ObjectiveThe objectives of the present study were to characterize the natural course of initially non-operated traumatic acute subdural hematoma (ASDH) and to identify the risk factors of hematoma progression.MethodsRetrospective analysis was performed using sequential computed tomography (CT) images maintained in a prospective observational database containing 177 ASDH cases treated from 2005 to 2011. Patients were allocated to four groups as followings; 136 (76.8%) patients to the spontaneous resolution group, 12 (6.8%) who underwent operation between 4 hours and 7 days to the rapid worsening group (RWG), 24 (13.6%) who experienced an increase of hematoma and that underwent operation between 7 and 28 days to the subacute worsening group (SWG), and 5 (2.8%) who developed delayed aggravation requiring surgery from one month after onset to the delayed worsening group (DWG). Groups were compared with respect to various factors.ResultsNo significant intergroup difference was found with respect to age, mechanism of injury, or initial Glasgow Coma Scale. The presence of combined cerebral contusion or subarachnoid hemorrhage was found to be a significant prognostic factor. Regarding CT findings, mixed density was common in the RWG and the SWG. Midline shifting, hematoma thickness, and numbers of CT slices containing hematoma were significant prognostic factors of the RWG and the SWG. Brain atrophy was more severe in the SWG and the DWG.ConclusionA large proportion of initially non-operated ASDHs worsen in the acute or subacute phase. Patients with risk factors should be monitored carefully for progression by repeat CT imaging.
To evaluate the learning curve of percutaneous endoscopic transforaminal lumbar discectomy (PETLD) from the novice stage to the proficient stage, we performed retrospective study for patients with lumbar disc herniation who underwent PETLD performed by a single surgeon and evaluated the surgeon's learning curve and the effect of surgical proficiency on outcomes. A total of 48 patients who underwent PETLD at the lower lumbar level (L3–S1) with a minimum 1-year follow-up were enrolled. The learning curve of the surgeon was assessed using cumulative study of operation time and linear regression analyses to reveal the correlation between operation time and case series number. Because the cutoff of familiarity was 25 cases according to the cumulative study of operation time, the patients were allocated into two groups: early group (n = 25) and late group (n = 23). The clinical, surgical, and radiological outcomes were retrospectively evaluated and compared between the two groups. According to linear regression analyses, the operation time was obtained using the following formula: operation time (minutes) = 69.925–(0.503 × [case number]) ( P < .001). As expected, the operation time was significantly different between the two groups (mean 66.00 ± 11.37 min in the early group vs 50.43 ± 7.52 min in the late group, P < .001). No differences were found between the two groups in demographic data and baseline characteristics. Almost all clinical outcomes (including pain improvement and patient satisfaction), surgical outcomes (including failure, recurrence, and additional procedure rates), and radiological outcomes (including change of disc height and sagittal angles) did not differ between the two groups. However, the late group demonstrated a more favorable postoperative volume index of the remnant disc (362.91 mm 3 [95% confidence interval, 272.81–453.02] in the early group vs 161.14 mm 3 [95% confidence interval, 124.31–197.97] in the late group, P < .001), and a lower complication rate related to exiting nerve root (16.0% in the early group vs 0% in the late group, P = .045). The learning curve of PETLD is not as difficult as that of other minimally invasive spine surgery technique. Although the overall outcomes were not different between the groups, the risks of incomplete decompression and exiting root injury-related complication were higher in the novice stage.
