Recommendations for inversion table therapy.

In the USA, low back pain related illness accounts for approximately 149 million workdays lost each year. Initial management of back pain typically involves allied healthcare professionals who implement various treatments, such as chiropractic manipulation, physiotherapy, and acupuncture which have varying outcomes and levels of supporting evidence. Another passive treatment for back pain is inversion table therapy (ITT). It is a form of spinal traction which is thought to have a role in relieving low back pain due to the gravity-facilitated traction of the spine which distracts the lumbar vertebrae. However, ITT is not without risk. According to the Food and Drug Administration (FDA) Medical Device Reporting Events Database, ITT has resulted in serious injuries including spinal cord injury, fractures, lacerations, and death. The FDA has regulated ITT for only manufacturers that indicated medical use; however, most manufacturers have not made such medical claims and were exempt from FDA regulation. This article discusses the risks of ITT, the current regulatory process for ITT, and the need for a better understanding of the role of ITT in the treatment of spinal pain while optimizing consumer safety.Implications for rehabilitationInversion table therapy (ITT) is a form of spinal traction which is thought to have a role in relieving low back pain due to the gravity-facilitated traction of the spine which distracts the lumbar vertebrae.According to the Food and Drug Administration (FDA) statistics, injuries due to non-powered traction from various medical devices have been rising since 2011.The FDA has regulated ITT for only manufacturers that indicated medical use; however, most manufacturers have not made such medical claims and were exempt from FDA regulation.This article discusses the risks of ITT, the current regulatory process for ITT, and the need for a better understanding of the role of ITT in the treatment of spinal pain while optimizing consumer safety.

Virtual learning during the COVID-19 pandemic: a turning point in neurosurgical education.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has caused dramatic changes in medical education. Social distancing policies have resulted in the rapid adoption of virtual learning (VL) by neurosurgeons as a method to exchange knowledge, but it has been met with variable acceptance. The authors surveyed neurosurgeons from around the world regarding their opinions about VL and how they see the future of neurosurgical conferences. METHODS: The authors conducted a global online survey assessing the experience of neurosurgeons and trainees with VL activities. They also questioned respondents about how they see the future of on-site conferences and scientific meetings. They analyzed responses against demographic data, regions in which the respondents practice, and socioeconomic factors by using frequency histograms and multivariate logistic regression models. RESULTS: Eight hundred ninety-one responses from 96 countries were received. There has been an increase in VL activities since the start of the COVID-19 pandemic. Most respondents perceive this type of learning as positive. Respondents from lower-income nations and regions such as Europe and Central Asia were more receptive to these changes and wanted to see further movement of educational activities (conferences and scientific meetings) into a VL format. The latter desire may be driven by financial savings from not traveling. Most queried neurosurgeons indicated that virtual events are likely to partially replace on-site events. CONCLUSIONS: The pandemic has improved perceptions of VL, and despite its limitations, VL has been well received by the majority of neurosurgeons. Lower-income nations in particular are embracing this technology. VL is still evolving, but its integration with traditional in-person meetings seems inevitable.

Minimally Invasive Unilateral Percutaneous Transfracture Fixation of a Hangman's Fracture Using Neuronavigation and Intraoperative Fluoroscopy.

BACKGROUND: Traumatic spondylolisthesis or hangman's fracture is a common cervical spine fracture. Most cases of traumatic spondylolisthesis are treated nonoperatively with external immobilization. The indications for surgery have generally included fracture instability or failed nonoperative management. Operative stabilization can be performed through either anterior or posterior approaches and has generally required instrumentation using open methods. We propose a technique for surgical repair of hangman's fracture that is minimally invasive and motion preserving using recent advances in 3-dimensional image-guidance technology. We believe this method represents another option in the treatment of hangman's fractures, because it allows for immediate stabilization, prompt recovery, and quick mobilization. CASE DESCRIPTION: We present the case of 2 patients with hangman's fractures who had undergone surgical unilateral transfixation with minimally invasive percutaneous screw placement. In both cases, we used 3-dimensional neuronavigation and bidirectional intraoperative fluoroscopy. The operative time from incision to closure was <30 minutes. Preparation and positioning after intubation varied from 40 to 150 minutes. No intraoperative complications occurred. Both patients were discharged within 48 hours postoperatively. The follow-up examinations at 3 months, 12 months, and 5 years revealed healthy bony fusion on computed tomography imaging and an excellent clinical recovery. CONCLUSION: We have provided 2 examples in which minimally invasive unilateral fixation of hangman's fractures proved to be safe and effective. In both cases, the patients were immediately relieved of their pain, quickly mobilized, and promptly discharged. The achievement of successful fusion confirmed at the follow-up examinations.

Wrong-sided and wrong-level neurosurgery: a national survey.

