RESUMEN
BACKGROUND: The comparative effectiveness of performing instrumented (rigid pedicle screws affixed to titanium alloy rods) lumbar spinal fusion in addition to decompressive laminectomy in patients with symptomatic lumbar grade I degenerative spondylolisthesis with spinal stenosis is unknown. METHODS: In this randomized, controlled trial, we assigned patients, 50 to 80 years of age, who had stable degenerative spondylolisthesis (degree of spondylolisthesis, 3 to 14 mm) and symptomatic lumbar spinal stenosis to undergo either decompressive laminectomy alone (decompression-alone group) or laminectomy with posterolateral instrumented fusion (fusion group). The primary outcome measure was the change in the physical-component summary score of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36; range, 0 to 100, with higher scores indicating better quality of life) 2 years after surgery. The secondary outcome measure was the score on the Oswestry Disability Index (range, 0 to 100, with higher scores indicating more disability related to back pain). Patients were followed for 4 years. RESULTS: A total of 66 patients (mean age, 67 years; 80% women) underwent randomization. The rate of follow-up was 89% at 1 year, 86% at 2 years, and 68% at 4 years. The fusion group had a greater increase in SF-36 physical-component summary scores at 2 years after surgery than did the decompression-alone group (15.2 vs. 9.5, for a difference of 5.7; 95% confidence interval, 0.1 to 11.3; P=0.046). The increases in the SF-36 physical-component summary scores in the fusion group remained greater than those in the decompression-alone group at 3 years and at 4 years (P=0.02 for both years). With respect to reductions in disability related to back pain, the changes in the Oswestry Disability Index scores at 2 years after surgery did not differ significantly between the study groups (-17.9 in the decompression-alone group and -26.3 in the fusion group, P=0.06). More blood loss and longer hospital stays occurred in the fusion group than in the decompression-alone group (P<0.001 for both comparisons). The cumulative rate of reoperation was 14% in the fusion group and 34% in the decompression-alone group (P=0.05). CONCLUSIONS: Among patients with degenerative grade I spondylolisthesis, the addition of lumbar spinal fusion to laminectomy was associated with slightly greater but clinically meaningful improvement in overall physical health-related quality of life than laminectomy alone. (Funded by the Jean and David Wallace Foundation and others; SLIP ClinicalTrials.gov number, NCT00109213.).
Asunto(s)
Laminectomía , Vértebras Lumbares/cirugía , Fusión Vertebral , Estenosis Espinal/cirugía , Espondilolistesis/cirugía , Anciano , Anciano de 80 o más Años , Descompresión Quirúrgica , Evaluación de la Discapacidad , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Reoperación/estadística & datos numéricos , Estenosis Espinal/complicaciones , Espondilolistesis/complicaciones , Resultado del TratamientoRESUMEN
OBJECTIVE: To determine whether patients who learned the views of an expert surgeons' panel's assessment of equipoise between 2 alternative operative treatments had increased likelihood of consenting to randomization. BACKGROUND: Difficulty obtaining patient consent to randomization is an important barrier to conducting surgical randomized clinical trials, the gold standard for generating clinical evidence. METHODS: Observational study of the rate of patient acceptance of randomization within a 5-center randomized clinical trial comparing lumbar spinal decompression versus lumbar spinal decompression plus instrumented fusion for patients with symptomatic grade I degenerative lumbar spondylolisthesis with spinal stenosis. Eligible patients were enrolled in the trial and then asked to accept randomization. A panel of 10 expert spine surgeons was formed to review clinical information and images for individual patients to provide an assessment of suitability for randomization. The expert panel vote was disclosed to the patient by the patient's surgeon before the patient decided whether to accept randomization or not. RESULTS: Randomization acceptance among eligible patients without expert panel review was 40% (19/48) compared with 81% (47/58) among patients undergoing expert panel review (Pâ<â0.001). Among expert-reviewed patients, randomization acceptance was 95% when all experts or all except 1 voted for randomization, 75% when 2 experts voted against randomization, and 20% with 3 or 4 votes against (Pâ<â0.001 for trend). CONCLUSIONS: Patients provided with an expert panel's assessment of their own suitability for randomization were twice as likely to agree to randomization compared with patients receiving only their own surgeon's recommendation.
