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1.
World Neurosurg ; 133: 90-96, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31568901

RESUMO

BACKGROUND: Although adjacent segment disease (ASD) following anterior cervical fusion has been well described in the literature, there is relative paucity of data on this pathology after posterior cervical fusion. To our knowledge, there have been no reported cases of proximal ASD following posterior fusion to C2. CASE DESCRIPTION: We present 2 cases of proximal ASD presenting as retroodontoid pseudotumors following posterior fusion to C2, both in middle-aged females without history of rheumatologic disease. The first occurred in a patient with Klippel-Feil deformity 13 years after C2-6 posterior cervical fusion, the second in a patient 3 and a half years following revisional circumferential C2-T2 fusion. Both were successfully treated with proximal extension of laminectomy and fusion to the occiput, supplemented in the first patient by transdural decompression of retroodontoid mass. CONCLUSIONS: Proximal ASD can manifest as retroodontoid pseudotumor at variable time intervals following posterior fusion to C2. Clinicians must account for this possibility in their decision making.


Assuntos
Vértebras Cervicais/cirurgia , Descompressão Cirúrgica/efeitos adversos , Cervicalgia/diagnóstico por imagem , Doenças da Coluna Vertebral/etiologia , Fusão Vertebral/efeitos adversos , Vértebras Cervicais/diagnóstico por imagem , Feminino , Humanos , Síndrome de Klippel-Feil/diagnóstico por imagem , Síndrome de Klippel-Feil/cirurgia , Imagem por Ressonância Magnética , Pessoa de Meia-Idade , Cervicalgia/cirurgia , Processo Odontoide/diagnóstico por imagem , Processo Odontoide/cirurgia , Doenças da Coluna Vertebral/diagnóstico por imagem , Doenças da Coluna Vertebral/cirurgia , Resultado do Tratamento
2.
World Neurosurg ; 133: e690-e694, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31568911

RESUMO

OBJECTIVE: Adjacent segment disease (ASD) is a long-term complication of lumbar spinal fusion. This study aims to evaluate demographic and operative factors that influence development of ASD after fusion for lumbar degenerative pathologies. METHODS: A retrospective cohort study was performed on patients undergoing instrumented lumbar fusion for degenerative disorders (spondylolisthesis, stenosis, or intervertebral disk degeneration) with a minimum follow-up of 6 months. RESULTS: Our inclusion criteria were met by 568 patients; 29.4% of patients had developed surgical ASD. Median follow-up was 2.8 years. Multivariate logistic regression analysis showed that decompression of segments outside the fusion construct had higher ASD (odds ratio = 2.6; P < 0.001), and those undergoing fusion for spondylolisthesis had lower ASD (odds ratio = 0.47; P = 0.003). CONCLUSIONS: Results of our study show that the most important surgical factor contributing to ASD is decompression beyond fused levels. Hence caution should be exercised when decompressing spinal segments outside the fusion construct. Conversely, spondylolisthesis patients had the lowest ASD rates in our cohort.


Assuntos
Descompressão Cirúrgica/efeitos adversos , Complicações Pós-Operatórias/etiologia , Fusão Vertebral/efeitos adversos , Adulto , Idoso , Estudos de Coortes , Feminino , Humanos , Vértebras Lombares , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco
3.
Ann R Coll Surg Engl ; 102(2): 104-109, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31508996

RESUMO

INTRODUCTION: Median arcuate ligament syndrome has been known anatomically for approximately 100 years and results from a compression of the coeliac axis by fibrous attachment of the diaphragmatic crura. Owing to the rarity of the disease and limited available data, many aspects of treatment are controversial. Currently, laparoscopic decompression is considered by several authors as standard surgical procedure. We present an analysis of the clinical routine of MALS therapy. METHODS: We conducted a prospective observational trial in patients with MALS between March 2016 and August 2018, in which clinical symptoms, diagnostic evaluation, procedures with complication analysis and follow-up data were recorded. RESULTS: A total of 18 patients (12 female, 6 male) with MALS, aged between 15 and 65 years, were included in this study. All patients presented with long-standing abdominal pain. Preoperative Doppler ultrasonography showed a flow velocity of the coeliac artery averaging 289.9cm/second in mid-position of the diaphragm, 285.9cm/second in expiration and 199.0cm/second in inspiration. All operated patients underwent laparoscopic decompression; two patients received an angiographic intervention. Postoperatively, a significant decrease of the flow velocity in mid-position of the diaphragm was detected (P = 0.018). At follow-up after 5.2 months, 50.0% of the patients were pain-free, 37.5% reported symptomatic relief and 12.5% showed evidence for a recurrence. CONCLUSION: MALS is challenging both diagnostically and therapeutically. Laparoscopy with release of the median arcuate ligament is an essential part of the therapy and can be confirmed by Doppler ultrasonography. Disease outcome is also influenced by several predictive factors.