ObjectiveWe evaluated the effect of intrawound application of vancomycin powder for infection prophylaxis in wounds caused by instrumented spinal surgery.MethodsFrom July 2012 to December 2012, 74 instrumented spinal fusion procedures were performed by 1 neurosurgeon at a single institute. We divided the patients into 2 groups, depending on the use of local application of vancomycin powder: Group A (intrawound application of vancomycin powder with perioperative intravenous cefazolin) and Group B (perioperative intravenous cefazolin alone). A retrospective cohort comparative study was conducted between the 2 groups. The age, sex, comorbidities, smoking, surgical procedure, and surgical site infection (SSI) of consecutive patients were analyzed.ResultsAmong the 74 patients, 34 patients were assigned to group A and 40 patients to group B. No wound infections were found in group A. However, in group B, 5 cases of SSI (12.5%) were found. A statistically significant reduction in SSI incidence was observed in group A (p<0.033). The 5 cases of SSI in group B consisted of 3 cases of deep wound infection and 2 cases of superficial wound infection. All SSIs were found in cases of posterior approach surgery and tended to be more frequent in older patients.ConclusionAdjunctive intrawound local application of vancomycin powder is a simple uncomplicated procedure and can result in a significant reduction of SSI in instrumented spinal fusions. Furthermore, culture of the drainage tip is very important for confirmation of deep wound infection.
A Solitary Fibrous Tumor (Sft) Is A Rare Neoplasm Originated From The Pleura, But They Can Occur In A Variety Of Extrathoracic Regions. Although Many Cases Of Primary Sft Have Been Reported, There Are Extremely Rare Repots To Date Of A Malignant Sft In The Spine Or Skull. A 54-year-woman Visited Our Hospital Due To Low Back Pain And Both Leg Radiating Pain. Several Imaging Studies Including Magnetic Resonance Imaging And Computed Tomography Revealed Expansive Enhanced Lesions In The Occipital Bone, T8, S1-2, And Ilium, With Neural Tissue Compression. We Performed Surgical Resection Of The Tumor In Each Site, And Postoperative Radiosurgery And Chemotherapy Were Performed. However, After Six Months, Tumors Were Recurred And Metastasized In Multiple Regions Including Whole Spine And Lung. The Authors Report Here The First Case Of Patient With Malignant Sft Of Tandem Lesions In The Various Bony Structures, Including Skull, Thoracic Spine, And Sacral Spine, With A Rapid Recurrence And Metastasis. Although Malignant Sft Is Extremely Rare, It Should Be Considered In The Differential Diagnosis And Carful Follow-up Is Needed.
Background: Transforaminal endoscopic lumbar discectomy (TELD) is regarded as an effective treatment option for soft lumbar disc herniation (LDH). There have been few studies evaluating the long-term outcomes of endoscopic procedures compared with conventional surgery. Objectives: The objective of this study was to demonstrate the clinical outcomes of TELD compared with those of open lumbar microdiscectomy. Study Design: Between January 2009 and September 2011, 335 consecutive patients with symptomatic LDH were treated with decompressive discectomy, either TELD or open microdiscectomy. Patients were prospectively entered into the clinical database and their records were retrospectively reviewed. Setting: Hospital and outpatient surgical center. Methods: Data from 298 patients who were treated with decompressive discectomy, either TELD or open microdiscectomy, were evaluated with a minimum 5-year follow-up period. Among them, 146 patients were treated using TELD (TELD group), and the remaining 152 patients using open microdiscectomy (Open group). Perioperative data and clinical outcomes were evaluated using the visual analog scale (VAS), the Oswestry Disability Index (ODI), and the modified Macnab criteria. Results: The VAS and ODI significantly improved in both groups. The rate of excellent or good outcomes was 88.36% and 87.5% in the TELD and Open group, respectively. The reoperation rate was 4.2% and 3.3% in the TELD and Open group, respectively. There were no significant differences in the clinical outcomes; however, operative time, hospital stay, and time to return to work were significantly shorter in the TELD group (P < 0.01). Limitations: First, the patient selection was not randomized; therefore, the risk of bias might be increased. Second, this study lacks analysis of the radiographic changes related to the degenerative change over the long-term follow-up period. Conclusions: The long-term results of TELD for soft LDH are comparable to those of conventional open microdiscectomy. The selective endoscopic discectomy technique under local anesthesia provides the typical advantages of minimally invasive procedures such as a shorter operation time, hospital stay, and recovery time. Key words: Endoscopic, discectomy, hospital stay, lumbar disc, microscopic, operative time, return to work, transforaminal
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