Asunto(s)
Laminectomía/métodos , Vértebras Lumbares , Estenosis Espinal/cirugía , Espondilolistesis/cirugía , Anciano , Anciano de 80 o más Años , Descompresión Quirúrgica/métodos , Femenino , Estudios de Seguimiento , Humanos , Laminectomía/instrumentación , Masculino , Persona de Mediana Edad , Selección de Paciente , Guías de Práctica Clínica como Asunto , Estudios Prospectivos , Estenosis Espinal/diagnóstico por imagen , Espondilolistesis/diagnóstico por imagen , Resultado del Tratamiento , Estados UnidosRESUMEN
BACKGROUND: Cranioplasty encompasses various cranial reconstruction techniques that are used following craniectomy due to stroke or trauma. Despite classical infectious signs, symptoms, and radiologic findings, however, the diagnosis of infection following cranioplasty can be elusive, with the potential to result in definitive treatment delay. We sought to determine if fever or leukocytosis at presentation were indicative of infection, as well as to identify any factors that may limit its applicability. METHODS: Following institutional review board approval, a retrospective cohort of 239 patients who underwent cranioplasty following craniectomy for stroke or trauma was established from 2001-2011 at a single center (Massachusetts General Hospital). Analysis was then focused on those who developed a surgical site infection, as defined by either frank intra-operative purulence or positive intra-operative cultures, and subsequently underwent operative management. RESULTS: In 27 total cases of surgical site infection, only two had a fever and four had leukocytosis at presentation. This yielded a false-negative rate for fever of 92.6% and for leukocytosis of 85.2%. In regard to infectious etiology, 22 (81.5%) cases generated positive intra-operative cultures, with Propionibacterium acnes being the most common organism isolated. Median interval to infection was 99 days from initial cranioplasty to time of infectious presentation, and average follow-up was 3.4 years. CONCLUSIONS: The utilization of fever and elevated white blood cell count in the diagnosis of post-cranioplasty infection is associated with a high false-negative rate, making the absence of these features insufficient to exclude the diagnosis of infection.
Asunto(s)
Craniectomía Descompresiva/efectos adversos , Fiebre/etiología , Leucocitosis/etiología , Infección de la Herida Quirúrgica/diagnóstico , Adolescente , Adulto , Anciano , Lesiones Encefálicas/cirugía , Niño , Preescolar , Reacciones Falso Negativas , Femenino , Infecciones por Bacterias Grampositivas/tratamiento farmacológico , Infecciones por Bacterias Grampositivas/etiología , Infecciones por Bacterias Grampositivas/microbiología , Humanos , Lactante , Masculino , Persona de Mediana Edad , Propionibacterium acnes , Estudios Retrospectivos , Accidente Cerebrovascular/cirugía , Colgajos Quirúrgicos/microbiología , Infección de la Herida Quirúrgica/complicaciones , Infección de la Herida Quirúrgica/cirugía , Adulto JovenRESUMEN
BACKGROUND AND OBJECTIVES: The Accreditation Council for Graduate Medical Education has approved 117 neurological surgery residency programs which develop and educate neurosurgical trainees. We present the current landscape of neurosurgical training in the United States by examining multiple aspects of neurological surgery residencies in the 2022-2023 academic year and investigate the impact of program structure on resident academic productivity. METHODS: Demographic data were collected from publicly available websites and reports from the National Resident Match Program. A 34-question survey was circulated by e-mail to program directors to assess multiple features of neurological surgery residency programs, including curricular structure, fellowship availability, recent program changes, graduation requirements, and resources supporting career development. Mean resident productivity by program was collected from the literature. RESULTS: Across all 117 programs, there was a median of 2.0 (range 1.0-4.0) resident positions per year and 1.0 (range 0.0-2.0) research/elective years. Programs offered a median of 1.0 (range 0.0-7.0) Committee on Advanced Subspecialty Training-accredited fellowships, with endovascular fellowships being most frequently offered (53.8%). The survey response rate was 75/117 (64.1%). Of survey respondents, the median number of clinical sites was 3.0 (range 1.0-6.0). Almost half of programs surveyed (46.7%) reported funding mechanisms for residents, including R25, T32, and other in-house grants. Residents received a median academic stipend of $1000 (range $0-$10 000) per year. Nearly all programs (93.3%) supported wellness activities for residents, which most frequently occurred quarterly (46.7%). Annual academic stipend size was the only significant predictor of resident academic productivity (R 2 = 0.17, P = .002). CONCLUSION: Neurological surgery residency programs successfully train the next generation of neurosurgeons focusing on education, clinical training, case numbers, and milestones. These programs offer trainees the chance to tailor their career trajectories within residency, creating a rewarding and personalized experience that aligns with their career aspirations.