Assuntos
Artéria Celíaca/cirurgia , Síndrome do Ligamento Arqueado Mediano/cirurgia , Dor Abdominal/diagnóstico por imagem , Dor Abdominal/etiologia , Adolescente , Adulto , Idoso , Velocidade do Fluxo Sanguíneo , Artéria Celíaca/diagnóstico por imagem , Artéria Celíaca/fisiopatologia , Descompressão Cirúrgica/efeitos adversos , Descompressão Cirúrgica/métodos , Feminino , Seguimentos , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Masculino , Síndrome do Ligamento Arqueado Mediano/complicações , Síndrome do Ligamento Arqueado Mediano/diagnóstico por imagem , Pessoa de Meia-Idade , Resultado do Tratamento , Ultrassonografia Doppler/métodos , Adulto Jovem
4.
World Neurosurg ; 133: 155-158, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31493605

RESUMO

BACKGROUND: Pseudohypoxic brain swelling (PHBS), also known as postoperative intracranial hypotension-associated venous congestion, is a rare complication after neurosurgery characterized by rapid and often severe postoperative deterioration in consciousness and distinct imaging findings on brain magnetic resonance imaging. Imaging findings associated with PHBS include computed tomography and magnetic resonance imaging findings that resemble hypoxic changes and intracranial hypotensive changes in basal ganglia and thalamus, telencephalic, and infratentorial regions without notable changes in intracranial vasculature. CASE DESCRIPTION: This report describes the case of an L4-5 microdiskectomy with posterior decompression and fusion complicated by clinical and radiographic findings resembling PHBS without a known intraoperative durotomy. CONCLUSIONS: Spine surgeons should be alerted to the possibility that PHBS may occur in patients even after an operation without known durotomy or cerebrospinal fluid leakage and with spontaneous clinical resolution unrelated to suction drainage changes or epidural blood patches.


Assuntos
Edema Encefálico/etiologia , Descompressão Cirúrgica/efeitos adversos , Hipotensão Intracraniana/etiologia , Fusão Vertebral/efeitos adversos , Espondilolistese/cirurgia , Idoso , Edema Encefálico/diagnóstico por imagem , Feminino , Humanos , Hipotensão Intracraniana/diagnóstico por imagem , Imagem por Ressonância Magnética , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/etiologia , Tomografia Computadorizada por Raios X , Resultado do Tratamento
5.
World Neurosurg ; 133: 314-317, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31648054

RESUMO

BACKGROUND: The adult spinal cord is typically resistant to hypoxic-ischemic injury because of collateral blood supply; however, congenital or acquired stenosis may result in baseline maximal vasodilation, such as superimposed hemodynamic stresses, that cannot be accommodated, leaving the spinal cord vulnerable to ischemic injury. We present a rare case of spinal cord hypoxic-ischemic injury in an adult with underlying cervical spinal stenosis. CASE DESCRIPTION: A 37-year-old man with a history of morbid obesity, diabetes mellitus, hypertension, and obstructive sleep apnea presented after developing progressive weakness in the extremities. Preoperative computed tomography myelography demonstrated ossification of the posterior longitudinal ligament and severe spinal canal narrowing. Approximately 1 week after posterior decompression, the patient experienced spinal hypoxic-ischemic injury. Imaging revealed cord expansion and abnormal T2 signal intensity. Axial diffusion tensor images of the brain revealed delayed ischemic leukoencephalopathy with restricted diffusion in the cerebral cortex and deep white matter; this led to the decision to withdraw care, and the patient died. CONCLUSIONS: We hypothesize that vascular dysregulation due to cervical stenosis made the cord parenchyma vulnerable to hypoxic and/or hypoperfusion stresses.


Assuntos
Descompressão Cirúrgica/efeitos adversos , Isquemia/etiologia , Leucoencefalopatias/etiologia , Ossificação do Ligamento Longitudinal Posterior/cirurgia , Medula Espinal/irrigação sanguínea , Estenose Espinal/cirurgia , Adulto , Evolução Fatal , Humanos , Isquemia/diagnóstico por imagem , Leucoencefalopatias/diagnóstico por imagem , Masculino , Ossificação do Ligamento Longitudinal Posterior/diagnóstico por imagem , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/etiologia , Medula Espinal/diagnóstico por imagem , Estenose Espinal/diagnóstico por imagem
6.
Ann R Coll Surg Engl ; 102(2): 141-143, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31660754

RESUMO

INTRODUCTION: Colonic stent insertion has been shown to be an effective treatment for patients with acute large bowel obstruction, either as a bridge to surgery or as definitive treatment. However, little is known of the role of secondary stent insertion following primary stent failure in patients considered inappropriate or high risk for emergency surgery. METHODS: Fourteen patients presenting with acute large bowel obstruction who had previously been treated with colonic stent insertion were studied. All underwent attempted placement of a secondary stent. RESULTS: Technical deployment of the stent was accomplished in 12 patients (86%) but only 9 (64%) achieved clinical decompression. Successful deployment and clinical decompression of a secondary stent was associated with older age (p=0.038). Sex, pathology, site of obstruction, duration of efficacy of initial stent and cause of primary failure were unrelated to outcome. No procedure related morbidity or mortality was noted following repeated intervention. CONCLUSIONS: Secondary colonic stent insertion appears an effective, safe treatment in the majority of patients presenting with acute large bowel obstruction following failure of a primary stent.


