The spine journal : official journal of the North American Spine Society
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Comparative Study Observational Study
Patterns of lumbar disc degeneration are different in degenerative disc disease and disc prolapse magnetic resonance imaging analysis of 224 patients.
Existing research on lumbar disc degeneration has remained inconclusive regarding its etiology, pathogenesis, symptomatology, prevention, and management. Degenerative disc disease (DDD) and disc prolapse (DP) are common diseases affecting the lumbar discs. Although they manifest clinically differently, existing studies on disc degeneration have included patients with both these features, leading to wide variations in observations. The possible relationship or disaffect between DDD and DP is not fully evaluated. ⋯ The results suggest that patients with disc prolapse, and those with back pain with DDD are clinically and radiologically different groups of patients with varying patterns, severity, and extent of disc degeneration. This is the first study in literature to compare and identify significant differences in these two commonly encountered patient groups. In patients with single-level DP, the majority of the other discs are nondegenerate, the lower lumbar spine is predominantly involved and the end-plate damage is higher. Patients with back pain and DDD have larger number of degenerate discs, early multilevel degeneration, and predominant upper lumbar degeneration. The knowledge that these two groups of patients are different clinically and radiologically is critical for our improved understanding of the disease and for future studies on disc degeneration and disc prolapse.
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Comparative Study
Lumbar surgery in work-related chronic low back pain: can a continuum of care enhance outcomes?
Systematic reviews of lumbar fusion outcomes in purely workers' compensation (WC) patient populations have indicated mixed results for efficacy. Recent studies on lumbar fusions in the WC setting have reported return-to-work rates of 26% to 36%, reoperation rates of 22% to 27%, and high rates of persistent opioid use 2 years after surgery. Other types of lumbar surgery in WC populations are also acknowledged to have poorer outcomes than in non-WC. The possibility of improving outcomes by employing a biopsychosocial model with a continuum of care, including postoperative functional restoration in this "at risk" population, has been suggested as a possible solution. ⋯ Lumbar surgery in the WC system (particularly lumbar fusion) have the potential achieve positive outcomes that are comparable to CDOLD patients treated nonoperatively. This study suggests that surgeons have the opportunity to improve lumbar surgery outcomes in the WC system, even for complex fusion CDOLD patients with multiple prior operations, if they control postoperative opioid dependence and prevent an excessive length of disability. Through early referral of patients (who fail to respond to usual postoperative care) to interdisciplinary rehabilitation, the surgeon determining this continuum of care may accelerate recovery and achieve socioeconomic outcomes of relevance to the patient and WC jurisdiction through the combination of surgery and postoperative rehabilitation.
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Review Case Reports
Presentation of cauda equina syndrome due to an intradural extramedullary abscess: a case report.
Cauda equina syndrome is caused by compression or injury to the nerve roots distal to the level of the spinal cord. This syndrome presents as low back pain, motor and sensory deficits in the lower extremities, and bladder as well as bowel dysfunction. Although various etiologies of cauda equina syndrome have been reported, a less common cause is infection. ⋯ Cauda equina syndrome, presenting as a result of spinal infection, such as the case reported here, is extremely rare but clinically important. Surgical intervention is generally the recommended therapeutic modality.
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Comparative Study
The medial cortical pedicle screw--a new technique for cervical pedicle screw placement with partial drilling of medial cortex.
Studies on cadavers have shown that the appropriate insertion of cervical pedicle screw (C3-C7) should be done from a more lateral point and at a steeper angle in the axial plane, than that described by Abumi et al., to decrease the chances of lateral perforation. ⋯ With the use of the technique by Abumi et al., more than half of the cervical pedicle screw perforations described are lateral. Use of a blunt pedicle probe usually directs the surgeon toward the lateral cortex as the medial cortex is thicker and stronger. With the new medial cortical pedicle screw technique described, lateral perforations were low. However, surgeons attempting this technique should be aware of the increase in medial perforations experienced by the authors with the new technique. The study gives an additional option of technique to be considered by surgeons already using CPS placements in selected patients. Further evaluation for reproducibility of the medial cortical pedicle screw technique by other surgeons and testing of biomechanical strength of the screws is required.
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Randomized Controlled Trial Multicenter Study
Predicting medical complications after spine surgery: a validated model using a prospective surgical registry.
The possibility and likelihood of a postoperative medical complication after spine surgery undoubtedly play a major role in the decision making of the surgeon and patient alike. Although prior study has determined relative risk and odds ratio values to quantify risk factors, these values may be difficult to translate to the patient during counseling of surgical options. Ideally, a model that predicts absolute risk of medical complication, rather than relative risk or odds ratio values, would greatly enhance the discussion of safety of spine surgery. To date, there is no risk stratification model that specifically predicts the risk of medical complication. ⋯ We present a validated model for predicting medical complications after spine surgery. The value in this model is that it gives the user an absolute percent likelihood of complication after spine surgery based on the patient's comorbidity profile and invasiveness of surgery. Patients are far more likely to understand an absolute percentage, rather than relative risk and confidence interval values. A model such as this is of paramount importance in counseling patients and enhancing the safety of spine surgery. In addition, a tool such as this can be of great use particularly as health care trends toward pay-for-performance, quality metrics, and risk adjustment. To facilitate the use of this model, we have created a website (SpineSage.com) where users can enter in patient data to determine likelihood of medical complications after spine surgery.