Asunto(s)
Internado y Residencia , Humanos , Estados Unidos , Estudios Transversales , Educación de Postgrado en Medicina , Neurocirujanos , Encuestas y CuestionariosRESUMEN
BACKGROUND AND OBJECTIVES: Racial and socioeconomic disparities in spine surgery for degenerative lumbar spondylolisthesis persist in the United States, potentially contributing to unequal health-related quality of life (HRQoL) outcomes. This is important as lumbar spondylolisthesis is one of the most common causes of surgical low back pain, and low back pain is the largest disabler of individuals worldwide. Our objective was to assess the relationship between race, socioeconomic factors, treatment utilization, and outcomes in patients with lumbar spondylolisthesis. METHODS: This cohort study analyzed prospectively collected data from 9941 patients diagnosed with lumbar spondylolisthesis between 2015 and 2020 at 5 academic hospitals. Exposures were race, socioeconomic status, health coverage, and HRQoL measures. Main outcomes and measures included treatment utilization rates between racial groups and the association between race and treatment outcomes using logistic regression, adjusting for patient characteristics, socioeconomic status, health coverage, and HRQoL measures. RESULTS: Of the 9941 patients included (mean [SD] age, 67.37 [12.40] years; 63% female; 1101 [11.1%] Black, Indigenous, and People of Color [BIPOC]), BIPOC patients were significantly less likely to use surgery than White patients (odds ratio [OR] = 0.68; 95% CI, 0.62-0.75). Furthermore, BIPOC race was associated with significantly lower odds of reaching the minimum clinically important difference for physical function (OR = 0.74; 95% CI, 0.60; 0.91) and pain interference (OR = 0.77; 95% CI, 0.62-0.97). Medicaid beneficiaries were significantly less likely (OR = 0.65; 95% CI, 0.46-0.92) to reach a clinically important improvement in HRQoL when accounting for race. CONCLUSION: This study found that BIPOC patients were less likely to use spine surgery for degenerative lumbar spondylolisthesis despite reporting higher pain interference, suggesting an association between race and surgical utilization. These disparities may contribute to unequal HRQoL outcomes for patients with lumbar spondylolisthesis and warrant further investigation to address and reduce treatment disparities.