Assuntos
Doenças do Colo/cirurgia , Descompressão Cirúrgica/instrumentação , Obstrução Intestinal/cirurgia , Complicações Pós-Operatórias/epidemiologia , Stents , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Descompressão Cirúrgica/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Retratamento/instrumentação , Falha de Tratamento , Resultado do Tratamento
7.
Ann Vasc Surg ; 62: 70-75, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31207398

RESUMO

BACKGROUND: The objective of this study was to characterize phrenic nerve and brachial plexus variation encountered during supraclavicular decompression for neurogenic thoracic outlet syndrome and to identify associated postoperative neurologic complications. METHODS: A multicenter retrospective review was performed to evaluate anatomic variation of the phrenic nerve and brachial plexus from November 2010 to July 2018. After initial characterization, the following two groups were identified: variant anatomy (VA) group and standard anatomy (SA) group. Complications were analyzed and compared between the two groups. RESULTS: In total, 105 patients were identified, and 100 patients met inclusion criteria. Any anatomic variation of the standard course or configuration of the phrenic nerve and/or brachial plexus was encountered in 47 (47%) patients. Phrenic nerve anatomic variations were identified in 28 (28%) patients. These included 9 duplicated nerves, 6 lateral accessory nerves, 8 medial displacement, and 5 lateral displacement. Brachial plexus anatomic variation was found in 34 (34%) patients. The most common variant configuration of a fused middle and inferior trunk was identified in 25 (25%) patients. Combined phrenic nerve and brachial plexus anatomic variation was demonstrated in 15 (15%) patients. The VA and SA groups consisted of 47 and 53 patients, respectively. Transient phrenic nerve injury with postoperative elevation of the ipsilateral hemidiaphragm was documented in 3 (6.4%) patients in the VA group and 6 (11.3%) patients in the SA group (P = 0.49). Permanent phrenic nerve injury was identified in 1 (2.1%) patient in the VA group (P = 0.47) and none in the SA group. Transient brachial plexopathy was encountered in 1 (1.9%) patient in the SA group (P = 1.0) with full recovery to normal function. CONCLUSIONS: Anatomic variability of the phrenic nerve and brachial plexus are encountered more frequently than previously reported. While the incidence of nerve injury is low, surgeons operating within the thoracic aperture should be familiar with variant anatomy to reduce postoperative complications.


Assuntos
Neuropatias do Plexo Braquial/etiologia , Plexo Braquial/anormalidades , Descompressão Cirúrgica/efeitos adversos , Traumatismos dos Nervos Periféricos/etiologia , Nervo Frênico/anormalidades , Síndrome do Desfiladeiro Torácico/cirurgia , Adulto , Plexo Braquial/lesões , Plexo Braquial/fisiopatologia , Neuropatias do Plexo Braquial/fisiopatologia , Feminino , Humanos , Masculino , Maryland , Traumatismos dos Nervos Periféricos/fisiopatologia , Philadelphia , Nervo Frênico/lesões , Nervo Frênico/fisiopatologia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Síndrome do Desfiladeiro Torácico/diagnóstico por imagem , Síndrome do Desfiladeiro Torácico/fisiopatologia , Resultado do Tratamento
8.
Ann Vasc Surg ; 62: 248-257, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31449931

RESUMO

BACKGROUND: This study aims to identify potential risk factors for becoming symptomatic in patients with radiographic celiac artery compression (CAC) as well as prognostic factors for patients with median arcuate ligament syndrome (MALS) who underwent surgical ligament release. METHODS: This is a retrospective cohort study of patients with findings of CAC on computed tomography or magnetic resonance angiography (CT/MRA) who were asymptomatic and who were diagnosed with MALS at a single university hospital between January 2001 and 2018. RESULTS: Following a review of 1,330 CT/MRA reports, a total of 109 patients were identified as having radiographically apparent CAC. Among these, 48 (44.0%) patients were symptomatic. Univariate comparison between those with and without symptoms showed that symptomatic patients were more commonly younger than 30 years old [17/48 (35.4%) vs. 8/61 (13.1%), P = 0.006], had a history of prior abdominal surgery [25/48 (52.1%) vs. 18/61 (29.5%), P = 0.017], and had high-grade stenosis [32/43 (74.4%) vs. 25/61 (41.0%), P = 0.001]. Among 41 included patients who underwent surgical release of the median arcuate ligament including open, laparoscopic, and robotic approaches, 82.9% reported overall clinical improvement, 5/41 (12.2%) reported persistent pain, and 13/36 (36.0%) experienced pain recurrence. The only identified risk factor associated with symptom recurrence was American Society of Anesthesiologists class III [7/13 (53.8%) vs. 4/23 (17.4%), P = 0.029]. CONCLUSIONS: The severity of stenosis and prior abdominal surgery both contributed to symptom development in patients with radiographically apparent CAC from the median arcuate ligament.


Assuntos
Artéria Celíaca , Descompressão Cirúrgica , Síndrome do Ligamento Arqueado Mediano/cirurgia , Adulto , Idoso , Artéria Celíaca/diagnóstico por imagem , Artéria Celíaca/fisiopatologia , Angiografia por Tomografia Computadorizada , Descompressão Cirúrgica/efeitos adversos , Feminino , Hospitais com Alto Volume de Atendimentos , Hospitais Universitários , Humanos , Los Angeles , Angiografia por Ressonância Magnética , Masculino , Síndrome do Ligamento Arqueado Mediano/diagnóstico por imagem , Síndrome do Ligamento Arqueado Mediano/fisiopatologia , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular
9.
Ann Vasc Surg ; 62: 268-274, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31449939