OBJECT: Perhaps the single greatest error that a surgeon hopes to avoid is operating at the wrong site. In this report, the authors describe the incidence and possible determinants of incorrect-site surgery (ICSS) among neurosurgeons. METHODS: The authors asked neurosurgeons to complete an anonymous survey. These surgeons were asked to report the number of craniotomies and lumbar and cervical discectomies performed during the previous year, as well as whether ICSS had occurred. They were also asked detailed questions regarding the potential determinants of ICSS. RESULTS: There was a 75% response rate and a 68% survey completion rate. Participating neurosurgeons performed 4695 lumbar and 2649 cervical discectomies, as well as 10,203 craniotomies. Based on this self-reporting, the incidence of wrong-level lumbar surgery was estimated to be 12.8 [corrected] occurrences per 10,000 operations. The ICSSs per 10,000 cervical discectomies and craniotomies were 7.6 [corrected] and 2.0, [corrected] respectively. Neurosurgeons recognized fatigue, unusual time pressure, and emergent operations as factors contributing to ICSS. For spine surgery, in particular, unusual patient anatomy and a failure to verify the operative site by radiography were also commonly reported contributors. CONCLUSIONS: Neurosurgical ICSSs do occur, but are rare events. Although there are significant limitations to the survey-based methodology, the data suggest that the prevention of such errors will require neurosurgeons to recognize risk factors and increase the use of intraoperative imaging.

Cardiovascular risk factors for physician-diagnosed lumbar disc herniation.

BACKGROUND CONTEXT: Despite the high prevalence of lumbar disc disease among the general population, the determinants of this condition remain poorly understood. A recent hypothesis suggests that atherosclerotic vascular disease may play an important role in the etiology of this disorder. PURPOSE: To explore the relationship between cardiovascular risk factors and the incidence of lumbar disc herniation. STUDY DESIGN/SETTING: We prospectively examined the association between smoking, high cholesterol, high blood pressure, obesity, and diabetes and self-reported lumbar disc herniation. The study was conducted among 98,407 female nurses who in 1976 were ages 30-55 years, free of cancer (except non-melanoma skin cancer), lumbar disc disease, and who responded to the 1992 questionnaire regarding whether or not a physician diagnosis of lumbar disc herniation had been made. RESULTS: During 16 years of follow-up (438,662 person-years), 2,727 nurses who were free of cancer reported a physician-diagnosed lumbar disc herniation that was confirmed either by computed tomography or magnetic resonance imaging. After adjusting for age, body mass index, smoking, vigorous or moderate exercise, employment status, having seen a physician in the last year, and each of the following other factors, the multivariate relative risk for diabetes was 1.52 (95% confidence interval [95% CI], 1.17 to 1.98); for hypertension it was 1.25 (95% CI, 1.11 to 1.41); for high cholesterol it was 1.26 (95% CI, 1.10 to 1.44), and for having a parent who had suffered a myocardial infarction before age 60 it was 1.13 (95% CI, 1.02 to 1.26). In these models, compared with never smokers, the relative risk for past smokers was 1.10 (95% CI, 1.00 to 1.20), for current smokers the risk increased with the number of cigarettes smoked per day. A decrease in risk occurred after cessation. Also in these models, we noted a significant trend of increasing risk with higher body mass index (p=.01). CONCLUSIONS: Cardiovascular risk factors are significantly and independently associated with symptomatic lumbar disc herniation. These findings provide further confirmation that atherosclerosis may be involved in spinal disc degeneration. Modification of risk factors, particularly smoking, may also prove to be beneficial.

A follow-up study of infants with intracranial hemorrhage at full-term.

OBJECTIVE: To determine physical and cognitive outcomes of full-term infants who suffered intracranial hemorrhage (ICH) at birth. METHODS: A retrospective hospital-based, follow-up study of infants treated in London, Ontario between 1985 and 1996. Follow-up was conducted by telephone interviews and clinic visits. Outcome was measured according to physical and cognitive scales. Perinatal risk factors and hemorrhage characteristics were correlated with final outcome. RESULTS: For this study 66 infants with ICH were identified, of which seven died during the first week of life. We obtained follow-up in all but ten cases (median = 3-years; range 1.0 to 10.9 years). Overall, 57% of infants had no physical or cognitive deficits at follow-up. Death occurred most frequently among those with primarily subarachnoid hemorrhage (19%) and the most favorable outcomes occurred among those with subdural hemorrhage (80% had no disability). In univariate models, thrombocytopenia (platelet count < or = 70 x 10(9)/L), increasing overall hemorrhage severity, frontal location and spontaneous vaginal delivery as opposed to forceps-assisted delivery increased risk for poor outcome. In multivariate models, all these factors tended towards increased risk, but only thrombocytopenia remained significant for physical disability (OR = 7.6; 95% CI = 1.02 - 56.6); thrombocytopenia was borderline significant in similar models for cognitive disability (OR = 4.6; 95% CI = 0.9 - 23.9). CONCLUSION: Although forceps-assisted delivery may contribute to ICH occurrence, our study found better outcomes among these infants than those who had ICH following a spontaneous vaginal delivery. Hemorrhage in the frontal lobe was the most disabling hemorrhage location and if multiple compartments were involved, disability was also more likely to occur. However, in this report we found that the factor that was most likely to contribute to poor outcome was thrombocytopenia and this remained important in multivariate analysis.