Asunto(s)
Disparidades en Atención de Salud , Vértebras Lumbares , Calidad de Vida , Espondilolistesis , Humanos , Espondilolistesis/cirugía , Espondilolistesis/etnología , Masculino , Femenino , Anciano , Persona de Mediana Edad , Disparidades en Atención de Salud/estadística & datos numéricos , Disparidades en Atención de Salud/etnología , Vértebras Lumbares/cirugía , Estudios de Cohortes , Estados Unidos , Etnicidad/estadística & datos numéricos , Resultado del Tratamiento , Dolor de la Región Lumbar/cirugía , Dolor de la Región Lumbar/etnología , Estudios Prospectivos , Factores SocioeconómicosRESUMEN
Dabigatran etexilate (Pradaxa) is a novel oral anticoagulant that has gained FDA approval for the prevention of ischemic stroke and systemic embolism in patients with nonvalvular atrial fibrillation. In randomized trials, the incidence of hemorrhagic events has been demonstrated to be lower in patients treated with dabigatran compared with the traditional anticoagulant warfarin. However, dabigatran does not have reliable laboratory tests to measure levels of anticoagulation and there is no pharmacological antidote. These drawbacks are challenging in the setting of intracerebral hemorrhage. In this article, the authors provide background information on dabigatran, review the existing anecdotal experiences with treating intracerebral hemorrhage related to dabigatran therapy, present a case study of intracranial hemorrhage in a patient being treated with dabigatran, and suggest clinical management strategies. The development of reversal agents is urgently needed given the growing number of patients treated with this medication.
Asunto(s)
Antitrombinas/uso terapéutico , Bencimidazoles/uso terapéutico , Hemorragias Intracraneales/tratamiento farmacológico , Hemorragias Intracraneales/cirugía , Neurocirugia/métodos , beta-Alanina/análogos & derivados , Anciano de 80 o más Años , Animales , Dabigatrán , Femenino , Humanos , Hemorragias Intracraneales/diagnóstico , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , beta-Alanina/uso terapéuticoRESUMEN
Cerebral edema develops in response to and as a result of a variety of neurologic insults such as ischemic stroke, traumatic brain injury, and tumor. It deforms brain tissue, resulting in localized mass effect and increase in intracranial pressure (ICP) that are associated with a high rate of morbidity and mortality. When administered in bolus form, hyperosmolar agents such as mannitol and hypertonic saline have been shown to reduce total brain water content and decrease ICP, and are currently the mainstays of pharmacological treatment. However, surprisingly, little is known about the increasingly common clinical practice of inducing a state of sustained hypernatremia. Herein, we review the available studies employing sustained hyperosmolar therapy to induce hypernatremia for the prevention and/or treatment of cerebral edema. Insufficient evidence exists to recommend pharmacologic induction of hypernatremia as a treatment for cerebral edema. The strategy of vigilant avoidance of hyponatremia is currently a safer, potentially more efficacious paradigm.
Asunto(s)
Edema Encefálico/prevención & control , Edema Encefálico/terapia , Lesiones Encefálicas/metabolismo , Hipernatremia/metabolismo , Solución Salina Hipertónica/administración & dosificación , Edema Encefálico/etiología , Lesiones Encefálicas/complicaciones , Humanos , Hipernatremia/inducido químicamente , Presión Intracraneal/fisiologíaRESUMEN
Chordoma is a rare bone cancer that is aggressive, locally invasive, and has a poor prognosis. Chordomas are thought to arise from transformed remnants of notochord and have a predilection for the axial skeleton, with the most common sites being the sacrum, skull base, and spine. The gold standard treatment for chordomas of the mobile spine and sacrum is en-bloc excision with wide margins and postoperative external-beam radiation therapy. Treatment of clival chordomas is unique from other locations with an enhanced emphasis on preservation of neurological function, typified by a general paradigm of maximally safe cytoreductive surgery and advanced radiation delivery techniques. In this Review, we highlight current standards in diagnosis, clinical management, and molecular characterisation of chordomas, and discuss current research.
