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BACKGROUND: The Brain Trauma Foundation has developed treatment guidelines for the care of patients with acute traumatic brain injury. However, a method to provide broad acceptance and application of these guidelines has not been published. OBJECTIVE: To describe methods for the development, funding, and continued educational efforts of the Adam Williams Initiative; the experiences from the first 10 years may serve as a template for hospitals and nurses that seek to engage in long-term quality improvement collaborations with foundations and/or industry. METHODS: In 2004, the nonprofit Adam Williams Initiative was established with the goal of providing education and resources that would encourage hospitals across the United States to incorporate the Brain Trauma Foundation's guidelines into practice. RESULTS: Between 2004 and 2014, 37 hospitals have been funded by the Adam Williams Initiative and have had staff members participate in an immersion experience at Mission Hospital (Mission Viejo, California) during which team members received both didactic and hands-on education in the care of traumatic brain injury. CONCLUSIONS: Carefully cultivated relationships and relentless teamwork have contributed to successful implementation of the Brain Trauma Foundation's guidelines in US hospitals.
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Lesiones Encefálicas/terapia , Relaciones Comunidad-Institución , Conducta Cooperativa , Fundaciones/organización & administración , Hospitales/normas , Mejoramiento de la Calidad , Algoritmos , Lesiones Encefálicas/mortalidad , California , Fundaciones/economía , Adhesión a Directriz , Humanos , Guías de Práctica Clínica como Asunto , Resultado del TratamientoRESUMEN
OBJECTIVE: Minimally invasive surgery has seen increasing application in the treatment of spinal disorders. Treatment of degenerative spinal stenosis, with or without spondylolisthesis, with minimally invasive technique preserves stabilizing ligaments, bone, and muscle. Satisfactory results can be achieved without the need for fusion in most cases. METHODS: Fifty-four consecutive patients underwent bilateral decompressions from a unilateral approach for spinal stenosis using METRx instrumentation. Visual Analog Scale (VAS) pain scores were recorded preoperatively and patients were interviewed, in person or by phone, by our office nurse practitioner (LD) to assess postoperative VAS scores, and patient satisfaction with the clinical results 21-39 months postoperatively (median 27 months). RESULTS: Fifty-four patients underwent decompression at 77 levels (L4/5 = 43, L3/4 = 22, L5/S1 = 8, L1/2 = 4, L2/3 = 4), (single = 35, double = 16, triple = 2, quadruple = 1). There were 39 females and 15 males. The average age was 67 years. The average operative time was 78 minutes and the average blood loss was 37 ml per level. Twenty-seven patients had preoperative degenerative spondylolisthesis (Grade 1 = 26, Grade 2 = 1). Eight patients had discectomies and four had synovial cysts. Patient satisfaction was high. Use of pain medication for leg and back pain was low, and VAS scores improved by more than half. There were three dural tears. There were no deaths or infections. One patient with an unrecognized dural tear required re-exploration for repair of a pseudomeningocele and one patient required a lumbar fusion for pain associated with progression of her spondylolisthesis. CONCLUSIONS: Minimally invasive bilateral decompression of acquired spinal stenosis from a unilateral approach can be successfully accomplished with reasonable operative times, minimal blood loss, and acceptable morbidity. Two-year outcomes in this series revealed high patient satisfaction and only one patient progressed to lumbar fusion.
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To describe a new posterior minimally invasive method of facet stabilization for treatment of the degenerating lumbar motion segment. The biomechanics of this Percudyn (Interventional Spine; Irvine, CA) system are distinct from that of other interspinous dynamic stabilization systems as it acts bilaterally directly within the middle column of the spine. Based on biomechanical evalution, the paired prosthesis supports, cushions, and reinforces the facet complexes by limiting both extension and lateral bending thereby maintaining central and foraminal volumes. METHODS: the Percudyn device consists of a pedicle anchor upon which sits a cushioning polycarbonate-urethane stabilizer that serves as a mechanically reinforcing stop between the inferior and superior articular facets. A 1.5 cm skin incision is made bilaterally over the lower pedicle of the treated segment through which a Jamshidi needle is percutaneously targeted under biplanar fluoroscopic guidance into the caudal aspect of the superior articular process directly underneath the lip of the inferior facet from the level above. Progressive onestep tubular dilation is then performed to secure a small disposable working portal. Through this access, the Percudyn stabilizers are then placed over the wire and anchored bilaterally into the inferior pedicles of the degenerated motion segment. RESULTS: three patients (ages 26-41, male) with significant low back pain as well as radiculopathy with lateral recess stenosis from a large disc herniation/ ligamentum and facet hypertrophy (L4-5 and/or L5-S1) underwent a minimally invasive decompression/ discectomy and bilateral Percudyn placement at each disease level. Each patient had significant relief of both his radiculopathy and axial back pain post-operatively and was discharged home within 18 hours without sequelae. CONCLUSION: this novel technique of percutaneous posterior facet augmentation allows for safe placement of bilateral...
