Neurosurg Focus
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Historical Article
The "tract" of history in the treatment of lumbar degenerative disc disease.
In this paper past, present, and future treatments of degenerative disc disease (DDD) of the lumbar spine are outlined in a straight forward manner. This is done to review previous knowledge of the disease, define current treatment procedures, and discuss future perspectives. ⋯ In this paper, the authors attempt to outline the history of DDD of the lumbar spine in an unbiased and scientific fashion. Physiological, diagnostic, and therapeutic implications will all be addressed in this study.
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Historical Article
Evolution of the lateral extracavitary approach to the spine.
The development of alternative approaches to spine disorders marked an evolutionary change in the methods by which surgeons address diseases that affect the ventral portion of the spine. From the advent of spinal surgery until quite recently, physicians used posterior approaches almost exclusively for the treatment of all pathological processes. Surgeons subsequently became frustrated and disenchanted with outcomes of patients with anterior vertebral body disease when these procedures were applied. ⋯ In this paper, the authors chart the development of an influential approach to the spine that is designed to address these issues: the lateral extracavitary approach. They trace its origins to early precursor procedures and follow its use in current practice for the treatment of a variety of spinal disorders. They also examine its applications, role, and continued importance in the age of minimally invasive surgery.
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Comparative Study
Outcome of severe traumatic brain injury: comparison of three monitoring approaches.
The determination of cerebral perfusion pressure (CPP) is regarded as vital in monitoring patients with severe traumatic brain injury. Besides indicating the status of cerebral blood flow (CBF), it also reveals the status of intracranial pressure (ICP). The abnormal or suboptimal level of CPP is commonly correlated with high values of ICP and therefore with poor patient outcomes. ⋯ Only time between injury and arrival (p = 0.001) was statistically significant. There was a statistically significant difference in the proportions of good outcomes between the multimodality group compared with the group of patients that underwent a single intracranial-based monitoring method and the group that received no monitoring (p = 0.003) based on a disability rating scale after a follow up of 12 months. Death was the focus of outcome in this study in which the multimodality approach to monitoring had superior results.
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Review
What is the optimal threshold for cerebral perfusion pressure following traumatic brain injury?
Intensive care of the patient with traumatic brain injury centers on control of intracranial pressure and cerebral perfusion pressure (CPP). The optimal CPP by definition delivers an adequate supply of blood and oxygen to meet the metabolic demands of brain tissue. ⋯ No study that accurately assesses the efficacy of normal CPP compared with elevated CPP has been performed, but several studies demonstrate that a CPP threshold exists on an individual basis for patients with TBI. The use of brain monitors of cerebral metabolism and oxygen supply may assist the clinician in the selection of the optimal CPP for an individual patient.
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An intractable increase in intracranial pressure (ICP) leading to a progressive decrease in cerebral perfusion pressure (CPP) and cerebral blood flow (CBF) is the dominating cause of death in patients with severe brain trauma. Arterial hypotension may further compromise CPP (and CBF) and significantly contributes to death. In addition, the injured brain is sensitive to raised CPP due to an increased permeability of the blood-brain barrier (BBB) to crystalloids and an impaired pressure autoregulation of the CBF. ⋯ This level varies among different patients and different areas of the brain. In fact, the penumbral zones surrounding focal brain lesions appear to be the most sensitive. In the individual patient, preservation of normal cerebral energy metabolism within areas at risk during a decrease in CPP can be guaranteed by performing intracerebral microdialysis and bedside biochemical analyses.