Asunto(s)
Neoplasias Óseas/diagnóstico , Neoplasias Óseas/terapia , Cordoma/diagnóstico , Cordoma/terapia , Enfermedades Raras/diagnóstico , Enfermedades Raras/terapia , Neoplasias Óseas/patología , Cordoma/patología , Ensayos Clínicos Fase I como Asunto , Regulación Neoplásica de la Expresión Génica , Humanos , Pronóstico , Enfermedades Raras/patología , Receptores del Factor de Crecimiento Derivado de Plaquetas/metabolismo , Columna Vertebral/patología , Resultado del TratamientoRESUMEN
BACKGROUND: Cervical fusion surgery is associated with adjacent-level degeneration, but surgical and technical factors are difficult to dissociate from the mechanical effects of the fusion itself. OBJECTIVE: To determine the effect of fusion on adjacent-level degeneration in unoperated patients using a cohort of patients with congenitally fused cervical vertebrae. METHODS: We identified 96 patients with incidental single-level cervical congenital fusion on computed tomography imaging. We compared these patients to an age-matched control cohort of 80 patients without congenital fusion. We quantified adjacent-level degeneration through direct measurements of intervertebral disk parameters as well as the validated Kellgren & Lawrence classification scale for cervical disk degeneration. Ordinal logistic regression and 2-way analysis of variance testing were performed to correlate extent of degeneration with the congenitally fused segment. RESULTS: Nine hundred fifty-five motion segments were analyzed. The numbers of patients with C2-3, C3-4, C4-5, C5-6, and C6-7 congenitally fused segments were 47, 11, 11, 17, and 9, respectively. We found that patients with congenital fusion at C4-C5 and C5-C6 had a significantly greater extent of degeneration at adjacent levels compared with the degree of degeneration at the same levels in control patients and in patients with congenital fusion at other cervical levels, even while controlling for expected degeneration and age. CONCLUSION: Taken together, our data suggest that congenitally fused cervical spinal segments at C4-C5 and C5-C6 are associated with adjacent-level degeneration independent of fixation instrumentation. This study design removes surgical factors that might contribute to adjacent-level degeneration.
Asunto(s)
Degeneración del Disco Intervertebral , Disco Intervertebral , Fusión Vertebral , Humanos , Rango del Movimiento Articular , Fenómenos Biomecánicos , Vértebras Cervicales/diagnóstico por imagen , Vértebras Cervicales/cirugía , Degeneración del Disco Intervertebral/diagnóstico por imagen , Degeneración del Disco Intervertebral/cirugía , Fusión Vertebral/métodosRESUMEN
OBJECTIVE: Surgical skills laboratories augment educational training by deepening one's understanding of anatomy and allowing the safe practice of technical skills. Novel, high-fidelity, cadaver-free simulators provide an opportunity to increase access to skills laboratory training. The neurosurgical field has historically evaluated skill by subjective assessment or outcome measures, as opposed to process measures with objective, quantitative indicators of technical skill and progression. The authors conducted a pilot training module with spaced repetition learning concepts to evaluate its feasibility and impact on proficiency. METHODS: The 6-week module used a simulator of a pterional approach representing skull, dura mater, cranial nerves, and arteries (UpSurgeOn S.r.l.). Neurosurgery residents at an academic tertiary hospital completed a video-recorded baseline examination, performing supraorbital and pterional craniotomies, dural opening, suturing, and anatomical identification under a microscope. Participation in the full 6-week module was voluntary, which precluded randomizing by class year. The intervention group participated in four additional faculty-guided trainings. In the 6th week, all residents (intervention and control) repeated the initial examination with video recording. Videos were evaluated by three neurosurgical attendings who were not affiliated with the institution and who were blinded to participant grouping and year. Scores were assigned via Global Rating Scales (GRSs) and Task-based Specific Checklists (TSCs) previously built for craniotomy (cGRS, cTSC) and microsurgical exploration (mGRS, mTSC). RESULTS: Fifteen residents participated (8 intervention, 7 control). The intervention group included a greater number of junior residents (postgraduate years 1-3; 7/8) compared to the control group (1/7). External evaluators had internal consistency within 0.5% (kappa probability > Z of 0.00001). The total average time improved by 5:42 minutes (p < 0.003; intervention, 6:05, p = 0.07; control, 5:15, p = 0.001). The intervention group began with lower scores in all categories and surpassed the comparison group in cGRS (10.93 to 13.6/16) and cTSC (4.0 to 7.4/10). Percent improvements for the intervention group were cGRS 25% (p = 0.02), cTSC 84% (p = 0.002), mGRS 18% (p = 0.003), and mTSC 52% (p = 0.037). For controls, improvements were cGRS 4% (p = 0.19), cTSC 0.0% (p > 0.99), mGRS 6% (p = 0.07), and mTSC 31% (p = 0.029). CONCLUSIONS: Participants who underwent a 6-week simulation course showed significant objective improvement in technical indicators, particularly individuals who were early in their training. Small, nonrandomized grouping limits generalizability regarding degree of impact; however, introducing objective performance metrics during spaced repetition simulation would undoubtedly improve training. A larger multiinstitutional randomized controlled study will help elucidate the value of this educational method.