RESUMO

BACKGROUND: The optimal surgical approach and treatment algorithm for thoracic outlet syndrome (TOS) remain controversial. We sought to examine the outcomes of patients treated at a military medical treatment facility (MTF) for TOS. METHODS: A retrospective review was performed on all patients who had a first rib resection (FRR) for TOS over a 9-year period at a single MTF. Patient demographics, perioperative details, and patient outcomes were examined. Active duty (AD) status and return to AD were reviewed. RESULTS: From 2008 to 2016, 33 FRRs were performed in 32 patients. Of these, 30 patients were on AD with a mean age of 27 years (range, 19-44). The 29 male and 4 female patients were treated for symptoms of venous (23), neurogenic (6), or arterial (4) TOS. The mean time from onset of symptoms was 11 months (range, 1 to 120). The FRR was performed via a transaxillary (13), supraclavicular (12), or paraclavicular (8) approach. Of 21 AD patients with venous TOS, 16 (76%) underwent preoperative thrombolysis. A postoperative venogram or ultrasound was performed in 20 patients, documenting vein patency in 18 (90%). Nine patients underwent subsequent venoplasty or stent placement. Most patients (15) were placed on anticoagulation for 1-6 months. Two AD patients had perioperative complications including a lymph leak and brachial plexus palsy. Twenty-four (89%) patients returned to AD status. One recruit never returned to AD after successful FRR, and two other patients did not return for medical reasons unrelated to the FRR. CONCLUSIONS: Despite a variety of surgical approaches and often delayed presentation, we identified a high percentage of postoperative vein patency and return to AD status in our population. The debate over surgical approach remains; however, a multimodal approach individualized to the patient's presentation and meticulous surgical technique led to successful outcomes in our healthy military population.


Assuntos
Descompressão Cirúrgica/métodos , Militares , Osteotomia , Retorno ao Trabalho , Costelas/cirurgia , Síndrome do Desfiladeiro Torácico/cirurgia , Adulto , California , Descompressão Cirúrgica/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medicina Militar , Osteotomia/efeitos adversos , Complicações Pós-Operatórias/fisiopatologia , Recuperação de Função Fisiológica , Estudos Retrospectivos , Síndrome do Desfiladeiro Torácico/diagnóstico por imagem , Síndrome do Desfiladeiro Torácico/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular , Adulto Jovem
10.
Ann Vasc Surg ; 62: 128-132, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31476427

RESUMO

BACKGROUND: Rib resection in venous thoracic outlet syndrome (vTOS) may be approached via a transaxillary, supraclavicular, or infraclavicular approach based on surgeon preference. The purpose of this study was to evaluate long-term postoperative quality of life function after surgery for vTOS and to determine if there were long-term patency differences associated with the surgical approach or whether prophylactic postoperative venography was performed. METHODS: All patients with vTOS undergoing rib resection at a single institution were retrospectively reviewed. In 2012, we switched our approach to infraclavicular with postoperative venogram performed within 2 weeks of rib resection. Clinical records and imaging results were tabulated, and postoperative outcomes, complications, and long-term symptom follow up via the disabilities of the arm, shoulder, and hand score surveys. The disabilities of the arm, shoulder, and hand score ranges from 0 to 100 with lower numbers indicating better functional status (100 = worst). RESULTS: During the 19-year study period, we performed 109 rib resections in patients with vTOS (mean age, 29.8 years). From 2000 to 2012, 54 patients were approached via a supraclavicular approach, and from 2012 to 2018, 55 patients were approached via an infraclavicular approach. There was a significant decrease in the number of complications in the infraclavicular cohort compared with the supraclavicular group. There was no difference in patency between the 2 groups even with a higher rate of postoperative venogram in the infraclavicular cohort. There was no difference in long-term the disabilities of the arm, shoulder, and hand scores. There was an increased rate of complications in the supraclavicular cohort as compared with the infraclavicular group (P < 0.05). CONCLUSIONS: The infraclavicular approach in patients with vTOS is associated with a lower rate of complications, but long-term quality of life outcomes and patency are not different between groups.


Assuntos
Descompressão Cirúrgica/métodos , Osteotomia , Qualidade de Vida , Costelas/cirurgia , Síndrome do Desfiladeiro Torácico/cirurgia , Adulto , Descompressão Cirúrgica/efeitos adversos , Avaliação da Deficiência , Feminino , Humanos , Masculino , Osteotomia/efeitos adversos , Flebografia , Recuperação de Função Fisiológica , Estudos Retrospectivos , Síndrome do Desfiladeiro Torácico/diagnóstico por imagem , Síndrome do Desfiladeiro Torácico/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular
11.
Spine (Phila Pa 1976) ; 44(22): 1599-1605, 2019 Nov 15.
Artigo em Inglês | MEDLINE | ID: mdl-31689255