Anterior lumbar interbody fusion for treatment of failed back surgery syndrome: an outcome analysis.

OBJECTIVE: Anterior lumbar interbody fusion (ALIF) has gained popularity for the treatment of degenerative disease of the lumbar spine. In this report, we present our experience with the ALIF procedure for treatment of failed back surgery syndrome (FBSS) in a noncontrolled prospective cohort. METHODS: In a 2-year period, we treated patients diagnosed with FBSS with ALIF. Clinical and radiological outcomes were recorded in a prospective, nonrandomized, longitudinal manner. Neurological, pain, and functional outcomes were measured preoperatively and 12 months after surgery. Operative data, perioperative complications, and radiological and clinical outcomes were recorded. RESULTS: Thirty-three patients with a preoperative diagnosis of FBSS, with degenerative disc disease (n = 17), postsurgical spondylolisthesis (n = 13), or pseudarthrosis (n = 3), underwent ALIF. Back pain, leg pain, and functional status improved significantly, by 76% (P < 0.01), 80% (P < 0.01), and 67% (P < 0.01), respectively. CONCLUSION: On the basis of our results, we found ALIF to be a safe and effective procedure for the treatment of FBSS for selected patients.

Sex steroid hormone exposures and risk for meningioma.

OBJECT: The goal of this study was to investigate the risk of meningioma in relation to exogenous and endogenous sex hormones. METHODS: The study participants were female registered nurses from 11 US states who were between 30 and 55 years of age when they enrolled in the Nurses' Health Study cohort. These women completed biennial questionnaires between 1976 and 1996. All participants were free from cancer and other major medical illness at the onset of the study. The primary endpoint was meningioma as self-reported in biennial and supplemental questionnaires. During 1,213,522 person-years of follow-up review, 125 cases of meningioma were confirmed. After adjusting for age and body mass index (BMI), compared with postmenopausal women who had never used postmenopausal hormones, the relative risk (RR) for premenopausal women was 2.48 (95% confidence interval [CI] 1.29-4.77; p = 0.01) and the RR for postmenopausal women who received hormone therapy was 1.86 (95% CI 1.07-3.24; p = 0.03). The authors found no excess risk associated with past hormone use. In models that additionally controlled for hormone use and menopausal status, the authors found that, compared with women whose menarche occurred before they were 12 years of age, the RR for women whose menarche occurred at ages 12 through 14 years was 1.29 (95% CI 0.86-1.92; p = 0.21) and the RR for women whose menarche occurred after age 14 years was 1.97 (95% CI 1.06-3.66; p = 0.03). The authors also observed a tendency, albeit nonsignificant, for increased risk of meningioma in parous as opposed to nulliparous women (multivariate RR = 2.39, 95% CI 0.76-7.53; p = 0.14). A trend toward an increasing risk of meningioma with increasing BMI was also noted (p for trend = 0.06). No association was found for past or current use of oral contraceptives. CONCLUSIONS: The risk for meningiomas was increased among women exposed to either endogenous or exogenous sex hormones. An unexpected relationship with increasing age at menarche was also noted; this remains unexplained.

Risk factors for intracranial hemorrhage among full-term infants: a case-control study.

OBJECTIVE: To investigate the cause of intracranial hemorrhage among full-term infants. METHODS: A retrospective, hospital-based, matched case-control study was conducted at London Health Sciences Center, in southwestern Ontario, for the period from January 1, 1985, to December 31, 1996. Cases were diagnosed with magnetic resonance imaging, computed tomography, or ultrasonography within 7 days after birth. Control subjects were matched with respect to year of birth, sex, and, for nontransferred case patients only, obstetrician. RESULTS: Sixty-six full-term infants with intracranial hemorrhage were identified, and 104 control subjects were matched. Each factor was independently associated with increased risk of intracranial hemorrhage, as follows: forceps assistance (odds ratio [OR], 4.3; 95% confidence interval [CI], 1.2-15.1), compared with spontaneous vaginal delivery; 1-minute Apgar scores of 1 through 4 (OR, 110; 95% CI, 5.0-2400) and 5 through 8 (OR, 4.9; 95% CI, 1.3-18.3), compared with scores of 9 or 10 (corresponding 5-min Apgar scores were also statistically significant); and requirements for resuscitation (OR, 5.1; 95% CI, 1.8-14.1), compared with no resuscitation requirements. Of the 52 case patients for whom platelet counts were recorded within 48 hours after birth, 30.8% (95% CI, 18.3-43.3%) exhibited counts of less than 70 x 10(9)/L. Platelet counts of less than 50 x 10(9)/L were specifically associated with intraparenchymal hemorrhage and a more severe radiological grade. Forceps-associated hemorrhage was more frequently subarachnoid and subdural and less frequently intraparenchymal. Such hemorrhage also tended to be more caudal in location. CONCLUSION: Thrombocytopenia seems to be an important cause of intraparenchymal hemorrhage, and the use of forceps is more likely to be associated with subarachnoid and subdural hemorrhage.