Asunto(s)
Internado y Residencia , Entrenamiento Simulado , Humanos , Curriculum , Procedimientos Neuroquirúrgicos/métodos , Grabación en Video , Craneotomía , Competencia Clínica , Entrenamiento Simulado/métodosRESUMEN
BACKGROUND: Iatrogenic injury to the vertebral artery during posterior cervical fusion is a rare and potentially disastrous complication. Differentiating arterial from brisk venous bleeding would be ideal to assist in the intra-operative management. Definitive angiography is typically not feasible during most routine spine surgery. CASE DESCRIPTION: We describe the case of a patient undergoing an occipitocervical fusion, where brisk bleeding was encountered during dissection of the CB lateral mass. While the dissection was thought to be superficial to critical structures, the nature of the hemorrhage could not be definitely determined by visual inspection by two senior surgeons. The hemorrhage did not readily cease with standard maneuvers such as, the application of various hemostatic agents. Simultaneous blood gas analysis was performed on samples obtained from the patient's radial artery and from the hemorrhage in the operative bed. Comparative analysis concluded that the bleeding encountered in the surgical field was venous in nature. CONCLUSION: Blood gas analysis can be a useful adjunct in determining the nature of hemorrhage from vascular structures in spine surgery when visual inspection is indeterminate.
Asunto(s)
Análisis de los Gases de la Sangre/métodos , Complicaciones Intraoperatorias/diagnóstico , Monitoreo Intraoperatorio/métodos , Fusión Vertebral/efectos adversos , Lesiones del Sistema Vascular/diagnóstico , Arteria Vertebral/lesiones , Anciano , Vértebras Cervicales/cirugía , Femenino , HumanosRESUMEN
Neurosurgical patients are at a high risk for infectious sequelae following operations. For neurosurgery in particular, the risk of surgical site infection has a unique implication given the proximity of the CSF and the CNS. Patient factors contribute to some degree; for example, cancer and trauma are often associated with impaired nutritional status, known risk factors for infection. Additionally, care-based factors for infection must also be considered, such as the length of surgery, the administration of steroids, and tissue devascularization (such as a craniotomy bone flap). When postoperative infection does occur, attention is commonly focused on potential lapses in surgical "sterility." Evidence suggests that the surgical field is not free of microorganisms. The authors propose a paradigm shift in the nomenclature of the surgical field from "sterile" to "clean." Continued efforts aimed at optimizing immune capacity and host defenses to combat potential infection are warranted.
Asunto(s)
Sistema Nervioso Central/cirugía , Infecciones/complicaciones , Procedimientos Neuroquirúrgicos/efectos adversos , Complicaciones Posoperatorias/prevención & control , Esterilización/normas , Antibacterianos/uso terapéutico , Profilaxis Antibiótica , Vendajes , Guantes Quirúrgicos , Humanos , Cuidados Preoperatorios/métodosRESUMEN
Frontal sinus fractures are heterogeneous, and management of these fractures is often modified based on injury pattern and institutional experience. The optimal initial treatment of frontal sinus fractures is controversial. Treatment strategies are aimed at correcting cosmetic deformity, as well as at preventing delayed complications, including CSF fistulas, mucocele formation, and infection. Existing treatment options include observation, reconstruction, obliteration, cranialization, or a combination thereof. Modalities for treatment encompass both open surgical approaches and endoscopic techniques. In the absence of Class I data, the authors review the existing literature related to treatment strategies of frontal sinus fractures, particularly as they relate to CSF fistulas, to provide recommendations based on the best available evidence.
