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1.
N Engl J Med ; 382(12): 1093-1102, 2020 03 19.
Artigo em Inglês | MEDLINE | ID: mdl-32187469

RESUMO

BACKGROUND: The treatment of chronic sciatica caused by herniation of a lumbar disk has not been well studied in comparison with acute disk herniation. Data are needed on whether diskectomy or a conservative approach is better for sciatica that has persisted for several months. METHODS: In a single-center trial, we randomly assigned patients with sciatica that had lasted for 4 to 12 months and lumbar disk herniation at the L4-L5 or L5-S1 level in a 1:1 ratio to undergo microdiskectomy or to receive 6 months of standardized nonoperative care followed by surgery if needed. Surgery was performed by spine surgeons who used conventional microdiskectomy techniques. The primary outcome was the intensity of leg pain on a visual analogue scale (ranging from 0 to 10, with higher scores indicating more severe pain) at 6 months after enrollment. Secondary outcomes were the score on the Oswestry Disability Index, back and leg pain, and quality-of-life scores at 6 weeks, 3 months, 6 months, and 1 year. RESULTS: From 2010 through 2016, a total of 790 patients were screened; of those patients, 128 were enrolled, with 64 in each group. Among the patients assigned to undergo surgery, the median time from randomization to surgery was 3.1 weeks; of the 64 patients in the nonsurgical group, 22 (34%) crossed over to undergo surgery at a median of 11 months after enrollment. At baseline, the mean score for leg-pain intensity was 7.7 in the surgical group and 8.0 in the nonsurgical group. The primary outcome of the leg-pain intensity score at 6 months was 2.8 in the surgical group and 5.2 in the nonsurgical group (adjusted mean difference, 2.4; 95% confidence interval, 1.4 to 3.4; P<0.001). Secondary outcomes including the score on the Owestry Disability Index and pain at 12 months were in the same direction as the primary outcome. Nine patients had adverse events associated with surgery, and one patient underwent repeat surgery for recurrent disk herniation. CONCLUSIONS: In this single-center trial involving patients with sciatica lasting more than 4 months and caused by lumbar disk herniation, microdiskectomy was superior to nonsurgical care with respect to pain intensity at 6 months of follow-up. (Funded by Physicians' Services Incorporated Foundation; ClinicalTrials.gov number, NCT01335646.).


Assuntos
Tratamento Conservador , Discotomia , Glucocorticoides/administração & dosagem , Deslocamento do Disco Intervertebral/cirurgia , Modalidades de Fisioterapia , Ciática/terapia , Adulto , Tratamento Conservador/métodos , Estudos Cross-Over , Discotomia/efeitos adversos , Feminino , Seguimentos , Humanos , Injeções Epidurais , Análise de Intenção de Tratamento , Deslocamento do Disco Intervertebral/complicações , Deslocamento do Disco Intervertebral/tratamento farmacológico , Masculino , Dor/etiologia , Medição da Dor , Satisfação do Paciente , Complicações Pós-Operatórias , Qualidade de Vida , Ciática/etiologia , Ciática/cirurgia , Resultado do Tratamento
2.
J Comput Assist Tomogr ; 43(6): 976-980, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31688247

RESUMO

Endometriosis (EN) is a common gynecological condition characterized by the presence of functional endometrium located outside the uterine cavity. Sciatic nerve (SN) is rarely affected by EN. Magnetic resonance imaging allows a direct visualization of the spinal and SN, and it is the modality of choice for the study of SN involvement in extrapelvic EN. We report a case of an endometrioma located in the right SN with a systematic review of the literature.


Assuntos
Endometriose/diagnóstico por imagem , Nervo Isquiático/patologia , Ciática/diagnóstico por imagem , Adulto , Endometriose/complicações , Endometriose/cirurgia , Feminino , Humanos , Laparoscopia , Imagem por Ressonância Magnética/métodos , Nervo Isquiático/diagnóstico por imagem , Nervo Isquiático/cirurgia , Ciática/etiologia , Ciática/cirurgia , Resultado do Tratamento
3.
BMC Womens Health ; 19(1): 95, 2019 07 12.
Artigo em Inglês | MEDLINE | ID: mdl-31299947

RESUMO

BACKGROUND: The combination of intrapelvic and extrapelvic endometriosis is a very rare condition in gynecology. Patients with endometriosis involving the sciatic nerve are easily misdiagnosed because they usually present with atypical symptoms of endometriosis. Here, we present a rare case of an endometrioma passing through the left greater sciatic foramen. Removal of the endometriotic lesion was performed with a concomitant laparoscopic and transgluteal approach through the cooperation of gynecologists and orthopedic (neuro)surgeons. CASE PRESENTATION: A 20-year-old woman presented with complaints of severe dysmenorrhea lasting for more than 6 years and dysfunction of her left lower limb lasting for approximately 4 months. Both CT and MRI demonstrated a suspected intrapelvic and extrapelvic endometriotic cyst (7.3 cm × 8.1 cm × 6.5 cm) passing through the left greater sciatic foramen. Laparoscopic exploration showed a cyst full of dark fluid occupying the left obturator fossa and extending outside the pelvis. A novel combination of transgluteal laparoscopy was performed for complete resection of the cyst and decompression of the sciatic nerve. Postoperative pathology confirmed the diagnosis of endometriosis. Long-term follow-up observation showed persistent pain relief and lower limb function recovery in the patient. DISCUSSION AND CONCLUSIONS: When a woman complains of unexplained unilateral sciatica, especially a woman suffering from dysmenorrhea, endometriosis of the sciatica nerve should be considered as a potential etiology. Complete excision of the endometriotic lesion and adequate neurolysis (or decompression) of the sciatic nerve through the multidisciplinary cooperation of experienced gynecologists with proper training in laparoscopic pelvic (neuro)surgery and orthopedic (neuro)surgeons is effective.