RESUMO

STUDY DESIGN: Prospective observational study OBJECTIVE.: The aim of this study was to record daily opioid use and pain levels after 1-level lumbar decompression or microdiscectomy. SUMMARY OF BACKGROUND DATA: The standardization of opioid-prescribing practices through guidelines can decrease the risk of misuse and lower the number of pills available for diversion in this high-risk patient population. However, there is a paucity of quantitative data on the "minimum necessary amount" of opioid appropriate for post-discharge prescriptions. METHODS: At two institutions between September 2017 and 2018, we prospectively enrolled 85 consecutive adult patients who underwent one-level lumbar decompression or microdiscectomy. Patients with a history of opioid dependence were excluded. Daily opioid consumption and pain scores were collected using an automated text-messaging-based platform for 6 weeks or until consumption ceased. Refills during the study period were monitored. Patients were asked for the number of pills left over and the method of disposal. Opioid use was converted to oral morphine equivalents (OMEs). Results are also reported in terms of "pills" (oxycodone 5 mg equivalents) to facilitate clinical applications. Risk factors were compared between patients in the top and bottom half of opioid consumption. RESULTS: Total opioid consumption ranged from 0 to 118 pills, with a median consumption of 32 pills (236.3 OME). Seventy-five percent of patients consumed ≤57 pills (431.3 OME). Mean Numeric Rating Scale pain scores declined steadily over the first 2 weeks. By postoperative day 7 half of the study population had ceased taking opioids altogether. Only 22.4% of patients finished their initial prescription, and only 9.4% of patients obtained a refill. CONCLUSION: These data may be used to formulate evidence-based opioid prescription guidelines, establish benchmarks, and identify patients at the higher end of the opioid use spectrum. LEVEL OF EVIDENCE: 2.


Assuntos
Analgésicos Opioides , Descompressão Cirúrgica , Discotomia , Vértebras Lombares/cirurgia , Dor Pós-Operatória , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/uso terapêutico , Descompressão Cirúrgica/efeitos adversos , Descompressão Cirúrgica/estatística & dados numéricos , Discotomia/efeitos adversos , Discotomia/estatística & dados numéricos , Humanos , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/epidemiologia
12.
BMC Musculoskelet Disord ; 20(1): 448, 2019 Oct 15.
Artigo em Inglês | MEDLINE | ID: mdl-31615502

RESUMO

BACKGROUND: Osteonecrosis of the femoral head (ONFH) is a progressive disease that leads to collapse and the development of secondary arthritis. The preferred management of ONFH remains controversial. Arthroscopic-assisted management of ONFH is a new and evolving approach for hip preservation. We hypothesis that arthroscopy is able to improve ONFH outcomes by achieving accurate and minimally invasive decompression while successfully addressing concomitant intraarticular pathologies resulting in reliable mid-term outcomes. METHODS: This was a retrospective cohort analysis. All patients had atraumatic ONFH with a precollapse lesion and a minimum follow-up of 5 years. RESULTS: A total cohort of 11 hips (8 patients) was identified. The mean patient follow-up was 7 years ±1.48 years (range, 64-118 months). The Ficat-Alret classification found on preoperative imaging was Stage I-3 (27.2%), IIa-4 (36.4%), and IIb-4 (36.4%) hips. Four (36.4%) hips experienced mechanical issues, including locking, catching, and buckling. The most common concomitant pathology addressed at the time of arthroscopy, was labral repair/debridement-8 (73%), followed by microfracture-7 (64%). At final follow-up, 6 hips (54.5%) had not converted to THA. Upon further stratification, Stage I-100%, Stage IIa-75%, for a combined 87%, had not converted to THA, in contrast, 100% of hips categorized as Stage IIb had converted to THA. Ficat-Alret staging, especially Stage IIb, was significantly associated with conversion to THA. (p-value = 0.015) There were 0% major or minor complications. CONCLUSIONS: To our knowledge, this is the longest reported follow-up of arthroscopic-assisted management of ONFH. Arthroscopic-assisted management is a promising surgical approach that provides safe, accurate, and minimally invasive decompression, resulting in reliable results with an acceptable conversion rate to THA. LEVEL OF EVIDENCE: Level IV, Case Series.


Assuntos
Artroscopia/métodos , Descompressão Cirúrgica/métodos , Necrose da Cabeça do Fêmur/cirurgia , Tratamentos com Preservação do Órgão/métodos , Adolescente , Adulto , Artroplastia de Quadril/estatística & dados numéricos , Artroscopia/efeitos adversos , Descompressão Cirúrgica/efeitos adversos , Feminino , Cabeça do Fêmur/diagnóstico por imagem , Cabeça do Fêmur/patologia , Cabeça do Fêmur/cirurgia , Necrose da Cabeça do Fêmur/diagnóstico , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Tratamentos com Preservação do Órgão/efeitos adversos , Radiografia , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Índice de Gravidade de Doença , Resultado do Tratamento , Adulto Jovem
13.
Ned Tijdschr Geneeskd ; 1632019 09 24.
Artigo em Holandês | MEDLINE | ID: mdl-31556497

RESUMO

Lumbar spondylolisthesis is usually asymptomatic. However, symptomatic spondylolisthesis results in back and/or leg pain such as radicular syndrome or neurogenic claudication. Variation in symptoms is caused by different types of spondylolisthesis. Lytic spondylolisthesis, most common at L5S1, is caused by spondylolysis of the pars interarticularis. This results in foraminal nerve compression and radicular symptoms. Degenerative spondylolisthesis, most common at L4L5 in patients >50 years old, is caused by slippage of the vertebral body and lamina, resulting in lumbar spinal stenosis and neurogenic claudication. Iatrogenic spondylolisthesis develops in 1.6-32.0% of patients after decompression surgery, causing recurrent neurogenic symptoms. It is important to understand the main symptoms patients experience: back or leg pain. In both cases, the preferred treatment is conservative. Surgery is only an option if patients have persistent/progressive leg pain. Shared decision-making is necessary to select the most accurate surgery for each individual patient while also taking into account age, comorbidities and symptoms. Further research is necessary to determine the advantages of each surgery in order to improve advice to patients.