Descrever um método de estabilização facetária posterior minimamente invasivo para tratamento de segmento móvel degenerativo. A biomecânica do sistema Percudyn (Interventional Spine, Irvine, Califórnia) é distinta de outros sistemas de estabilização dinâmica inter-espinhosa, pois este atua direta e bilateralmente dentro da coluna média da coluna vertebral. Baseada em avaliações biomecânicas, a prótese dupla dá suporte, atua como amortecedor e reforça os complexos facetários limitando a extensão e a inclinação lateral, mantendo assim os volumes centrais e foraminais. MÉTODOS: o sistema Percudyn consiste de uma ancora pedicular sobre a qual está apoiado um estabilizador de plicarbonato-uretano que atua como um bloqueio mecanicamente reforçado entre as facetas inferiores e superiores. Uma incisão na pele de 1,5cm é feita bilateralmente sobre o pedículo inferior do segmento a ser tratado, por meio da qual é introduzida percutaneamente uma agulha de Jamshidi com auxílio de fluoroscopia biplanar em direção da porção caudal do processo articular superior, diretamente abaixo da borda da faceta inferior do nível superior. É feita uma dilatação tubular progressiva para assegurar um pequeno e temporário portal de trabalho. Por meio desse acesso, os estabilizadores Percudyn são colocados sobre o fio e ancorados bilateralmente nos pedículos inferiores de cada segmento móvel degenerativo. RESULTADOS: três pacientes (idade de 26 a 41 anos, sexo masculino) com lombalgia significativa, assim como radiculopatia e estenose do recesso lateral em consequência de um grande fragmento de disco herniado, ou hipertrofia ligamentar e facetária (L4-5 e/ou L5-S1) foram submetidos a uma descompressão/discectomia minimamente invasiva e implantação do Percudyn bilateralmente em cada segmento afetado. Todos os pacientes tiveram um alivio pós-operatório significante, tanto da radiculopatia como da dor axial lombar, e alta hospitalar até 18 horas sem sequelas...
Describir un método de estabilización facetárea posterior mínimamente invasiva para tratamiento del segmento móvil degenerativo. La biomecánica del sitema Percudyn (Interventional Spine, Irvine, California) es distinta de otros sistemas de estabilización dinámica interespinosa, pues ésta actúa directamente y bilateralmente dentro de la columna media de la columna vertebral. Con base en evaluaciones biomecánicas, la prótesis dupla da soporte, actúa como amortiguador y refuerza los complejos facetáreos limitando la extensión y la inclinación lateral, manteniendo así los volúmenes centrales y foraminales. MÉTODOS: el sistema Percudyn consiste de un áncora pedicular sobre la cual está apoyado un estabilizador de policarbonato-uretano, que actúa como un bloqueo mecánicamente reforzado entre las facetas inferiores y superiores. Una incisión en la piel de 1.5 cm es hecha bilateralmente sobre el pedículo inferior del segmento a ser tratado, a través del cual es introducida percutáneamente una aguja de Jamshidi con auxilio de fluoroscopia biplanar en dirección a la porción caudal del proceso articular superior, directamente abajo del borde de la faceta inferior del nivel superior. Es hecha una dilatación tubular progresiva para sujetar un pequeño y temporal portal de trabajo. A través de este acceso, los estabilizadores Percudyn son puestos sobre el hilo o alambre y ancorados bilateralmente en los pedículos inferiores de cada segmento móvil degenerativo. RESULTADOS: tres pacientes (edad de 26 a 41 años, sexo masculino) con lumbalgia significativa, así como radiculopatía y estenosis del receso lateral en consecuencia de un fragmento grande del disco herniado, o hipertrofia ligamentar y facetárea (L4-5 y/o L5-S1) fueron sometidos a una descompresión/ disectomía mínimamente invasiva e implantación del Percudyn bilateralmente en cada segmento afectado. Todos los pacientes tuvieron un alivio postoperatorio significativo tanto de la radiculopatía...