Assuntos
Dismenorreia/cirurgia , Endometriose/cirurgia , Laparoscopia/métodos , Ciática/cirurgia , Dismenorreia/etiologia , Dismenorreia/patologia , Endometriose/complicações , Endometriose/patologia , Feminino , Humanos , Extremidade Inferior/patologia , Extremidade Inferior/cirurgia , Pelve/patologia , Pelve/cirurgia , Nervo Isquiático/patologia , Nervo Isquiático/cirurgia , Ciática/etiologia , Ciática/patologia , Adulto Jovem
4.
Spine (Phila Pa 1976) ; 44(10): 740-746, 2019 May 15.
Artigo em Inglês | MEDLINE | ID: mdl-30395083

RESUMO

STUDY DESIGN: Qualitative study. OBJECTIVE: The objective of this study was to compare the perceptions of patients and surgeons regarding the risks and benefits of lumbar decompressive surgery for sciatica following a consultation meeting. SUMMARY OF BACKGROUND DATA: Evidence regarding pain improvement in patients following lumbar decompressive surgery for sciatica is inconsistent. Given this inconsistency, patients choosing to undergo lumbar decompressive surgery must accept the risks associated with the surgery despite uncertainty regarding benefits. This raises questions as to the nature of informed decision-making for patients choosing to undergo surgery for sciatica. METHODS: We undertook a qualitative descriptive study with 12 adult lumbar decompressive surgery candidates and six of their spine surgeons and analyzed data using inductive content analysis. RESULTS: Our analysis revealed that most patients were satisfied with the consultation despite limited understanding of lumbar decompressive surgery. We found discrepancies between patients' preoperative expectations and understanding of information provided by surgeons and what surgeons believed they had conveyed. Surgeons and patients disagreed on how much information is needed about postsurgical activity modifications and long-term outcomes to make a decision about whether or not to undergo surgery, with patients desiring more information. As a result, for most patients, the decision-making process extended beyond the information provided by surgeons and incorporated information from family members, friends, family doctors, and the internet. CONCLUSION: Our results highlight misunderstandings between patients and surgeons, particularly in regard to prognosis and activity modifications. Since this information is important for patients choosing whether to undergo a surgical intervention, our study provides guidance to improve informed decisions about sciatica and, potentially, other elective surgeries. LEVEL OF EVIDENCE: 4.


Assuntos
Tomada de Decisão Clínica/métodos , Satisfação do Paciente/estatística & dados numéricos , Ciática , Cirurgiões/estatística & dados numéricos , Humanos , Relações Médico-Paciente , Pesquisa Qualitativa , Ciática/epidemiologia , Ciática/cirurgia
6.
J Minim Invasive Gynecol ; 26(2): 360-361, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-29702268

RESUMO

STUDY OBJECTIVE: To demonstrate the laparoscopic approach to malformed branches of the vessels entrapping the nerves of the sacral plexus. DESIGN: A step-by-step explanation of the surgery using video (educative video) (Canadian Task force classification II). The university's Ethics Committee ruled that approval was not required for this video. SETTING: Kocaeli Derince Education and Research Hospital, Kocaeli, Turkey. PATIENT: A 26-year-old patient who had failed medical therapy and presented with complaints of numbness and burning pain on the right side of her vagina and pain radiating to her lower limbs for a period of approximately 36 months. INTERVENTION: The peritoneum was incised along the external iliac vessels, and these vessels were separated from the iliopsoas muscle on the right side of the pelvis. The laparoscopic decompression of intrapelvic vascular entrapment was performed at 3 sites: the lumbosacral trunk, sciatic nerve, and pudendal nerve. The aberrant dilated veins were gently dissected from nerves, and then coagulated and cut with the LigaSure sealing device (Medtronic, Minneapolis, Minn). MEASUREMENTS AND MAIN RESULTS: The operation was completed successfully with no complications, and the patient was discharged from the hospital 24 hours after the operation. At a 6-month follow-up, she reported complete resolution of dyspareunia and sciatica (visual analog scale score 1 of 10). CONCLUSION: A less well-known cause of chronic pelvic pain is compression of the sacral plexus by dilated or malformed branches of the internal iliac vessels. Laparoscopic management of vascular entrapment of the sacral plexus has been described by Possover et al [1,2] and Lemos et al [3]. This procedure appears to be feasible and effective, but requires significant experience and familiarity with laparoscopy techniques and pelvic nerve anatomy.


