The spine journal : official journal of the North American Spine Society
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Observational Study
One-year outcomes of surgical versus nonsurgical treatments for discogenic back pain: a community-based prospective cohort study.
The clinical entity "discogenic back pain" remains controversial at fundamental levels, including its pathophysiology, diagnostic criteria, and optimal treatment. This is true despite availability of four randomized trials comparing the efficacy of surgical and nonsurgical treatments. One trial showed benefit for lumbar fusion compared with unstructured nonoperative care, and three others showed roughly similar results for lumbar surgery and structured rehabilitation. ⋯ The surgical group showed greater improvement at 1 year compared with the nonsurgical group, although the composite success rate for both treatment groups was only fair. The results should be interpreted cautiously because outcomes are short term, and treatment was not randomly assigned. Only 5% of nonsurgical patients received cognitive behavior therapy. Nonsurgical treatment that patients received was variable and mostly not compliant with major guidelines.
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In vitro nondestructive flexibility testing of the CerviCore total disc replacement (TDR) was performed. It was hypothesized that TDR would not significantly alter biomechanics relative to intact, whereas rigid fixation would cause significant changes. ⋯ With regard to ROM, LZ, IAR, and coupling, deviations from intact biomechanics were less substantial after TDR than after plating. Facet load alterations were minimal with either construct. Our results show that this particular TDR permits ROM and maintains some measures of kinematics in a cadaver model.
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Intervertebral disc and facet joints are the two primary load-bearing structures of the lumbar spine, and altered loading to these structures may be associated with frontal plane spinal deviations. ⋯ Facet loading increased during simulated pelvic obliquity in frontal and transverse planes, whereas intradiscal pressures were decreased compared with sagittal and frontal plane motions alone. Altered spinopelvic alignment may increase the loads experienced by spinal tissue, especially the facet joints.
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Spine-related health-care expenditures accounted for $86 billion dollars in 2005, a 65% increase from 1997. However, when adjusting for inflation, surgeons have seen decreased reimbursement rates over the last decade. ⋯ Based on this analysis, the proportion of overall costs allocated to professional fees for a noninstrumented lumbar laminectomy is small, whereas those allocated to hospital costs are far greater. These findings suggest that the current focus on decreasing physician reimbursement as the principal cost saving strategy will lead to minimal reimbursement for surgeons without a substantial drop in the overall cost of procedures performed.
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Comparative Study
C1 lateral mass screw placement via the posterior arch: a technique comparison and anatomic analysis.
Instrumentation of C1 is becoming increasingly common. Starting points initially described for C1 lateral mass screws at the lateral mass/posterior arch junction are technically challenging. Recently, a number of techniques have evolved advocating varying starting points and trajectories. Despite being technically easier, there are new safety concerns. Insufficient evidence exists for optimal C1 lateral mass screw placement with starting points in the posterior arch. ⋯ C1 lateral mass screws could be virtually placed bilaterally in each of 100 clinical cases without violating critical structures. However, none of the previously described approaches worked in every case because of significant anatomic variability. The vertical starting point was particularly critical, and vertebral groove height was the most limiting variable. Although a reliable safe zone could be found in every case, preoperative planning is essential to avoid critical structures.