Assuntos
Dor nas Costas/etiologia , Claudicação Intermitente/etiologia , Vértebras Lombares/patologia , Radiculopatia/etiologia , Estenose Espinal/etiologia , Espondilolistese/complicações , Idoso , Descompressão Cirúrgica/efeitos adversos , Descompressão Cirúrgica/métodos , Feminino , Humanos , Vértebras Lombares/cirurgia , Masculino , Pessoa de Meia-Idade , Espondilolistese/patologia , Espondilolistese/cirurgia
14.
J Orthop Surg Res ; 14(1): 306, 2019 Sep 11.
Artigo em Inglês | MEDLINE | ID: mdl-31511030

RESUMO

BACKGROUND: Core decompression (CD) is an important method for the treatment of osteonecrosis of the femoral head (ONFH). Few articles investigate the influence of core decompression on outcomes of ONFH. This study was carried out to observe the safety and effectiveness of core decompression in the treatment of ONFH. METHODS: A comprehensive literature search of databases including PubMed, Embase, and Cochrane Library was performed to collect the related studies. The medical subject headings used were "femur head necrosis" and "Core decompression." The relevant words in title or abstract included but not limited to "Osteonecrosis of the Femoral Head," "femoral head necrosis," "avascular necrosis of femoral head," and "ischemic necrosis of femoral head." The methodological index for nonrandomized studies was adopted for assessing the studies included in this review. RESULTS: Thirty-two studies included 1865 patients (2441 hips). Twenty-one studies (1301 hips) using Ficat staging standard, 7 studies (338hips) using Association Research Circulation Osseous (ARCO) staging standard, and University of Pennsylvania system for staging avascular necrosis (UPSS) staging criteria for 4 studies (802 hips). All the studies recorded the treatment, 22 studies (1379 hips) were treated with core decompression (CD) alone, and 7 studies (565 hips) were treated with core decompression combined with autologous bone (CD Autologous bone). Nine subjects (497 hips) were treated with core decompression combined with autologous bone marrow (CD Marrow). Twenty-seven studies (2120 hips) documented the number of conversion to total hip replacement (THA), and 26 studies (1752hips) documented the number of radiographic progression (RP). Twenty-one studies recorded the types of complications and the number of cases, a total of 69 cases. The random-effect model was used for meta-analysis, and the results showed that the overall success rate was 65%. The rate of success showed significant difference on the outcomes of different stages. The rate of success, conversion to THA, and radiographic progression showed significant difference on the outcomes of ONFH using different treatments. CONCLUSIONS: Core decompression is an effective and safe method of treating ONFH. The combined use of autologous bone or bone marrow can increase the success rate. For advanced femoral head necrosis, the use of CD should be cautious. High-quality randomized controlled trials and prospective studies will be necessary to clarify the effects of different etiology factors, treatments, and postoperative rehabilitation. Until then, the surgeon can choose core decompression to treat ONFH depending on the patient's condition. LEVEL OF EVIDENCE: I Meta-analysis.


Assuntos
Descompressão Cirúrgica/métodos , Necrose da Cabeça do Fêmur/cirurgia , Transplante de Medula Óssea , Transplante Ósseo , Terapia Combinada , Descompressão Cirúrgica/efeitos adversos , Cabeça do Fêmur/cirurgia , Humanos , Complicações Pós-Operatórias , Resultado do Tratamento
15.
World Neurosurg ; 132: e732-e738, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31415897

RESUMO

OBJECTIVE: Cauda equina syndrome (CES) is a potentially devastating spinal condition requiring prompt diagnosis and intervention. This study examines the relationship between timing of surgery and patient outcomes such as mortality and total complications, and longitudinal trends in timing of operative treatment over the years 2000-2014. METHODS: This study considered patients in the Healthcare Cost and Utilization Project National Inpatient Sample Database between 2000 and 2014 who had both an International Classification of Disease, Ninth Edition, Clinical Modification code for CES (344.61) and an International Classification of Disease, Ninth Edition, Clinical Modification procedure code for either disc excision (8051) or spinal canal exploration and decompression (0309) in their inpatient record. Patients were separated into an early surgical intervention cohort versus a delayed intervention cohort, and associated outcomes were analyzed using linear regression. Trends in timing of surgery were examined for the years 2000-2014, and linear regression was used to assess degree of change over time. RESULTS: In total, 20,924 patients with CES met inclusion criteria. Following adjustment for demographic variables, the delayed-intervention group was associated with statistically significant increased inpatient mortality (odds ratio [OR] 9.60, P = 0.002), total complications (OR 1.41, P = 0.018), and non-routine discharge (OR 2.37, P < 0.0001). The proportion of patients receiving early intervention within 48 hours remained unchanged from 2000 to 2014 ranging from 80.2% (2000-2002) to 76.2% (2012-2014) (P = 0.190). CONCLUSIONS: This study represents the largest investigation to date examining CES and reveals the timing of surgical management for CES has not changed appreciably from 2000 to 2014 despite mounting evidence for early decompression. Patients receiving decompression within 0 or 1 day after admission are associated with improved inpatient outcomes, including lower complication and mortality rates.