Assuntos
Laparoscopia/métodos , Neuralgia do Pudendo/etiologia , Ciática/etiologia , Adulto , Dor Crônica/cirurgia , Descompressão Cirúrgica/métodos , Dispareunia/cirurgia , Feminino , Humanos , Plexo Lombossacral/cirurgia , Dor Pélvica/etiologia , Pelve/cirurgia , Nervo Pudendo/cirurgia , Neuralgia do Pudendo/cirurgia , Nervo Isquiático/cirurgia , Ciática/cirurgia
7.
Br J Neurosurg ; 33(5): 562-565, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28906149

RESUMO

Intrapelvic sciatic nerve schwannomas are rare causes for non-discogenic sciatica. We describe a 44-year-old female who had a palpable mass on digital rectal examination that exhibited a positive Tinel's sign. The schwannoma was excised by a posterior transgluteal approach. Patients with negative spinal imaging should undergo pelvic scanning to rule out these tumors.


Assuntos
Neurilemoma/cirurgia , Neoplasias do Sistema Nervoso Periférico/cirurgia , Ciática/diagnóstico , Adulto , Exame Retal Digital , Feminino , Humanos , Achados Incidentais , Imagem por Ressonância Magnética/métodos , Imagem Multimodal , Neurilemoma/complicações , Neurilemoma/patologia , Neoplasias do Sistema Nervoso Periférico/complicações , Neoplasias do Sistema Nervoso Periférico/patologia , Nervo Isquiático , Ciática/cirurgia , Tomografia Computadorizada por Raios X
8.
Rev. esp. cir. ortop. traumatol. (Ed. impr.) ; 62(5): 322-327, sept.-oct. 2018. ilus, tab, graf
Artigo em Espanhol | IBECS | ID: ibc-177652

RESUMO

Introducción: El síndrome de glúteo profundo (SGP) es una enfermedad caracterizada por la compresión a nivel extra-pélvico del nervio ciático (NC) por cualquier estructura en el espacio glúteo profundo. El objetivo de este estudio fue evaluar los resultados clínicos en pacientes con SGP manejados con técnica endoscópica. Métodos: Estudio retrospectivo de pacientes con SGP intervenidos con técnica endoscópica entre 2012 al 2016 con seguimiento mínimo de 12 meses. Los pacientes fueron evaluados antes de la intervención y durante el primer año de seguimiento con las escalas WOMAC y VAIL. Resultados: Se incluyeron 44 cirugías en 41 pacientes (36 mujeres y 5 varones) con un promedio de edad de 48,4±14,5 años. La causa más frecuente de atrapamiento fueron las bandas fibrovasculares, hubo 2 casos de variante anatómica en la salida del nervio, y en un caso aislado, el atrapamiento del NC fue atribuido a la aplicación de biopolímeros en la región glútea. Se encontró mejoría de la funcionalidad y dolor valorado con la escala WOMAC con una mediana de 63 a 26 puntos después de la intervención (p<0,05). Al final del seguimiento un paciente continuaba con dolor residual del nervio cutáneo femoral posterior. Cuatro casos requirieron de revisión a los 6 meses posteriores al procedimiento, por atrapamiento de tejido de cicatrización alrededor del NC. Conclusión: La liberación endoscópica del NC es una alternativa en el manejo del SGP al mejorar la función y disminuir el grado de dolor, cuando existe una adecuada selección de pacientes


Introduction: Deep gluteal syndrome (DGS) is characterized by compression, at extra-pelvic level, of the sciatic nerve within any structure of the deep gluteal space. The objective was to evaluate the clinical results in patients with DGS treated with endoscopic technique. Methods: Retrospective study of patients with DGS treated with an endoscopic technique between 2012 and 2016 with a minimum follow-up of 12 months. The patients were evaluated before the procedure and during the first year of follow-up with the WOMAC and VAIL scale. Results: Forty-four operations on 41 patients (36 women and 5 men) were included with an average age of 48.4±14.5. The most common cause of nerve compression was fibrovascular bands. There were two cases of anatomic variant at the exit of the nerve; compression of the sciatic nerve was associated with the use of biopolymers in the gluteal region in an isolated case. The results showed an improvement of functionality and pain measured with the WOMAC scale with a mean of 63 to 26 points after the procedure (P<.05). However, at the end of the follow-up one patient continued to manifest residual pain of the posterior cutaneous femoral nerve. Four cases required revision at 6 months following the procedure due to compression of the scarred tissue surrounding the sciatic nerve. Conclusion: Endoscopic release of the sciatic nerve offers an alternative in the management of DGS by improving functionality and reducing pain levels in appropriately selected patients


Assuntos
Humanos , Masculino , Feminino , Adulto Jovem , Adulto , Pessoa de Meia-Idade , Idoso , Ciática/cirurgia , Neuropatia Ciática/cirurgia , Endoscopia/métodos , Síndromes de Compressão Nervosa/cirurgia , Estudos Retrospectivos , Resultado do Tratamento , Nádegas/cirurgia
9.
World Neurosurg ; 120: e1331-e1336, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30261375

RESUMO

BACKGROUND: Limited data have been reported showing whether the second-generation Wallis interspinous spacer improves function after lumbar spine decompression or discectomy. METHODS: We evaluated Wallis interspinous spacer placement in patients with low back pain or sciatica secondary to a confirmed diagnosis of primary lumbar disc herniation. The patients were treated from July 2008 to July 2011 at 1 institution. Of the 77 patients, 40 allocated to undergo posterior lumbar discectomy with Wallis implantation and 37 without Wallis implantation. The primary outcomes were the visual analog scale score, Japanese Orthopedics Association score, and Oswestry Disability Index. The secondary outcomes were the intervertebral disc height, range of motion of the operated segments, complications, and operating time. RESULTS: At 3 years, the improvements in the primary outcomes were not different between the 2 groups (P > 0.05). The disc height was significantly greater in the Wallis group than in the control group (P < 0.001). Two patients in the Wallis group and three patients in the control group underwent further surgery to treat repeated prolapse of the index segment or an adjacent segment. No significant difference was found in the complication rate between the 2 groups (P > 0.05). CONCLUSIONS: We found that discectomy combined with Wallis implantation was not beneficial for pain relief or lumbar function improvement compared with lumbar discectomy alone. Although the Wallis implant was associated with maintenance of the intervertebral disc height and limited range of motion of the spine, it is probably incapable of preventing recurrent herniation or adjacent segment degeneration.