Asunto(s)
Fístula/líquido cefalorraquídeo , Fístula/prevención & control , Seno Frontal/lesiones , Fracturas Craneales/líquido cefalorraquídeo , Manejo de la Enfermedad , Fístula/cirugía , Humanos , Masculino , Persona de Mediana Edad , Fracturas Craneales/complicaciones , Fracturas Craneales/cirugía , Resultado del TratamientoRESUMEN
Disability secondary to disorders of the spine is a significant problem worldwide. In the USA, there has been a recent surge in the costs associated with caring for spinal pathology; from 1997 to 2005, there was a growth of 65% in healthcare expenditures on spinal disease, totalling $86 billion in 2005. Increasingly, there has been media and public scrutiny over the rapid rise in the volume of procedures with spinal instrumentation; some have suggested that this rise has been fuelled by non-medical drivers such as the financial incentives involved with the use of instrumentation; others suggest that innovation in spine technology and devices has led to improved options for the treatment of spine pathology.In this context, we conducted a review of the literature to assess the use of instrumentation in lumbar procedures and its relationship to successful fusion and patient outcome. Our review suggests that there is data supporting the thesis that lumbar instrumentation improves rates of fusion. However, there is no consistent correlation between increased rates of fusion and improved patient outcomes.
Asunto(s)
Fijadores Internos , Vértebras Lumbares , Procedimientos Ortopédicos , Enfermedades de la Columna Vertebral/cirugía , Humanos , Fusión Vertebral , Resultado del TratamientoRESUMEN
Incidental vertebral lesions on imaging of the spine are commonly encountered in clinical practice. Contributing factors include the aging population, the increasing prevalence of back pain, and increased usage of MR imaging. Additionally, refinements in CT and MR imaging have increased the number of demonstrable lesions. The management of incidental findings varies among practitioners and commonly depends more on practice style than on data or guidelines. In this article we review incidental findings within the vertebral column and review management of these lesions, based on available Class III data.
Asunto(s)
Hallazgos Incidentales , Enfermedades de la Columna Vertebral/diagnóstico , Columna Vertebral/anomalías , Columna Vertebral/patología , Humanos , Enfermedades de la Columna Vertebral/terapiaRESUMEN
Disorders of the spine are common in clinical medicine, and spine surgery is being performed with increasing frequency in the US. Although many patients with an established diagnosis of a true surgically treatable lesion are referred to a neurosurgeon, the evaluation of patients with spinal disorders can be complex and fraught with diagnostic pitfalls. While "common conditions are common," astute clinical acumen and vigilance are necessary to identify lesions that masquerade as surgically treatable spine disease that can lead to erroneous diagnosis and treatment. In this review, the authors discuss musculoskeletal, peripheral nerve, metabolic, infectious, inflammatory, and vascular conditions that mimic the syndromes produced by surgical lesions. It is possible that nonsurgical and surgical conditions coexist at times, complicating treatment plans and natural histories. Awareness of these diagnoses can help reduce diagnostic error, thereby avoiding the morbidity and expense associated with an unnecessary operation.