Assuntos
Síndrome da Cauda Equina/cirurgia , Descompressão Cirúrgica/métodos , Procedimentos Neurocirúrgicos/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Síndrome da Cauda Equina/mortalidade , Criança , Pré-Escolar , Estudos de Coortes , Bases de Dados Factuais , Descompressão Cirúrgica/efeitos adversos , Feminino , Mortalidade Hospitalar , Humanos , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Tempo para o Tratamento , Resultado do Tratamento , Adulto Jovem
16.
World Neurosurg ; 132: e463-e471, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31470148

RESUMO

BACKGROUND: Despite improved medical management, the incidence of spinal pathology remains high in patients with Parkinson disease (PD). Several studies have investigated lumbar spine surgery in this population, but data regarding costs and perioperative complications for patients undergoing cervical decompression/fusion on a nationwide scale are lacking. METHODS: Cases of cervical spinal decompression, fusion, or exploration in years 2008-2014 were collected via the Healthcare Cost and Utilization Project National Inpatient Sample. Demographics, complications, outcome, and total charges were compared in patients with and without PD (NPD). Confounding variables were identified for multivariate analysis. RESULTS: Data were available for 195,341 cervical spine cases, of which PD was prevalent in 779 cases (0.4%). Cases with PD experienced greater overall complication rates (12.5 vs. 7.6%; P < 0.001). Multivariate analysis revealed longer lengths of stay for the PD cohort (mean = 1.21 days longer; P < 0.001) and decreased routine discharge (odds ratio = 0.308; P < 0.001). There was no significant difference in mean total charges between PD and NPD (-$1532; P = 0.337). Mortality rates did not significantly differ for either group. CONCLUSIONS: Although patients with PD experience greater complication rates and non-home discharges following cervical spine surgery compared with NPD patients, the overall clinical impact of these results may be minimal relative to surgery at other spinal levels in this population.


Assuntos
Vértebras Cervicais/cirurgia , Descompressão Cirúrgica/efeitos adversos , Doença de Parkinson , Complicações Pós-Operatórias/epidemiologia , Fusão Vertebral/efeitos adversos , Idoso , Feminino , Humanos , Incidência , Pacientes Internados , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Doença de Parkinson/complicações , Estudos Retrospectivos , Doenças da Coluna Vertebral/complicações , Doenças da Coluna Vertebral/cirurgia
17.
World Neurosurg ; 132: 197-201, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31450001

RESUMO

BACKGROUND: Gunshot wounds are the most common etiology of penetrating spine injuries and have been increasing in incidence in civilian populations. Although these injuries typically result in severe neurologic deficits, operative intervention remains is controversial and is usually reserved for patients with neurologic deterioration, a persistent externalized cerebrospinal fluid fistula, mechanical instability, metallic toxicity, or a bullet location at high risk of migration. CASE DESCRIPTION: A previously asymptomatic patient who had sustained a gunshot wound to the cervical spine 20 years previously presented with new-onset progressive myelopathy and radiculopathy secondary to heterotopic ossification (HO) surrounding the retained bullet fragments near the left lateral masses of C5-T1. Computed tomography myelography demonstrated no cranial migration of contrast material past this region of the spine, suggesting severe spinal canal stenosis. Intraoperatively, bullet shrapnel and heterotopic bone fragments were found within the central canal causing compression of the spinal cord. Following decompression and stabilization, the patient had complete resolution of his symptoms and returned to his neurologic baseline. Although HO has been reported as a complication following through and through gunshot wounds, there is a paucity of literature discussing HO formation around retained bullet fragments in the spine. CONCLUSIONS: HO surrounding retained bullet fragments in the spine is a rare cause of progressive neurologic deterioration following gunshot wounds. Surgical excision of the shrapnel and heterotopic bone can lead to symptomatic relief, and therefore surgery should be considered as a treatment option in carefully selected patients.


Assuntos
Vértebras Cervicais/diagnóstico por imagem , Vértebras Cervicais/lesões , Ossificação Heterotópica/diagnóstico por imagem , Ossificação Heterotópica/cirurgia , Traumatismos da Medula Espinal/diagnóstico por imagem , Traumatismos da Medula Espinal/cirurgia , Ferimentos por Arma de Fogo/diagnóstico por imagem , Ferimentos por Arma de Fogo/cirurgia , Adulto , Vértebras Cervicais/cirurgia , Descompressão Cirúrgica/efeitos adversos , Humanos , Laminectomia , Masculino , Procedimentos Neurocirúrgicos/métodos , Radiculopatia/etiologia , Tomografia Computadorizada por Raios X , Resultado do Tratamento
18.
Khirurgiia (Mosk) ; (6): 94-100, 2019.
Artigo em Russo | MEDLINE | ID: mdl-31317947

RESUMO

Carpal tunnel syndrome (CTS) requires special attention due to its different reasons and course. Knowledge about the variability of median nerve (MN) topography in carpal canal region, features of diagnosis and treatment extends outlooks on this pathology. Aggregating rare clinical cases from the Medline and Pubmed databases is useful to form personified approach. There are 3 types of topographic variations which should be considered to prevent false-positive diagnosis of pathology: recurrent branch location, early bi- and trifurcations of MN, anastomoses. Since acute CTS is treated only by surgery, every surgical approach is aimed at minimally invasiveness and fast recovery. Endoscopic decompression (ED) is more favorable regarding these aspects. However, this method cannot be considered as perfect due to available data about incomplete decompression and certain incidence of recurrences. The last ones are absent after microsurgical decompression as a rule. It can be concluded that only individual approach is advisable for complete release of CTS without iatrogenic damage and recurrences.