Assuntos
Fixadores Internos , Deslocamento do Disco Intervertebral/cirurgia , Vértebras Lombares/cirurgia , Adolescente , Adulto , Idoso , Discotomia , Feminino , Seguimentos , Humanos , Deslocamento do Disco Intervertebral/complicações , Dor Lombar/etiologia , Dor Lombar/cirurgia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Ciática/etiologia , Ciática/cirurgia , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
10.
World Neurosurg ; 117: 242-245, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-29929032

RESUMO

BACKGROUND: The authors report the case of a 76-year-old woman presenting with leg pain, numbness, and weakness mimicking a lumbosacral radiculopathy. CASE DESCRIPTION: Initial lumbar spine magnetic resonance imaging demonstrated mild root compression, but lumbar decompression afforded only transient symptomatic relief. Postoperative magnetic resonance imaging of the lumbosacral plexus and sciatic nerve revealed a gluteal venous varix compressing the sciatic nerve just distal to the piriformis muscle. Neurolysis and surgical resection of the offending varix resulted in resolution of her symptoms. CONCLUSIONS: Variceal compression is a rare cause of extraspinal origin of lower extremity radicular pain. It should be considered if there is lack of correlation between radiologic findings and the clinical picture or if there is a failure of response to treatment of the assumed spinal cause.


Assuntos
Síndromes de Compressão Nervosa/etiologia , Ciática/etiologia , Varizes/complicações , Idoso , Descompressão Cirúrgica , Diagnóstico Diferencial , Feminino , Humanos , Vértebras Lombares/diagnóstico por imagem , Vértebras Lombares/cirurgia , Síndromes de Compressão Nervosa/diagnóstico por imagem , Síndromes de Compressão Nervosa/cirurgia , Reoperação , Nervo Isquiático/diagnóstico por imagem , Ciática/diagnóstico por imagem , Ciática/cirurgia , Varizes/diagnóstico por imagem , Varizes/cirurgia
11.
Spine J ; 18(12): 2278-2287, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-29730458

RESUMO

BACKGROUND CONTEXT: Patients with large annular defects after lumbar discectomy for disc herniation are at high risk of symptomatic recurrence and reoperation. PURPOSE: The present study aimed to determine whether a bone-anchored annular closure device, in addition to lumbar microdiscectomy, resulted in lower reherniation and reoperation rates plus increased overall success compared with lumbar microdiscectomy alone. DESIGN: This is a multicenter, randomized superiority study. PATIENT SAMPLE: Patients with symptoms of lumbar disc herniation for at least 6 weeks with a large annular defect (6-10 mm width) after lumbar microdiscectomy were included in the study. OUTCOME MEASURES: The co-primary end points determined a priori were recurrent herniation and a composite end point consisting of patient-reported, radiographic, and clinical outcomes. Study success required superiority of annular closure on both end points at 2-year follow-up. METHODS: Patients received lumbar microdiscectomy with additional bone-anchored annular closure device (n=276 participants) or lumbar microdiscectomy only (control; n=278 participants). This research was supported by Intrinsic Therapeutics. Two authors received study-specific support morethan $10,000 per year, 8 authors received study-specific support less than $10,000 per year, and 11 authors received no study-specific support. RESULTS: Among 554 randomized participants, 550 (annular closure device: n=272; control: n=278) were included in the modified intent-to-treat efficacy analysis and 550 (annular closure device: n=267; control: n=283) were included in the as-treated safety analysis. Both co-primary end points of the study were met, with recurrent herniation (50% vs. 70%, P<.001) and composite end point success (27% vs. 18%, P=.02) favoring annular closure device. The frequency of symptomatic reherniation was lower with annular closure device (12% vs. 25%, P<.001). There were 29 reoperations in 24 patients in the annular closure device group and 61 reoperations in 45 control patients. The frequency of reoperations to address recurrent herniation was 5% with annular closure device and 13% in controls (P=.001). End plate changes were more prevalent in the annular closure device group (84% vs. 30%, P<.001). Scores for back pain, leg pain, Oswestry Disability Index, and health-related quality of life at regular visits were comparable between groups over 2-year follow-up. CONCLUSIONS: In patients at high risk of herniation recurrence after lumbar microdiscectomy, annular closure with a bone-anchored implant lowers the risk of symptomatic recurrence and reoperation. Additional study to determine outcomes beyond 2 years with a bone-anchored annular closure device is warranted.