Asunto(s)
Errores Diagnósticos , Procedimientos Neuroquirúrgicos , Procedimientos Ortopédicos , Enfermedades de la Columna Vertebral/diagnóstico , Enfermedades de la Columna Vertebral/cirugía , Adulto , Anciano , Diagnóstico Diferencial , Errores Diagnósticos/prevención & control , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
OBJECT: Previous methods to determine stroke prevalence, such as nationwide surveys, are labor-intensive endeavors. Recent advances in search engine query analytics have led to a new metric for disease surveillance to evaluate symptomatic phenomenon, such as influenza. The authors hypothesized that the use of search engine query data can determine the prevalence of stroke. METHODS: The Google Insights for Search database was accessed to analyze anonymized search engine query data. The authors' search strategy utilized common search queries used when attempting either to identify the signs and symptoms of a stroke or to perform stroke education. The search logic was as follows: (stroke signs + stroke symptoms + mini stroke--heat) from January 1, 2005, to December 31, 2010. The relative number of searches performed (the interest level) for this search logic was established for all 50 states and the District of Columbia. A Pearson product-moment correlation coefficient was calculated from the statespecific stroke prevalence data previously reported. RESULTS: Web search engine interest level was available for all 50 states and the District of Columbia over the time period for January 1, 2005-December 31, 2010. The interest level was highest in Alabama and Tennessee (100 and 96, respectively) and lowest in California and Virginia (58 and 53, respectively). The Pearson correlation coefficient (r) was calculated to be 0.47 (p = 0.0005, 2-tailed). CONCLUSIONS: Search engine query data analysis allows for the determination of relative stroke prevalence. Further investigation will reveal the reliability of this metric to determine temporal pattern analysis and prevalence in this and other symptomatic diseases.
Asunto(s)
Estudios Transversales/métodos , Internet , Motor de Búsqueda , Accidente Cerebrovascular/epidemiología , Geografía , Humanos , Internet/tendencias , Prevalencia , Motor de Búsqueda/tendenciasRESUMEN
OBJECT: Resolution of syringomyelia is common following hindbrain decompression for Chiari malformation, yet little is known about the kinetics governing this process. The authors sought to establish the volumetric rate of syringomyelia resolution. METHODS: A retrospective cohort of patients undergoing hindbrain decompression for a Chiari malformation Type I with preoperative cervical or thoracic syringomyelia was identified. Patients were included in the study if they had at least 3 neuroimaging studies that detailed the entirety of their preoperative syringomyelia over a minimum of 6 months postoperatively. The authors reconstructed the MR images in 3 dimensions and calculated the volume of the syringomyelia. They plotted the syringomyelia volume over time and constructed regression models using the method of least squares. The Akaike information criterion and Bayesian information criterion were used to calculate the relative goodness of fit. The coefficients of determination R(2) (unadjusted and adjusted) were calculated to describe the proportion of variability in each individual data set accounted for by the statistical model. RESULTS: Two patients were identified as meeting inclusion criteria. Plots of the least-squares best fit were identified as 4.01459e(-0.0180804)(x) and 13.2556e(-0.00615859)(x). Decay of the syringomyelia followed an exponential model in both patients (R(2) = 0.989582 and 0.948864). CONCLUSIONS: Three-dimensional analysis of syringomyelia resolution over time enables the kinetics to be estimated. This technique is yet to be validated in a large cohort. Because syringomyelia is the final common pathway for a number of different pathological processes, it is possible that this exponential only applies to syringomyelia related to treatment of Chiari malformation Type I.
Asunto(s)
Craniectomía Descompresiva/efectos adversos , Rombencéfalo/cirugía , Siringomielia/diagnóstico , Siringomielia/etiología , Malformación de Arnold-Chiari/cirugía , Estudios de Cohortes , Humanos , Imagenología Tridimensional , Imagen por Resonancia Magnética , Estudios RetrospectivosRESUMEN
Chiari malformations (Types I-IV) are abnormalities of the posterior fossa that affect the cerebellum, brainstem, and the spinal cord with prevalence rates of 0.1%-0.5%. Case reports of familial aggregation of Chiari malformation, twin studies, cosegregation of Chiari malformation with known genetic conditions, and recent gene and genome-wide association studies provide strong evidence of the genetic underpinnings of familial Chiari malformation. The authors report on a series of 3 family pairs with Chiari malformation Type I: 2 mother-daughter pairs and 1 father-daughter pair. The specific genetic causes of familial Chiari malformation have yet to be fully elucidated. The authors review the literature and discuss several candidate genes. Recent advances in the understanding of the genetic influences and pathogenesis of familial Chiari malformation are expected to improve management of affected patients and monitoring of at-risk family members.