgow Coma Scale score lower than 9. The protocol was focused on resuscitation from acidosis, maintenance of a CPP greater than 60 mm Hg through whatever means necessary as well as elevation of the head of the bed, mannitol infusion, and ventriculostomy with cerebrospinal fluid drainage for control of ICP. ⋯ Data from this preliminary study indicate that intense, aggressive management of CPP can lead to good neurological outcomes despite extremely high ICP. Aggressive CPP therapy should be performed and maintained even though apparently lethal ICP levels may be present. Further study is needed to support these encouraging results.
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The atlantoaxial region has been extensively described as a spinal segment especially prone to injury in children. In this clinical review, the authors evaluate and summarize the management of 23 pediatric cases of atlantoaxial instability treated between March 1990 and October 2002. Four broad categories of atlantoaxial problems were observed-atlantoaxial rotatory subluxation in six patients, anterior-posterior atlantoaxial instability caused by ligamentous injury or congenital ligamentous laxity (10 patients), atlantoaxial fracture with or without dislocation (five patients), and atlantooccipital dislocation (two patients). ⋯ Various techniques of surgical stabilization including transarticular screws with sublaminar wiring, transoral decompression with posterior plating, and laminectomy with Steinmann pin occipital-cervical fusion were used with good results. Both patients with atlantooccipital dislocation underwent immediate Locksley occipital-cervical fusion, with marked neurological improvement. Individualized case management must be based on clinical presentation, with internal fixation being the last resort.
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Review
What is the optimal threshold for cerebral perfusion pressure following traumatic brain injury?
Intensive care of the patient with traumatic brain injury centers on control of intracranial pressure and cerebral perfusion pressure (CPP). The optimal CPP by definition delivers an adequate supply of blood and oxygen to meet the metabolic demands of brain tissue. ⋯ No study that accurately assesses the efficacy of normal CPP compared with elevated CPP has been performed, but several studies demonstrate that a CPP threshold exists on an individual basis for patients with TBI. The use of brain monitors of cerebral metabolism and oxygen supply may assist the clinician in the selection of the optimal CPP for an individual patient.