Assuntos
Discotomia/métodos , Deslocamento do Disco Intervertebral/cirurgia , Vértebras Lombares/cirurgia , Microcirurgia/métodos , Adulto , Idoso , Dor nas Costas/cirurgia , Prótese Ancorada no Osso , Discotomia/instrumentação , Feminino , Humanos , Deslocamento do Disco Intervertebral/prevenção & controle , Masculino , Pessoa de Meia-Idade , Medição da Dor , Qualidade de Vida , Reoperação/estatística & dados numéricos , Ciática/cirurgia , Adulto Jovem
12.
Rev Esp Cir Ortop Traumatol ; 62(5): 322-327, 2018.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-29807785

RESUMO

INTRODUCTION: Deep gluteal syndrome (DGS) is characterized by compression, at extra-pelvic level, of the sciatic nerve within any structure of the deep gluteal space. The objective was to evaluate the clinical results in patients with DGS treated with endoscopic technique. METHODS: Retrospective study of patients with DGS treated with an endoscopic technique between 2012 and 2016 with a minimum follow-up of 12 months. The patients were evaluated before the procedure and during the first year of follow-up with the WOMAC and VAIL scale. RESULTS: Forty-four operations on 41 patients (36 women and 5 men) were included with an average age of 48.4±14.5. The most common cause of nerve compression was fibrovascular bands. There were two cases of anatomic variant at the exit of the nerve; compression of the sciatic nerve was associated with the use of biopolymers in the gluteal region in an isolated case. The results showed an improvement of functionality and pain measured with the WOMAC scale with a mean of 63 to 26 points after the procedure (P<.05). However, at the end of the follow-up one patient continued to manifest residual pain of the posterior cutaneous femoral nerve. Four cases required revision at 6 months following the procedure due to compression of the scarred tissue surrounding the sciatic nerve. CONCLUSION: Endoscopic release of the sciatic nerve offers an alternative in the management of DGS by improving functionality and reducing pain levels in appropriately selected patients.


Assuntos
Descompressão Cirúrgica/métodos , Endoscopia , Síndrome do Músculo Piriforme/cirurgia , Ciática/cirurgia , Adulto , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Síndrome do Músculo Piriforme/diagnóstico por imagem , Estudos Retrospectivos , Ciática/diagnóstico por imagem , Resultado do Tratamento
13.
World Neurosurg ; 115: 166-169, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29689402

RESUMO

BACKGROUND: Clips implanted during intracranial neurosurgical procedures sometimes migrate intradurally with rare cases of spinal migration. The appearance of radicular symptoms of topography concordant with the position of the foreign body leads to discussion about the optimal therapeutic strategy. CASE DESCRIPTION: We report the case of a 52-year-old woman suffering from L5 radicular pain resistant to medical treatment in the presence of L4L5 lumbar stenosis and a neurosurgical clip migrated to the L5S1 level. This clip had been implanted 19 years earlier during a surgical procedure in the posterior fossa, for resection of a juvenile astrocytoma. The imputability of this clip was deemed low given its location and history. A laminarthrectomy associated with circumferential arthrodesis of the L4L5 level was performed allowing complete improvement of radiculopathy. Surgical removal of the clip was not performed. CONCLUSION: Craniospinal migrations of neurosurgical clips are rare. Their imputability in the appearance of root symptoms is random and is based on a bundle of clinical, radiologic, and neurophysiologic arguments. Surgical removal should not be the standard treatment, especially if there is another cause of root compression.


Assuntos
Migração de Corpo Estranho/diagnóstico por imagem , Hemostasia Cirúrgica/efeitos adversos , Vértebras Lombares/diagnóstico por imagem , Procedimentos Neurocirúrgicos/efeitos adversos , Radiculopatia/diagnóstico por imagem , Ciática/diagnóstico por imagem , Dura-Máter/diagnóstico por imagem , Dura-Máter/cirurgia , Feminino , Migração de Corpo Estranho/complicações , Migração de Corpo Estranho/cirurgia , Hemostasia Cirúrgica/instrumentação , Humanos , Vértebras Lombares/cirurgia , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/instrumentação , Dor/diagnóstico por imagem , Dor/etiologia , Radiculopatia/etiologia , Radiculopatia/cirurgia , Ciática/etiologia , Ciática/cirurgia , Instrumentos Cirúrgicos/efeitos adversos
14.
J Neurosurg Spine ; 28(5): 481-485, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29424674

RESUMO

OBJECTIVE In this paper, the authors sought to verify whether corset adoption could improve the short-term and midterm outcome scores of patients after single-level lumbar discectomy. METHODS A monocentric, randomized controlled trial of 54 consecutive patients who underwent single-level lumbar discectomy at the authors' institution was performed from September 2014 to August 2015. Patients were randomly assigned to use or not use a lumbar corset in the upright position. Patients with previous interventions for disc herniation or with concomitant canal or foraminal stenosis were excluded. The visual analog scale, Oswestry Disability Index, and Roland Morris Disability Questionnaire were used to compare groups at the 1- and 6-month follow-up time points. RESULTS No significant differences between the 2 groups were reported at either time point for any given outcome irrespective of the scale used. CONCLUSIONS Corset adoption does not improve the short-term and midterm outcomes of patients after single-level lumbar discectomy.