Assuntos
Síndrome do Túnel Carpal/diagnóstico , Síndrome do Túnel Carpal/cirurgia , Nervo Mediano/cirurgia , Procedimentos Neurocirúrgicos/métodos , Doença Aguda , Síndrome do Túnel Carpal/etiologia , Descompressão Cirúrgica/efeitos adversos , Descompressão Cirúrgica/métodos , Humanos , Doença Iatrogênica/prevenção & controle , Nervo Mediano/anatomia & histologia , Nervo Mediano/patologia , Microcirurgia , Procedimentos Cirúrgicos Minimamente Invasivos , Procedimentos Neurocirúrgicos/efeitos adversos , Recidiva
19.
Surg Technol Int ; 35: 441-446, 2019 11 10.
Artigo em Inglês | MEDLINE | ID: mdl-31282983

RESUMO

To clarify outcomes and develop a novel classification according to CSF fistula in a selective cohort with intraoperative spinal dural tear, we examined 72 consecutive patients who underwent spinal dural repair after microdiscectomy (n=42) or lumbar spinal decompression (n=30). Group 1 consisted of 25 patients with Type I (mild) dural tear who were treated with either tissue-glue-coated collagen sponge or fibrin glue. Group 2 consisted of 26 patients with Type II (moderate) dural tear who were treated with both tissue-glue-coated collagen sponge and fibrin glue. Group 3 consisted of 21 patients with Type III (severe) dural tear who were treated with polypropylene suture along with tissue-glue-coated collagen sponge and/or fibrin glue. Evident postoperative internal or external CSF leak was used to determine the patient's postoperative result. Postoperative internal or external CSF leak was not evident during a minimum 1-year follow-up in Group 1. In contrast, internal CSF leak was evident in both Groups 2 (n=3) and 3 (n=3) during the same follow-up. No external CSF leak was noted in any of the patients. Three patients underwent re-do spinal surgery for CSF leak repair. Patients in all groups satisfactorily avoided CSF leak. According to the intraoperative findings of a distinct dural tear, patients can be treated adequately with a specific surgical technique.


Assuntos
Dura-Máter/lesões , Fístula/cirurgia , Procedimentos Neurocirúrgicos/métodos , Coluna Vertebral/cirurgia , Traumatismos do Sistema Nervoso/classificação , Traumatismos do Sistema Nervoso/cirurgia , Descompressão Cirúrgica/efeitos adversos , Discotomia/efeitos adversos , Dura-Máter/cirurgia , Fístula/etiologia , Humanos , Análise de Intenção de Tratamento , Adesivos Teciduais/uso terapêutico , Traumatismos do Sistema Nervoso/etiologia
20.
Spine (Phila Pa 1976) ; 44(19): 1371-1380, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31261267

RESUMO

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: The aim of this study was to examine variation in spine surgery utilization between the province of Ontario and state of New York among all patients and pre-specified patient subgroups. SUMMARY OF BACKGROUND DATA: Spine surgery is common and costly. Within-country variation in utilization is well studied, but there has been little exploration of variation in spine surgery utilization between countries. METHODS: We used population-level administrative data from Ontario (years 2011-2015) and New York (2011-2014) to identify all adults who underwent inpatient spinal decompression or fusion surgery using relevant procedure codes. Patients were stratified according to age and surgical urgency (elective vs. emergent). We calculated standardized utilization rates (procedures per-10,000 population per year) for each jurisdiction. We compared Ontario and New York with respect to patient demographics and the percentage of hospitals performing spine surgery. We compared utilization rates of spinal decompression and fusion surgery in Ontario and New York among all patients and after stratifying by surgical urgency and patient age. RESULTS: Patients in Ontario were older than patients in New York for both decompression (mean age 58.8 vs. 51.3 years; P < 0.001) and fusion (58.1 vs. 54.9; P < 0.001). A smaller percentage of hospitals in Ontario than New York performed decompression (26.1% vs. 54.9%; P < 0.001) or fusion (15.2% vs. 56.7%; P < 0.001). Overall, utilization of spine surgery (decompression plus fusion) in Ontario was 6.6 procedures per-10,000 population per-year and in New York was 16.5 per-10,000 per-year (P < 0.001). Ontario-New York differences in utilization were smaller for emergent cases (2.0 per 10,000 in Ontario vs. 2.5 in New York; P < 0.001), but larger for elective cases (4.6 vs. 13.9; P < 0.001). The lower utilization in Ontario was particularly large among younger patients (age <60 years). CONCLUSION: We found significantly lower utilization of spine surgery in Ontario than in New York. These differences should inform policy reforms in both jurisdictions. LEVEL OF EVIDENCE: 3.


Assuntos
Descompressão Cirúrgica , Fusão Vertebral , Coluna Vertebral/cirurgia , Adulto , Descompressão Cirúrgica/efeitos adversos , Descompressão Cirúrgica/estatística & dados numéricos , Humanos , Pessoa de Meia-Idade , New York/epidemiologia , Ontário/epidemiologia , Estudos Retrospectivos , Fusão Vertebral/efeitos adversos , Fusão Vertebral/estatística & dados numéricos
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