The spine journal : official journal of the North American Spine Society
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Comparative Study
The related outcome and complication rate in primary lumbar microscopic disc surgery depending on the surgeon's experience: comparative studies.
Studies concerning intraoperative complications and their influence on the clinical outcome of microscopic disc surgery are quite rare. Complication rates vary between 1.5% and 15.8%. A correlation between the surgeon's experience and the complication rate may be expected. ⋯ Microscopic disc surgery requires a course of instruction and a considerable number of surgeries under supervision by experienced surgeons. To shorten the learning curve, a number of standardized surgery steps to clearly identify anatomical landmarks are helpful. During training, these landmarks can be checked by an experienced surgeon to minimize the rate of intraoperative complications. Initial postoperative ischiatic pain was correlated to an incidental durotomy with p<.001. For long-term results after disc surgery, however, socioeconomic and work-related factors are of greater importance in spinal disc surgery than the incidence of intraoperative complications.
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Clinical Trial
The endoscopically assisted simultaneous posteroanterior reconstruction of the thoracolumbar spine in prone position.
The reconstruction of the anterior column of the thoracolumbar spine has become more common in the last few years, due largely to the unfavorable results of exclusively posterior surgical treatment, which has been associated with a lack of about 10 degrees of kyphosis correction after removal of the instrumentation. The minimally invasive anterior techniques have reduced the morbidity of the anterior approach significantly. ⋯ The approach to the anterior spine in prone position is feasible by using a self-holding retractor system for the region between T4 and L4. The duration of anesthesia for the one-stage simultaneous procedure was reduced by about 40 minutes, because changing the position of the patient is no longer necessary. The minimal incision, in combination with the retractor system, significantly reduces cost by allowing the use of less expensive instruments and implants. The advantages of the open and the endoscopic techniques are combined, while their disadvantages are minimized. The main advantage of the prone position is the opportunity to access the anterior and posterior spine simultaneously, which is especially helpful in reduction maneuvers.
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Chronic lumbar discogenic pain (CLDP) impairs the patient's physical abilities to function within the normal physiologic loading ranges of activities of daily living. The pathogenesis of CLDP is multifactorial and not well understood. Conservative therapeutic regimens often fail to achieve sufficient pain relief. Surgical options vary greatly in surgical invasiveness as well as outcome. Definitive surgical treatment is often 360-degree fusion. The morbidity associated with this approach is significant, considering that only 65% to 80% of patients obtain satisfactory clinical results. This has spawned interest in minimally invasive surgical options, such as intradiscal electrothermal therapy (IDET; ORATEC Interventions, Inc., Menlo Park, CA), but results are conflicting. ⋯ Posterolateral transforaminal SED and radiofrequency thermal annuloplasty were used to interrupt the purported annular defect pain sensitization process, thought to be necessary in the genesis of chronic lumbar discogenic pain. Lack of clinical benefit from the subject procedure did not degrade any subsequent surgical or nonsurgical treatment options. The experience gained from this study warrants further investigation into the cellular and molecular processes that provided back pain relief in these patients.
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Obtaining adequate purchase with standard pedicle screw techniques remains a challenge in poor quality bone. The development of alternate insertion techniques and screw designs was prompted by recognition of potential fixation complications. An expandable pedicle screw design has been shown to significantly improve fixation compared to a conventional screw in poor quality bone. ⋯ PMMA cement augmentation of the expandable pedicle screw may be a viable clinical option for achieving fixation in severely osteoporotic bone.
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Optimal treatment of nonmalignant chronic spinal disorders (CSDs) may require the use of one or more nonopioid psychotropic medications. Vast research literature has documented high rates of psychiatric disorders in patients with CSDs. Psychotropic medications are one type of effective treatment for these disorders. Many medications of this type are also used as adjuvants to primary analgesic medications. ⋯ Psychotropic medications are extremely useful in the treatment of psychiatric disorders comorbid with CSDs and modestly useful as analgesic adjuvants, particularly with pain of neuropathic etiology. Familiarity with these medications will aid the primary treating physician in optimizing outcomes in this difficult group of patients.