In degenerative disease of the lumbar spine a high pelvic incidence with diminished lumbar lordosis seems to predispose to adjacent segment disease. Patients with such pelvic incidence-lumbar lordosis mismatch exhibit a 10-times higher risk for undergoing revision surgery than controls if sagittal malalignment is maintained after lumbar fusion surgery.
One hundred and one consecutive adolescent scoliosis patients instrumented from the posterior between 1995 and 2002, with a minimum follow-up of 24 months (maximum 106 months), were reviewed for incidence of infection. Stainless steel implants with pedicle screws were used in the thoracic and lumbar spine of all patients. All were operated on by a single surgeon. There were no early infections. Incidence of late infection was 6.9% (seven patients). Clinical indicators for infection were the sudden onset of local pain and swelling without fever after an initial pain-free interval. There were no reliable laboratory parameters. Normal CRP and ESR did not rule out a late infection. Extended cultures were done from intraoperative swabs. Propionibacterium acnes was found in six patients. There were no other organisms identified. No causative organism could be identified in one patient, despite extended cultures. All patients were successfully treated with implant removal and antibiotic therapy for 4-9 weeks. No pseudarthrosis was seen on implant removal. Despite bony fusion, loss of correction between 10 degrees and 26 degrees was observed in three patients after implant removal.
Both methods provide efficient postoperative analgesia. However, double epidural catheter technique provides better postoperative analgesia, earlier recovery of bowel function, fewer side effects, and a higher patient satisfaction.
Five cases of presumed nicotine withdrawal delirium among brain-injured patients treated in a neurologic intensive care unit are presented. Each patient had a history of heavy tobacco use and experienced dramatic and sustained clinical improvement within hours of transdermal nicotine replacement. These preliminary observations suggest that nicotine withdrawal may be an under-recognized cause of delirium in patients with acute brain injury.
BackgroundLumbar spinal stenosis is the most frequent reason for spinal surgery in elderly people. For patients with moderate or severe symptoms different conservative and surgical treatment modalities are recommended, but knowledge about the effectiveness, in particular of the conservative treatments, is scarce. There is some evidence that surgery improves outcome in about two thirds of the patients. The aims of this study are to derive and validate a prognostic prediction aid to estimate the probability of clinically relevant improvement after surgery and to gain more knowledge about the future course of patients treated by conservative treatment modalities.Methods/DesignThis is a prospective, multi-centre cohort study within four hospitals of Zurich, Switzerland. We will enroll patients with neurogenic claudication and lumbar spinal stenosis verified by Computer Tomography or Magnetic Resonance Imaging. Participating in the study will have no influence on treatment modality. Clinical data, including relevant prognostic data, will be collected at baseline and the Swiss Spinal Stenosis Questionnaire will be used to quantify severity of symptoms, physical function characteristics, and patient's satisfaction after treatment (primary outcome). Data on outcome will be collected 6 weeks, and 6, 12, 24 and 36 months after inclusion in the study. Applying multivariable statistical methods, a prediction rule to estimate the course after surgery will be derived.DiscussionThe ultimate goal of the study is to facilitate optimal, knowledge based and individualized treatment recommendations for patients with symptomatic lumbar spinal stenosis.
Perioperative oral controlled-release oxycodone reduces postoperative IV morphine consumption after lumbar discectomy while providing good analgesia with fewer side effects compared with placebo.
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