The Prospective Lumbar Discectomy Study enrolled 740 patients in a multiphysician, multicenter, consecutive patient protocol to evaluate the indications and efficacy of lumbar discectomy. Five hundred and thirteen patients could be evaluated at 3 months after surgery. Stepwise logistic regression showed that the factors of fraction of pain referred to the back, work-related injury, absence of back pain on straight leg-raise examination, correspondence of leg pain to typical radicular patterns, leg pain on straight leg-raise examination, and reflex asymmetry were independently predictive of good outcome from surgery. Univariate analysis of the cases with different numbers of predictive factors present showed that use of the operating microscope, sensory deficit, central disc bulge, and free disc fragment were correlated with outcome only in subgroups. An analysis of unsatisfactory outcomes showed two patterns: one of failure as a result of mechanical back pain and one of failure as a result of radiculopathy. Factors predictive of outcome did not influence the type of failure, In a stepwise logistic regression analysis, facetectomy and preoperative sensory deficit were associated with increased likelihood of mechanical back pain failure, while preoperative motor deficit was associated with an increased likelihood of radicular failure. The results support several intuitively derived and commonly believed principles of lumbar disc surgery.
We report two patients who underwent orbital exploration yielding the diagnosis of sclerosing orbital pseudotumor. The presenting symptoms were exophthalmos, visual loss, abnormal ocular mobility, and ocular pain. Computed tomographic (CT) scans showed masses in the orbital apex. Steroids were ineffective. Orbital pseudotumor is a heterogeneous diagnostic category of lymphoid infiltrations of the orbit with a wide spectrum of pathological conditions and intraorbital locations. The clinical presentation typically includes the sudden onset of pain, diplopia, lid edema, and exophthalmos. Visual loss is uncommon. Most cases resolve spontaneously or respond to steroid treatment. Although fibrosis may be a prominent histological finding, the literature contains little information concerning its significance. We discuss the evidence for considering the sclerosing pseudotumors to be a significant variant with unique clinical behavior. Although features suggestive of pseudotumor were present in our case, the presence of visual loss and an apical mass shown on the CT scan led to the presumptive diagnosis of tumor and exploratory operation. Neurosurgeons should be aware of this entity as a cause of visual loss and orbital mass. Proper suspicion may in some cases permit transorbital biopsy and avoid craniotomy, inasmuch as operation is of no therapeutic benefit in this disease.
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