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Humanos , Fenómenos Biomecánicos , Dolor de la Región Lumbar , Procedimientos Ortopédicos , Radiculopatía , Procedimientos Quirúrgicos OperativosAsunto(s)
Lesiones Encefálicas/complicaciones , Lesiones Encefálicas/fisiopatología , Hipoxia Encefálica/diagnóstico , Monitoreo Fisiológico/métodos , Lesiones Encefálicas/terapia , Humanos , Hipoxia Encefálica/etiología , Hipoxia Encefálica/prevención & control , Presión Intracraneal/fisiología , Consumo de Oxígeno/fisiologíaRESUMEN
OBJECT: Biomechanical testing and fluoroscopic imaging were used to study an extension-limiting device that has been developed to support and cushion the facet complex. It is a titanium screw-based system with a polycarbonate-urethane bumper that lies against the inferior articular process and is anchored into the pedicle by the screw for posterior dynamic stabilization (PDS). METHODS: Six human cadaveric spines were dissected from L-2 to L-5, leaving all ligamentous structures intact. The intact spines were first tested in flexion and extension, lateral bending, and axial rotation at 67.5 Nm. The PDS devices were inserted at L3-4 and testing was repeated. Fluoroscopic analysis of posterior disc height and foraminal area of the intact and instrumented spines while loaded was performed. All test data were compared using a one-way analysis of variance (statistical significance was set at p < 0.05). Instrumented spines had 62% less motion during flexion and 49% less motion during extension compared with the intact spines. Neuroimaging analysis showed 84% less compression of the posterior disc of the instrumented spines during extension, and no difference during flexion compared with intact spines. After instrumentation was affixed, the foraminal area was 36% larger than in intact spines during extension and 9% larger during flexion. During axial loading, compression of the posterior disc was decreased by 70%, and analysis showed 10% decompression prior to loading just from implanting the devices. CONCLUSIONS: The PDS system has the benefit of being a completely percutaneous one, which can be used at all levels of the lumbar spine, including S-1. The PDS system limits spinal motion, enlarges the foramina, and achieves discal decompression.
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Vértebras Lumbares/fisiología , Vértebras Lumbares/cirugía , Procedimientos Quirúrgicos Mínimamente Invasivos/instrumentación , Prótesis e Implantes , Fusión Vertebral/instrumentación , Osteofitosis Vertebral/cirugía , Soporte de Peso/fisiología , Anciano , Anciano de 80 o más Años , Cadáver , Fuerza Compresiva/fisiología , Femenino , Fluoroscopía , Humanos , Imagenología Tridimensional , Disco Intervertebral/fisiología , Disco Intervertebral/cirugía , Vértebras Lumbares/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Movimiento , Osteofitosis Vertebral/diagnóstico por imagen , Osteofitosis Vertebral/fisiopatologíaRESUMEN
OBJECT: The DIAM is a polyester-encased silicone interspinous dynamic stabilization device that can unload the anterior column and reestablish the functional integrity of the posterior column. METHODS: The DIAM was implanted in 104 patients between May 1, 2001 and October 30, 2001. A retrospective evaluation was performed based on chart review and patient questionnaire at a median follow-up interval of 18.1 months. There were no implant migrations, infections, or neurological injuries. Of the 20 patients who suffered adverse events, 13 underwent second lumbar spinal operations 0 to 19 months after the initial surgery (in seven the event occurred in a location other than the lumbar spine). The pain level as recorded by the physician showed improvement in 88.5%, no change in 9.6%, aggravation in 0%, and was indeterminate in 1.9%. The questionnaire revealed that at 18 months postoperatively, analgesic usage was decreased in 63.1%, increased in 12.3%, and unchanged in 24.6% of patients, and activities of daily living were improved in 46.2%, decreased in 30.8%, and unchanged in 23.1%. Specific outcomes measures for sitting, standing, physical activity, and psychosocial functioning revealed similar results. CONCLUSIONS: The DIAM implant appears to be a useful and effective alternative in the surgical management of a wide range of lumbar disorders. Patient complications are few and satisfaction is high.
