Neurosurgery clinics of North America
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Neurosurg. Clin. N. Am. · Apr 1992
ReviewInfections in neurologic surgery. The intraventricular use of antibiotics.
Intraventricular antibiotic therapy appears to be a useful treatment modality in those CSF infections in which systemic therapy may fail. Consideration should be given to using this form of treatment when infecting organisms are only sensitive to antibiotics with poor penetration of the CSF (e.g., aminoglycosides and vancomycin) and for cases in which intravenous therapy has failed to sterilize the CSF, toxicity from systemic therapy precludes further increases in dosages, and shunts or other CSF hardware might be expected to reduce the efficacy of systemic therapy by providing a foreign body to harbor organisms. Shunts or reservoirs that are infected may be successfully sterilized with IVT therapy alone or in conjunction with systemic therapy, but this has a lower success rate than cases in which the shunt is removed. ⋯ CNS fungal infections can be treated effectively with IVT amphotericin B but with a high risk of significant toxicity. Miconazole appears to be safer than amphotericin B but there is less clinical experience with this drug. Table 1 summarizes the dosages, indications, and toxicity of those antibiotics commonly used for intraventricular administration, which have been reported previously.
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Suppuration involving the epidural and subdural spaces is a rare occurrence in modern neurosurgical practice. Early diagnosis and appropriate treatment of infections of the dural spaces may avert the high incidence of neurologic disability and death traditionally associated with them, however. Prompt neurosurgical intervention in the treatment of these lesions has been the standard with which all other therapies have been compared.
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The failed back or postlaminectomy syndrome is obviously multidimensional. Failure of therapy may result from structural abnormalities in the back, psychosocial influences, or a combination of both. The causes of back pain are largely unknown. ⋯ New additions to this category can be reduced by rigorous attention to physical abnormalities, so that surgery is undertaken only for clear indications, and appreciation of the importance of the psychologic aspects of disability from low back pain. The smaller group suffering principally from physical abnormalities can be improved by reparative surgery or pain-relieving procedures if intensive conservative rehabilitation efforts fail. All surgical procedures fail occasionally, and as long as there is a need for reparative surgery, some patients will fail to benefit or be worsened by the procedures.(ABSTRACT TRUNCATED AT 400 WORDS)
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Because most people in the United States have occasional back pain, demand for the treatment of back pain is widespread. Yet, few treatments have proven to be more effective than placebo therapy. We examine patterns of treatment that have emerged in the absence of definitive treatment. ⋯ Average lengths of stay for surgical and nonsurgical low back pain hospitalizations decreased. We explore why, in the instance of low back pain surgery, change was resisted, whereas, in the instance of average lengths of stay, change was accepted. In view of why change may be resisted or accepted, we discuss interventions designed to change physicians' practice style.
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If return to work is part of the expected outcome, more and more data indicate that medical care alone does not hold the key to providing success. Our modern physical treatments may seem a humane alternative to no treatment, but they have not been proven to significantly alter the natural course of back problems. Even the results of strongly indicated surgical treatment differ little from doing nothing at all after a 4-year period. ⋯ This humane approach to care has evolved from common frustrations of dealing with patients with back problems, observations in the third world, and information gained from scientific studies. Medical pain, and physical models alone are unsuccessful. To be humane and successful, we can no longer ignore the nonphysical factors that can, and do, influence patients' responses to physical treatment, especially when return to work is part of the expected outcome.