Assuntos
Braquetes , Discotomia , Vértebras Lombares/cirurgia , Cuidados Pós-Operatórios , Adulto , Avaliação da Deficiência , Feminino , Humanos , Dor Lombar/reabilitação , Dor Lombar/cirurgia , Masculino , Pessoa de Meia-Idade , Ciática/reabilitação , Ciática/cirurgia , Falha de Tratamento
15.
Biomed Res Int ; 2018: 7692794, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30662915

RESUMO

Objective: To compare the clinical efficacy and complications which obtained foraminoplasty at the tip or base of the superior articular process (SAP) for the patients with lateral recess stenosis treated by percutaneous endoscopic lumbar discectomy (PELD). Methods: Between January 2015 and January 2016, 156 patients of lumbar disc herniation accompanying with lateral recess stenosis were treated with PELD in five tertiary hospitals and fulfilled the 2-year follow-up. Among them, 78 patients obtained a foraminoplasty at the tip of SAP (group A), and foraminoplasty at the base of SAP was performed in the other 78 cases (group B). Clinical efficacy was evaluated using the visual analog scale (VAS) score for back and leg pain, Oswestry Disability Index (ODI), and 36-item Short-Form Health Survey (SF-36) score. The intervals of follow-up were scheduled at 1 month, 3 months, 6 months, 1 year, and 2 years after surgery. Results: Mean operative duration is shorter in group B (55 versus 61 min, P = 0.047). Only one case belonged to group A could not tolerate the neural irritation and required conversion to an open procedure. During the surgery, no dura tears, cauda equina syndrome, or infections were observed. 5 patients experienced transient dysesthesia located at the exiting nerve in group A, while no cases complained dysesthesia in group B. 2 cases who suffered temporary motor weakness all belonged to group A. A total of 5 cases obtained a revision surgery after recurrence in the follow-up, in which 3 patients belonged to group A. Compared to the preoperative data, significant improvements in VAS scores of low back pain and sciatica, ODI, and SF-36 PCS and MC were observed in the follow-up, respectively (P < 0.05, respectively). However, no statistical difference was observed at all time-points after surgery between these two groups (P > 0.05, respectively). Conclusions: For the patients of LDH accompanying with lateral recess stenosis, compared with the routine foraminoplasty at the tip of SAP, our modified foraminoplastic technique does not only change place of foraminoplasty to the base of SAP but also simplified puncture process in transforaminal PELD. Although there was no significant difference in symptom relief, the modified foraminoplasty showed the advantages in decreasing the incidence of postoperative neural dysfunction and reducing operation time.


Assuntos
Constrição Patológica/cirurgia , Foraminotomia/efeitos adversos , Degeneração do Disco Intervertebral/cirurgia , Deslocamento do Disco Intervertebral/cirurgia , Idoso , Discotomia Percutânea/métodos , Endoscopia/métodos , Feminino , Seguimentos , Foraminotomia/métodos , Humanos , Dor Lombar/cirurgia , Vértebras Lombares/cirurgia , Região Lombossacral/cirurgia , Masculino , Pessoa de Meia-Idade , Medição da Dor/métodos , Reoperação/métodos , Estudos Retrospectivos , Ciática/cirurgia , Resultado do Tratamento
16.
World Neurosurg ; 109: e761-e769, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29074423

RESUMO

BACKGROUND: Recurrent symptoms of sciatica after previous surgical intervention is a relatively common and troublesome clinical problem. Percutaneous endoscopic lumbar decompression has been proved to be an effective method for recurrent lumbar disc herniation. However, the prognostic factors and outcomes of percutaneous endoscopic lumbar reoperation (PELR) for recurrent sciatica symptoms were still unknown. The purpose of this study was to evaluate the outcomes and prognostic factors of patients who underwent PELR for recurrent sciatica symptoms. METHODS: From 2009 to 2015, 94 patients who underwent PELR for recurrent sciatica symptoms were enrolled. The primary surgeries include transforaminal lumbar interbody fusion (n = 16), microendoscopic discectomy (n = 31), percutaneous endoscopic lumbar decompression (PELD, n = 17), and open discectomy (n = 30). The mean follow-up period was 36 months, and 86 (91.5%) patients had obtained at least 24 months' follow-up. RESULTS: Of the 94 patients with adequate follow-up, 51 (54.3%) exhibited excellent improvement, 23 (24.5%) had good improvement, and 7 (7.4%) had fair improvement according to modified Macnab criteria. The average re-recurrence rate was 9.6%, with no difference among the different primary surgery groups (PELD, 3/17; microendoscopic discectomy, 2/31; open discectomy, 3/30; transforaminal lumbar interbody fusion, 1/16). There was a trend toward greater rates of symptom recurrence in the primary group of PELD who underwent percutaneous endoscopic lumbar reoperation compared with other groups, but this did not reach statistical significance (P > 0.05). Multivariate analysis suggested that age, body mass index, and surgeon level was independent prognostic factors. Obesity (hazard ratio 13.98, 95% confidence interval 3.394-57.57; P < 0.001) was the risk factor affecting re-recurrence according to logistic regression analysis. CONCLUSIONS: PELR is a safe and effective treatment for recurrent sciatica symptoms regardless of different primary operation type. Obesity, inferior surgeon level, and patient age older than 40 years were associated with a worse prognosis. Obesity was also a strong and independent predictor of re-recurrence sciatica symptoms after percutaneous endoscopic lumbar decompression.