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Vértebras Lumbares/cirugía , Prótesis e Implantes , Fusión Vertebral/instrumentación , Osteofitosis Vertebral/cirugía , Estenosis Espinal/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Humanos , Disco Intervertebral/diagnóstico por imagen , Disco Intervertebral/fisiología , Disco Intervertebral/cirugía , Vértebras Lumbares/diagnóstico por imagen , Vértebras Lumbares/fisiología , Masculino , Persona de Mediana Edad , Satisfacción del Paciente , Poliésteres , Radiografía , Estudios Retrospectivos , Siliconas , Fusión Vertebral/métodos , Osteofitosis Vertebral/diagnóstico por imagen , Osteofitosis Vertebral/fisiopatología , Estenosis Espinal/diagnóstico por imagen , Estenosis Espinal/fisiopatología , Soporte de PesoRESUMEN
Ischemic stroke patients presenting to acute care hospitals require an organized response from multiple disciplines and clinical areas. Patients presenting within 6 hours of stroke onset constitute a category of stroke patient known as the "hyperacute stroke patient." This category of stroke patients is eligible for treatment using intravenous recombinant tissue plasminogen activator when treated within 3 hours, or interventional treatment options when treated within 6 hours of stroke onset. Guidelines have been established identifying critical elements for hospitals in order to be designated as primary or comprehensive stroke centers. Research studies exploring treatment options for stroke, as well as general care priorities exist in the scientific literature but must be integrated into hospital-based protocols. Recommended interventions are highlighted to assist critical care practitioners in the delivery of care for stroke patients. Coordinated teams using an evidence-based approach can optimize the outcomes of the stroke patient population.
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Isquemia Encefálica/complicaciones , Cuidados Críticos/métodos , Tratamiento de Urgencia/métodos , Accidente Cerebrovascular , Terapia Trombolítica/métodos , Enfermedad Aguda , Anciano , Algoritmos , Angiografía Cerebral , Protocolos Clínicos , Cuidados Críticos/normas , Árboles de Decisión , Tratamiento de Urgencia/normas , Medicina Basada en la Evidencia/métodos , Fibrinolíticos/uso terapéutico , Humanos , Joint Commission on Accreditation of Healthcare Organizations , Masculino , Guías de Práctica Clínica como Asunto , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/terapia , Terapia Trombolítica/normas , Factores de Tiempo , Activador de Tejido Plasminógeno/uso terapéutico , Tomografía Computarizada por Rayos X , Gestión de la Calidad Total/organización & administración , Resultado del Tratamiento , Estados UnidosRESUMEN
Patients with severe traumatic brain injury resulting in increased intracranial pressure refractory to first-tier interventions challenge the critical care team. After exhausting these initial interventions, critical care practitioners may utilize barbiturate-induced coma in an attempt to reduce the intracranial pressure. Titrating appropriate levels of barbiturate is imperative. Underdosing the drug may fail to control the intracranial pressure, whereas overdosing may lead to untoward effects such as hypotension and cardiac compromise. Monitoring for a therapeutic level of barbiturate coma includes targeting drug levels and using continuous electroencephalogram monitoring, considered the gold standard. New technology, the Bispectral Index monitor, utilizes electroencephalogram principles to monitor the level of sedation and hypnosis in the critical care environment. This technology is now being considered for targeting appropriate levels of barbiturate coma.
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Lesiones Encefálicas/complicaciones , Cuidados Críticos/métodos , Monitoreo de Drogas/métodos , Electroencefalografía/métodos , Electromiografía/métodos , Hipnóticos y Sedantes/uso terapéutico , Hipertensión Intracraneal/prevención & control , Pentobarbital/uso terapéutico , Adulto , Algoritmos , Lesiones Encefálicas/terapia , Protocolos Clínicos , Cuidados Críticos/normas , Árboles de Decisión , Monitoreo de Drogas/enfermería , Monitoreo de Drogas/normas , Electroencefalografía/enfermería , Electromiografía/enfermería , Medicina Basada en la Evidencia , Humanos , Hipertensión Intracraneal/diagnóstico , Hipertensión Intracraneal/etiología , Masculino , Examen Neurológico/métodos , Examen Neurológico/enfermería , Evaluación en Enfermería , Selección de Paciente , Guías de Práctica Clínica como Asunto , Procesamiento de Señales Asistido por Computador , Índices de Gravedad del Trauma , Resultado del TratamientoRESUMEN
INTRODUCTION: The value of brain tissue oxygenation (PbtO2) measurements in determining brain death is unknown. METHODS: Eleven of 72 patients who had brain tissue oxygen monitors placed experienced brain death. Admission diagnoses included six severe traumatic brain injuries, one multiple trauma with cardiac arrest, one brain tumor, one subarachnoid hemorrhage, one intracerebral hemorrhage, and one cerebral stroke. Eleven males and zero females were studied, with an average age of 26 years (range: 20-70 years). Nine patients had Glasgow Coma Scores (GCS) of 3 on admission, one patient had a GCS of 5, and one patient had a GCS of 15. RESULTS: Time from admission to declaration of brain death varied from 5 hours to 7 days; the most common interval was 1 or 2 days. Cerebral perfusion pressure (CPP) fell to 0 in eight patients, which indicated primary failure of cerebral perfusion. CPP stayed above 60 mmHg in three patients, indicating primary tissue failure, possibly of the cerebral microvasculature. PbtO2 fell to 0 in all patients who experienced brain death, and all patients with PbtO2 of 0 experienced brain death. None of the 61 patients who did not experience brain death had confirmed PbtO2 readings of 0. CONCLUSION: PbtO2 can be successfully and accurately used as a bedside adjunctive test for brain death. The use of PbtO2 as a sole confirmatory test for brain death in the setting of an appropriate clinical examination will require the evaluation of a larger number of patients to assess its sensitivity and specificity.
