Neurochirurgie
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The sitting position for pineal tumour removal remains controversial as regards the number of potential complications despite good surgical conditions. ⋯ In training teams, the sitting position remains the gold standard for pineal tumour removal.
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Review Meta Analysis
From "mechanical" to "neuropathic" back pain concept in FBSS patients. A systematic review based on factors leading to the chronification of pain (part C).
Beyond initial lesions, any form of spinal (re)operation can cause direct potential aggression to the nervous system by contact with neural tissue or by imprinting a morphological change on the neural tissue. The potential consequences of nerve root injury affect both peripheral and axial dermatomal distribution. The hypothesis of a possible neuropathic aspect associated with the back pain component of failed back surgery syndrome (FBSS) therefore appears to be reasonable. Its pathophysiology remains unclear due to the permanent interplay between nociceptive and neuropathic pain components, resulting in the coexistence of physiological and pathological pain at the same anatomical site. This paper is designed to extensively review the fundamental mechanisms leading to chronification of pain and to suggest considering the emerging concept of "neuropathic back pain". ⋯ A clear understanding of the factors leading to the chronification of back pain should help us to move to the choice of mechanism related pain treatments to improve outcomes in FBSS chronic condition.
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The solution to the failed back syndrome will come from the surgeon who masters the technology, the pathology and the surgery and who understands the patient. The back is normally dynamic and the failed back is no longer dynamic. ⋯ Welfare systems that promote disability may undermine successful therapy. Solutions to great problems usually come from men who are passionate, observing and skilful.
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Failed back surgery syndrome (FBSS) is defined as persistent pain more than 3 months after any form of spinal surgery. Due to its multifactorial origin, FBSS is often difficult to treat. In this context of failed back surgery, a very thorough assessment must be conducted concerning the site and characteristics of the pain (nociceptive or neuropathic), its mode of onset (presence or absence of pain-free intervals), and its impact on the patient's work and social life. ⋯ The treatment of failed back surgery syndrome with a predominant neuropathic component is based on the use of analgesics, especially antiepileptics, antidepressants or transcutaneous electrical stimulation. Epidural spinal infiltration should be considered as second-line treatment in view of the risk of serious neurological complications. Management must be based on a global, multidisciplinary approach with identification of any cognitive or behavioural disorders in combination with an appropriate functional rehabilitation programme.
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In the context of failed back surgery syndrome (FBSS) treatment, the current practice in neurostimulation varies from center-to-center and most clinical decisions are based on an individual diagnosis. Neurostimulation evaluation tools and pain relief assessment are of major concern, as they now constitute one of the main biases of clinical trials. Moreover, the proliferation of technological devices, in a fertile and unsatisfied market, fosters and only furthers the confusion. There are three options available to apply scientific debates to our daily neurostimulation practice: intentional ignorance, standardized evidence-based practice or alternative data mining approach. ⋯ By creating an international prospective database, the purpose of the PROBACK project was to set up a process of extraction and comparative analysis of data derived from the selection, implantation and follow-up of FBSS patients candidates for implanted neurostimulation. This evaluation strategy should help to change the opinions of each implanter and each health system towards a more rational decision-making approach subtended by mathematical reality.