The magnitude of the tissue damage from surgery impacts the trauma response. This response is proportional to the severity of surgical stress. Systemic cytokines are recognized as markers of postoperative tissue trauma. Microendoscopic discectomy (MED) recently has become popular for treating lumbar disc herniations, and is associated with favorable clinical outcomes compared with open discectomy (OD). This study postulates that MED is a less traumatic procedure, and therefore has a lower surgical stress response compared to OD. In this study, a quantitative comparison of the overall effects of surgical trauma resulting from MED and OD was performed through analyzing patient systemic cytokines response. From April, 2002 to June, 2003 consecutive patients who had symptomatic lumbar disc herniations were prospectively randomized to undergo either intracanalicular MED ( N = 10) or OD ( N = 12). In this study, the Vertebroscope System (Zeppelin, Pullach, Germany) was used to perform the endoscopic discectomy procedure in all MED patients. Serum levels of tumor necrosis factor-a (TNF-a), Interleukin-I 0 (IL-I 0). (IL-6), and Interleukin-8 (IL-8) were measured before surgery and at 1.2,4, 8 and 24h after surgery using an enzyme-linked immunosorbent assay. Serum C-reactive protein (CRP) was measured at the same time interval. The results showed the MED patients had shorter postoperative hospital stay (mean, 3.57 f 0.98 vs. 5.92 f 2.39 days, p = 0.025) and less intraoperative blood loss (mean, 87.5 f 69.4 vs. 190 f 115ml, p = 0.042). The operating length, including the set-up time, was longer in the MED group (mean, 109 f 35.9 vs. 72.1 f 17.8min, p = 0.01). The mean size of skin incision made for the MED patients was 1.86 f 0.13cm (range 1.7-2.0cm); and 6.3 f 0.98cm for the O D patients (range 5.5-8cm), p = 0.001. The patients' pain severity of the involved limbs on 10-point Visual Analog Scale before operation in MED group was 7.5 f 0.3 (range 6-9) and 8 f 0.2 (range 7-9) in OD group, p = 0.17; and after surgery, 1.5 f 0.2 (range 1-2) in MED group and 1.4 f 0.1 (range 1-3) in O D group, p = 0.9 1. CRP levels peaked at 24h in both groups, and OD patients displayed a significantly greater postoperative rise in serum CRP (mean, 27.78 & 15.02 vs.13.84 f 6.25mg/l, p = 0.026). Concentrations of TNF-a, IL-I 0, and IL-8 were detected only sporadically. Serum IL-6 increased less significantly following MED than after OD. In the MED group, IL-6 level peaked 8 h after surgery, with the response statistically less than in the open group (mean, 6.27 f 5.96 vs. 17.18 f 11.60pg/ml, p = 0.025). A statistically significant correlation was identified between IL-6 and CRP values ( r = 0.79). Using the modified MacNab criteria, the clinical outcomes were 90% satisfactory (9/10) in MED patients and 91.6% satisfactory (1 1/12) in O D patients at a mean 18.9 months (range 10-25) follow-up. Based on the current data, surgical trauma, as reflected by systemic IL-6 and CRP response, was significantly less following MED than following O...

The contact history of patients with a rapid onset of cellulitis can alert clinicians to a differential diagnosis of soft-tissue infection with Vibrio vulnificus (contact with seawater or raw seafood) or Aeromonas species (contact with fresh or brackish water, soil, or wood). Early fasciotomy and culture-directed antimicrobial therapy should be aggressively performed in those patients with hypotensive shock, leukopenia, severe hypoalbuminemia, and underlying chronic illness, especially a combination of hepatic dysfunction and diabetes mellitus.

BackgroundPseudomeningoceles are a rare complication after spinal surgery, and studies on these complex formations are few.MethodsBetween October 2000 and March 2008, 11 patients who developed symptomatic pseudomeningoceles after spinal surgery were recruited. In this retrospective study, we reported our experiences in the management of these complex, symptomatic pseudomeningoceles after spinal surgery. A giant pseudomeningocele was defined as a pseudomeningocele >8 cm in length. We also evaluated the risk factors for the formation of giant pseudomeningoceles.ResultsAll patients were treated successfully with a combined treatment protocol of open revision surgery for extirpation of the pseudomeningoceles, repair of dural tears, and implantation of a subarachnoid catheter for drainage. Surgery-related complications were not observed. Recurrence of pseudomeningocele was not observed for any patient at a mean follow-up of 16.5 months. This result was confirmed by magnetic resonance imaging.ConclusionsWe conclude that a combined treatment protocol involving open revision surgery for extirpation of pseudomeningoceles, repair of dural tears, and implantation of a subarachnoid catheter for drainage is safe and effective to treat giant pseudomeningoceles.

The MASS technique is safe and effective and has proved to be an excellent alternative in managing thoracic spine metastasis. Surgeons may use progressively smaller incisions (5-6 cm in length) for the procedure. The learning curve for performing MASS procedures was not steep.

Level III Prognostic study. See the Guidelines for Authors for complete descriptions of levels of evidence.

(a) Well-selected patients and attention to details are essential to optimizing surgical results. (b) A refined technique for less invasive tumor surgery has been developed. (c) Surgeons had better experience with the standard anterior spinal approach and showed no hesitation in converting to an open procedure when necessary. A procedure failure does not mean a treatment failure.

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