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Muerte Encefálica/diagnóstico , Muerte Encefálica/metabolismo , Encéfalo/metabolismo , Consumo de Oxígeno/fisiología , Adulto , Anciano , Presión Sanguínea , Muerte Encefálica/fisiopatología , Circulación Cerebrovascular , Femenino , Humanos , Presión Intracraneal , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Reproducibilidad de los ResultadosRESUMEN
The authors present an in-depth retrospective analysis of retractor systems for anterior odontoid screw fixation. They discuss various modifications and innovations of such systems and describe their own tubular retractor system, in which a beveled end conformal to the ventral surface of the vertebral column at the C2-3 level is introduced together with an incorporated light source. This new retractor system allows optimal anatomical exposure for controlled odontoid screw placement with improved protection of surrounding vital structures.
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Tornillos Óseos , Fijación Interna de Fracturas/instrumentación , Apófisis Odontoides/cirugía , Fracturas de la Columna Vertebral/cirugía , Anciano , Anciano de 80 o más Años , Diseño de Equipo , Femenino , Humanos , Músculos del Cuello , Estudios RetrospectivosRESUMEN
OBJECTIVE: Synovial cysts are a rare cause of lumbar radiculopathy and back pain. Surgical treatment is directed at complete excision of the cyst. We used minimally invasive surgical techniques for a series of patients, to assess the effectiveness of this approach for resection of synovial cysts. METHODS: Seventeen patients (10 female and 7 male patients) with presumed synovial cysts, as indicated on magnetic resonance imaging scans, underwent surgical resection with the 18-mm METRx tubular retractor system (Medtronic Sofamor Danek, Memphis, TN). A unilateral approach was used, with either an operating microscope (13 cases) or a magnifying endoscope (4 cases), depending on the preference of the surgeon. Outcomes were reported by using modified MacNab criteria. RESULTS: The average patient age was 64 years (range, 46-82 yr). The L4-L5 level was most commonly affected (82% of cases). Grade 1 spondylolisthesis at the level harboring the synovial cyst was observed for 47% of the patients; all cases of spondylolisthesis involved the L4-L5 level. The mean operative time was 97 minutes, and the average blood loss was 35 ml. Excellent or good results were achieved for 94% of the patients. A dural tear that did not violate the arachnoid membrane occurred during surgery for one patient but did not require further treatment. CONCLUSION: Synovial cysts can be effectively treated with a tubular retractor system in conjunction with an endoscope or microscope. Use of the tubular retractor minimizes soft-tissue trauma, incision length, blood loss, and disruption of ligamentous and bony structures. This may be particularly significant when synovial cysts are associated with spondylolisthesis, minimizing the risk of progressive instability and the need for fusion.