Assuntos
Vértebras Lombares/cirurgia , Neuroendoscopia/métodos , Reoperação/métodos , Ciática/diagnóstico , Ciática/cirurgia , Adulto , Idoso , Bases de Dados Factuais/tendências , Discotomia Percutânea/métodos , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Resultado do Tratamento
17.
Surgeon ; 16(3): 146-150, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28522270

RESUMO

BACKGROUND AND PURPOSE: There are no significant differences in outcomes between patients receiving inpatient and day-case lumbar microdiscectomy, but the latter is still underused in the NHS. Here we aimed to identify factors contributing to successful same-day discharge in day-case patients. METHODS: This was a retrospective observational study of patients undergoing elective lumbar microdiscectomy between August 2012 and December 2014. Age, gender, day of surgery, distance to hospital, ASA grade, regular opiate use, smoking status, order on the operating list, and side and level of surgery were examined by logistic regression to assess their influence on same-day discharge. RESULTS: 28/95 (29.5%) patients were discharged on the day of surgery. Age (p = 0.041), ASA grade (p = 0.016), distance to hospital (p = 0.011), and position on the list (p = 0.004) were associated with day-case discharge by univariate analysis. ASA grade (p = 0.032; OR 0.176), distance to hospital (p = 0.003; OR 0.965), and position on the operating list (morning case; p = 0.011; OR 8.901) remained significant in multivariate analysis. Thirteen (13.7%) patients were identified who could have been managed as day cases had they been listed for morning operations. CONCLUSIONS: Day-case lumbar microdiscectomy is viable when patients are carefully selected. Younger, fit patients living close to the hospital and operated on in the morning are more likely to be discharged on the same day. Knowledge of these factors while planning elective lists can help optimise bed space and improve spinal services.


Assuntos
Procedimentos Cirúrgicos Ambulatórios , Discotomia/métodos , Deslocamento do Disco Intervertebral/cirurgia , Vértebras Lombares/cirurgia , Ciática/cirurgia , Adulto , Idoso , Procedimentos Cirúrgicos Eletivos , Feminino , Humanos , Deslocamento do Disco Intervertebral/complicações , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Melhoria de Qualidade , Estudos Retrospectivos , Ciática/etiologia , Reino Unido , Adulto Jovem
18.
Evid. actual. práct. ambul ; 21(4): 124-126, 2018.
Artigo em Espanhol | LILACS | ID: biblio-1015690

RESUMO

La lumbociatalgia es un problema clínico común, que en la mayoría de los casos se autolimita y se puede tratar en forma conservadora, usando medidas no farmacológicas y analgésicos como paracetamol o los antiinflamatorios no esteroi-deos. Otro medicamento muy utilizado en nuestro medio es la pregabalina, a pesar de que no se encuentra aprobada para dicha indicación. En este trabajo, el autor se pregunta acerca de la utilidad clínica de la pregabalina y luego de hacer una búsqueda bibliográfica sobre la evidencia más actualizada y de mejor calidad acerca del tema, concluye que no es efectiva para lumbociatalgia y que se acompaña de efectos adversos significativos. Esto coincide con las recomenda-ciones de las guías internacionales, que en su mayoría desaconsejan el uso de anticonvulsivantes para la lumbalgia. (AU)


Sciatica is a common clinical situation, in most cases self-limited and which can be managed conservatively with nonpharmaco-logic treatment and analgesics, such as paracetamol or nonsteroidal anti-inflammatory drugs. Pregabalin is also commonly used, despite not being approved for this indication. In this article, the author queries about the clinical usefulness of pregabalin, and after carrying out a bibliographic search of the most recent and best-quality evidence, concludes that it is not effective in sciatica while it causes significant adverse effects. This is in line with the recommendations of most international guidelines,that do not recommend the use of anticonvulsivants drugs for the treatment of lumbalgia. (AU)


Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Adulto Jovem , Ciática/tratamento farmacológico , Dor Lombar/tratamento farmacológico , Prática Clínica Baseada em Evidências/tendências , Pregabalina/efeitos adversos , Anticonvulsivantes/efeitos adversos , Ciática/cirurgia , Ciática/terapia , Anti-Inflamatórios não Esteroides/uso terapêutico , Dor Lombar/cirurgia , Dor Lombar/terapia , Pregabalina/administração & dosagem , Pregabalina/uso terapêutico , Analgésicos/uso terapêutico , Bloqueio Nervoso/tendências
19.
Rev. bras. cir. plást ; 32(4): 570-578, out.-dez. 2017. ilus, tab
Artigo em Inglês, Português | LILACS | ID: biblio-878780

RESUMO

Introdução: A úlcera por pressão (UPP) é uma das complicações mais comuns em portadores de lesão medular, dos mais graves e frequentes problemas destes pacientes. A incidência e evolução depende dos grupos estudados, tendo as crianças e adolescentes características específicas durante o crescimento. A maior parte das descrições na literatura referem-se a adultos que desenvolveram UPP durante internação. O objetivo é descrever os resultados de pacientes operados para fechamento de úlcera por pressão na unidade de Pediatria do Hospital Sarah Brasília. Métodos: Estudo descritivo, retrospectivo de pacientes operados de 2005 a 2010 devido à lesão por pressão e análise estatística. Resultados: 116 pacientes foram admitidos para tratamento cirúrgico de UPP no Hospital Sarah, sendo 20 (17,2%) internados na Pediatria; 15 (75%) homens e 5 (25%) mulheres, todos provenientes de ambiente comunitário; 60% localizadas na região isquiática; com seguimento de 15 anos; 70% eram portadores de malformação do tubo neural. Os procedimentos cirúrgicos foram indicados para úlcera por pressão grau III e IV. Utilizou-se retalho do músculo glúteo (3), em ilha (8) ou península (3), fechamento primário e coccigectomia; retalho do músculo tensor da fáscia lata. Três casos apresentaram complicações, 65% evoluíram com recidiva e 15% com surgimento de novas lesões na região pélvica. Conclusão: A principal causa de lesão por pressão em Pediatria foi devido à malformação do tubo neural (70%), adquiridas na comunidade, localizadas na região isquiática. Embora estivessem em atendimento no programa de reabilitação, ainda foi observado alto índice de recidivas (65%).


Introduction: Pressure ulcers (PUs), or pressure sores, are among the most common serious complications in patients with spinal cord injury. The incidence and evolution in children and adolescents have specific characteristics. Most prior reports evaluated adults who developed PUs in the hospital. The objective is to describe the outcomes of surgical PU closure in children and adolescents in the Hospital Sarah Brasília pediatric unit. Methods: This was a retrospective statistical analysis of patients who underwent surgery for PUs. Statistical analysis of the incidence of PUs was performed using Epi Info version 3.2.2. Results: Of 116 patients who underwent surgery for PUs at the Hospital Sarah between 2005 and 2010, 20 (17.2%) were admitted to the Pediatric Unit. All 15 (75%) male and 5 (25%) female patients were admitted from a community setting. PUs were located in the ischial region in 60% of patients. The followup period was 15 years. Neural tube malformations were present in 70% of patients. We performed surgery for grade III and IV PUs, using gluteal flaps, primary closure and coccygectomy, and tensor fascia lata flaps. Three cases had complications, 65% developed recurrences, and 15% developed new ulcers in the pelvic region. Conclusion: The main cause of PUs in pediatric cases admitted to the rehabilitation hospital was a neural tube malformation (70%) in the ischial region. Despite admission to the rehabilitation program, a high recurrence rate (65%) was observed.


Assuntos
Humanos , Masculino , Feminino , Criança , Adolescente , História do Século XXI , Pediatria , Reabilitação , Ciática , Procedimentos Cirúrgicos Operatórios , Úlcera , Estudos Retrospectivos , Lesão por Pressão , Tubo Neural , Pediatria/métodos , Reabilitação/métodos , Ciática/cirurgia , Ciática/terapia , Procedimentos Cirúrgicos Operatórios/métodos , Úlcera/cirurgia , Lesão por Pressão/cirurgia , Lesão por Pressão/complicações , Lesão por Pressão/terapia , Tubo Neural/cirurgia
20.
PLoS One ; 12(10): e0186148, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-29023556

RESUMO

INTRODUCTION: Correlation between magnetic resonance imaging (MRI) and clinical features in cauda equina syndrome (CES) is unknown; nor is known whether there are differences in MRI spinal canal size between lumbar herniated disc patients with CES versus lumbar herniated discs patients without CES, operated for sciatica. The aims of this study are 1) evaluating the association of MRI features with clinical presentation and outcome of CES and 2) comparing lumbar spinal canal diameters of lumbar herniated disc patients with CES versus lumbar herniated disc patients without CES, operated because of sciatica. METHODS: MRIs of CES patients were assessed for the following features: level of disc lesion, type (uni- or bilateral) and severity of caudal compression. Pre- and postoperative clinical features (micturition dysfunction, defecation dysfunction, altered sensation of the saddle area) were retrieved from the medical files. In addition, anteroposterior (AP) lumbar spinal canal diameters of CES patients were measured at MRI. AP diameters of lumbar herniated disc patients without CES, operated for sciatica, were measured for comparison. RESULTS: 48 CES patients were included. At MRI, bilateral compression was seen in 82%; complete caudal compression in 29%. MRI features were not associated with clinical presentation nor outcome. AP diameter was measured for 26 CES patients and for 31 lumbar herniated disc patients without CES, operated for sciatica. Comparison displayed a significant smaller AP diameter of the lumbar spinal canal in CES patients (largest p = 0.002). Compared to average diameters in literature, diameters of CES patients were significantly more often below average than that of the sciatica patients (largest p = 0.021). CONCLUSION: This is the first study demonstrating differences in lumbar spinal canal size between lumbar herniated disc patients with CES and lumbar herniated disc patients without CES, operated for sciatica. This finding might imply that lumbar herniated disc patients with a relative small lumbar spinal canal might need to be approached differently in managing complaints of herniated disc. Since the number of studied patients is relatively small, further research should be conducted before clinical consequences are considered.


Assuntos
Deslocamento do Disco Intervertebral/diagnóstico por imagem , Imagem por Ressonância Magnética/métodos , Polirradiculopatia/diagnóstico por imagem , Ciática/cirurgia , Canal Vertebral/patologia , Adulto , Descompressão Cirúrgica , Discotomia , Feminino , Humanos , Deslocamento do Disco Intervertebral/complicações , Deslocamento do Disco Intervertebral/patologia , Deslocamento do Disco Intervertebral/cirurgia , Masculino , Pessoa de Meia-Idade , Polirradiculopatia/etiologia , Polirradiculopatia/patologia , Polirradiculopatia/cirurgia , Complicações Pós-Operatórias/classificação , Canal Vertebral/diagnóstico por imagem , Resultado do Tratamento
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