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Vértebras Lumbares/cirugía , Procedimientos Quirúrgicos Mínimamente Invasivos , Quiste Sinovial/cirugía , Anciano , Anciano de 80 o más Años , Descompresión Quirúrgica , Femenino , Humanos , Dolor de la Región Lumbar/etiología , Dolor de la Región Lumbar/patología , Dolor de la Región Lumbar/cirugía , Vértebras Lumbares/patología , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Espondilolistesis/etiología , Espondilolistesis/patología , Espondilolistesis/cirugía , Quiste Sinovial/complicaciones , Quiste Sinovial/patología , Resultado del Tratamiento , Articulación Cigapofisaria/patología , Articulación Cigapofisaria/cirugíaRESUMEN
OBJECTIVE: The wide exposure required for a standard posterior lumbar interbody fusion (PLIF) can cause unnecessary trauma to the lumbar musculoligamentous complex. By combining existing microendoscopic, percutaneous instrumentation and interbody technologies, a novel, minimally invasive, percutaneous PLIF technique was developed to minimize such iatrogenic tissue injury (MIP-PLIF). METHODS: The MIP-PLIF technique was validated in three cadaveric torsos with six motion segments decompressed and fused. Preoperative variables measured from imaging included interpedicular distance, pedicular height and width, interspinous distance, lordosis, intervertebral height, Cobb angle, and foraminal height and volume. Using the METRx and MD spinal access systems (Medtronic Sofamor Danek, Memphis, TN), bilateral laminotomies were performed using a hybrid of microsurgical and microendoscopic techniques. The intervertebral disc spaces were then distracted and prepared with the Tangent (Medtronic Sofamor Danek) interbody instruments. Either a 10 or 12 by 22 mm interbody graft was then placed. Using the Sextant (Medtronic Sofamor Danek) system, percutaneous pedicle screw-rod fixation of the motion segment was completed. We then applied MIP-PLIF in three patients. RESULTS: For segments with preoperative intervertebral/foraminal height loss, MIP-PLIF was effective in restoring both heights in all cases. The amount of improvement (9.7 to 38% disc height increase; 7.7 to 29.9% foraminal height increase) varied directly with the size of the graft used and the original degree of disc and foraminal height loss. Segmental lordosis improved by 29% on average. Graft and screw placement was accurate in the cadavers, except for a single Grade 1 screw violation of one pedicle. The average operative time was 3.5 hours per level. In our three clinical cases, the MIP-PLIF procedure required a mean of 5.4 hours, estimated blood loss was 185 ml, and inpatient stay was 2.8 days, with no intravenous narcotic use after 2 days in any of the patients. All screw and graft placements were confirmed. CONCLUSION: A complete PLIF procedure can be safely and effectively performed using minimally invasive techniques, thereby potentially reducing the pain and morbidity associated with standard open surgery. Prospective, randomized outcome studies will be required to validate the efficacy of this exciting new surgical technique.
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Vértebras Lumbares/cirugía , Procedimientos Quirúrgicos Mínimamente Invasivos , Fusión Vertebral/métodos , Anciano , Dolor de Espalda/cirugía , Tornillos Óseos , Trasplante Óseo , Cadáver , Humanos , Persona de Mediana Edad , Espondilolistesis/cirugíaRESUMEN
OBJECT: The authors studied a consecutive series of patients with spinal stenosis in whom surgery was performed by a single surgeon who used a microscopic tubular retractor system (METRx-MD); patients underwent prospective evaluation involving radiography and magnetic resonance (MR) imaging. The objective was to assess the feasibility and surgery-related efficacy of performing unilateral-approach bilateral decompression and utilization of METRx-MD instrumentation in patients with spinal stenosis. METHODS: Seventeen consecutive patients with spinal stenosis underwent bilateral decompression; surgery was performed via a unilateral approach using METRx-MD instrumentation. The procedures were performed on an outpatient basis after induction of general anesthesia. Preoperative and 3-month follow-up plain radiographs with flexion-extension views were obtained. Preoperative and postoperative MR imaging was also performed. All studies were assessed by a single radiologist blinded to the clinical results. Twenty-two levels were surgically decompressed. The mean operative time was 90 minutes and the mean blood loss was 28 ml per level. Preoperatively stenosis was severe at 13 levels, moderate/severe at eight, and moderate at one. Postoperatively stenosis was absent at 13 levels, mild at seven, mild/moderate at one, and moderate at one. Preoperatively degenerative spondylolisthesis was documented in eight patients, with flexion-extension radiography revealing motion in three cases. On early (3-month) postoperative x-ray films there was no evidence of progression in any case. Grade I spondylolisthesis developed postoperatively in one patient, who remained asymptomatic. CONCLUSIONS: Minimally invasive bilateral decompression and instrumentation-assisted fusion can be successfully performed via a unilateral approach in patients with acquired spinal stenosis; the procedure can be undertaken on an outpatient basis, with reasonable operative times, minimal blood loss, and acceptable morbidity rates.
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Descompresión Quirúrgica/instrumentación , Lateralidad Funcional/fisiología , Vértebras Lumbares/cirugía , Microcirugia/instrumentación , Estenosis Espinal/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Vértebras Lumbares/patología , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Examen Neurológico , Complicaciones Posoperatorias/diagnóstico , Estudios Prospectivos , Estenosis Espinal/diagnóstico , Instrumentos Quirúrgicos , Tomografía Computarizada por Rayos XAsunto(s)
Distinciones y Premios , Lesiones Encefálicas/terapia , Modelos Organizacionales , Investigación en Enfermería , Guías de Práctica Clínica como Asunto , Gestión de la Calidad Total/organización & administración , California , Humanos , Evaluación de Resultado en la Atención de Salud , Grupo de Atención al PacienteRESUMEN
OBJECT: Application of minimally invasive techniques to lumbar disc surgery has led to the development of the Microscopic Endoscopic Tubular Retractor System (METRx-MD). A prospective evaluation of results and complications was undertaken. METHODS: One hundred thirty-five patients underwent surgery in which the METRx-MD system was used; most procedures were performed on an outpatient basis, and general anesthesia was induced in all cases. All patients were followed prospectively. Outcomes were measured using a visual analog scale (VAS), the Oswestry Disability Index (ODI), and the Short Form-36 (SF-36) questionnaires. Follow-up data were collected by an outside company, which also tabulated the data. Data were collected in 129 of 135 patients. Improvement was seen on the VAS (Scores 7-2), ODI (Scores 57-16), and SF-36 scales (bodily pain Scores 20-60). Patient satisfaction with results was 94% and with office services 88%. Thirty-six percent of patients returned to work at 0 to 2 weeks, 38% at 3 to 5 weeks, and 25% at 5 to 26 weeks. Hospital charges decreased by $2395 (18%). The mean operative time was 66 minutes, and the mean blood loss was 22 ml. Complications included one superficial wound infection, one discitis, three durotomies, and three cases of excessive bleeding (> 100 ml). There were five reoperations: four for recurrent disc herniations, (two ipsilateral and two contralateral to the index site) and one for spinal stenosis contralateral to the index site. CONCLUSIONS: Minimally invasive surgery in which the METRx-MD system is used is clinically effective and cost effective. Patient satisfaction was high. A mean per case cost savings of $2395 was realized. Complications rates were comparable with those associated with traditional microdiscectomy procedures.
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Discectomía/instrumentación , Desplazamiento del Disco Intervertebral/cirugía , Vértebras Lumbares/cirugía , Microcirugia/instrumentación , Adulto , Discectomía/métodos , Femenino , Estudios de Seguimiento , Humanos , Desplazamiento del Disco Intervertebral/diagnóstico por imagen , Estudios Longitudinales , Vértebras Lumbares/diagnóstico por imagen , Masculino , Microcirugia/métodos , Dimensión del Dolor , Estudios Prospectivos , RadiografíaRESUMEN
OBJECT: The objective of this study was to assess the feasibility and efficacy of treating spondylolisthesis-related spinal stenosis via unilateral approach bilateral decompression in which METRx-MD instrumentation is placed. METHODS: Eight consecutive patients with spinal stenosis underwent bilateral decompressions via a unilateral approach in which METRx-MD instrumentation was placed. The procedures were performed on an outpatient basis after induction of general anesthesia. The patients underwent preoperative and 3-month postoperative plain radiography in which flexion-extension x-ray films were obtained. Preoperative and postoperative magnetic resonance imaging was also performed. All radiographs and neuroimages were read by a single radiologist blinded to the clinical results. Eight vertebral levels in the eight patients were surgically decompressed (in one patient an additional level of nonspondylolisthesis-related stenosis was decompressed). The mean operative time was 92 minutes and the mean blood loss was 33 ml/level. Preoperatively stenosis was severe in five patients, moderate/severe in two, and moderate in one; postoperatively stenosis was absent in five, mild in two, and mild/moderate in one. Motion was detected on flexion-extension radiographs in three patients, but on early (3-month) postoperative radiographs there was no evidence of progression. CONCLUSIONS: By following the authors' procedure, minimally invasive bilateral decompression of acquired spinal stenosis associated with spondylolisthesis can be successfully performed on an outpatient basis, with reasonable operative times, minimal blood loss, and acceptable morbidity.