Total disc replacement for chronic low back pain: background and a systematic review of the literature.
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In this paper the rationale for total disc replacement is discussed, and the authors suggest seven requirements that should be met before the implantation of these devices can be accepted as regular procedures. In an attempt to answer the questions raised, a systematic literature search was performed. The search yielded no controlled trials and nine case series with a total of 564 arthroplasties in 411 patients. The devices used were SB Charite in eight and Acroflex in one study. The percentage results classified as "good" or "excellent" in the studies varied from 50 to 81%. Complications were observed in 3-50% of the patients. Twenty-two of the operated levels were fused either spontaneously or after additional surgery. A meta-analysis to compare the results with other treatments could not be performed due to the lack of comparative studies. Despite the fact that these devices have been implanted for almost 15 years, on the basis of this literature survey there are currently insufficient data to assess the performance of total disc replacement adequately. There is no evidence that disc replacement reliably, reproducibly, and over longer periods of time fulfils the three primary aims of clinical efficacy, continued motion, and few adjacent segment degenerative problems. Total disc replacement seems to be associated with a high rate of re-operations, and the potential problems that may occur with longer follow-up have not been addressed. Therefore, total disc replacements should be considered experimental procedures and should only be used in strict clinical trials. (+info)
Surgical management of the spinal deformity in Ehlers-Danlos syndrome type VI.
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Five patients with Ehlers-Danlos syndrome type VI were surgically treated for their spinal deformities. All of them were female. All but one had a double-major thoracic and lumbar curve. One had a mild scoliotic curve but severe thoracic lordosis. Anterior discectomy and fusion and posterior instrumentation was performed in a single stage in two patients, while two had anterior and posterior surgery performed in two stages. The remaining patient underwent posterior surgery only, because of the relative mildness of the deformity and adequate flexibility. Two serious vascular complications were confronted. One patient experienced avulsion of segmental arteries and rupture of iliac artery and vein during anterior surgery. Another patient had avulsion of superior gluteal artery, which happened during subperiosteal dissection to harvest iliac bone graft. Fortunately, we did not see any temporary or permanent neurological complications. The spinal fusions appeared solid radiographically, with no implant failure and loss of correction after an average follow-up of 4 years. (+info)
Endovascular exclusion of iliac artery to iliac vein fistula after lumbar disk surgery.
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Iliac arteriovenous (AV) fistula is rare after lumbar disk surgery. Traditionally, open repair through the arterial lumen was performed. We report endovascular exclusion of an iliac AV fistula in a 41-year-old woman 8 years after lumbar diskectomy. An angiogram showed an AV fistula connecting the right common iliac artery and vein. This was repaired with placement of two covered wall stents in the right common artery and external iliac artery, and embolization of the right internal iliac artery. Contrast medium-enhanced computed tomography scan at 5 months confirmed elimination of the AV fistula and right iliac artery patency. This technique should be considered in management of iliac AV fistulas. (+info)
Survival analysis is a better estimate of recurrent disc herniation.
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Studies on recurrent disc herniation quote rates of recurrence without regard to the times of recurrence and the influence of longer follow-up. Our objective was to assess the use of survival analysis to measure the rate of revision after lumbar microdiscectomy. We undertook a retrospective analysis of the hospital records of 993 patients who underwent lumbar microdiscectomy over a period of ten years. After calculating the overall rate of revision for the mean length of follow-up, we carried out a survival analysis using the life-table method. During the study period 49 patients had a revision microdiscectomy. This gave an overall rate of revision of 4.9% at a mean follow-up of 5.25 years. Using survival analysis, the rate of revision was 7.9% at a follow-up of ten years when the number at risk was 84. Survival analysis gives a more accurate estimation of the true rate of recurrence for patients undergoing lumbar microdiscectomy. The method allows better comparison between different interventions for disc herniation. (+info)
Classification and management of early complications in open lumbar microdiscectomy.
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Complications and side effects in any kind of surgery, especially in spine surgery, should be evaluated to prevent those problems in the future. Since retrospective studies are of minor value and randomized controlled studies for complications are impossible to perform because of ethical and legal reasons, so-called "expert opinion" has to take their place in evidence-based medicine. On the basis of an analysis of the results of three spine centers together with the opinions of experienced spine surgeons, the authors have drawn up a classification of complications in open lumbar disc surgery and recommendations on how to manage common complications such as excessive bleeding, dural opening, nerve root lesions and recurrent disc herniation. The management of intraoperative complications should have the same training in microdiscectomy instructional courses as the operation itself. (+info)
Results of hemivertebrectomy and fusion for symptomatic thoracic disc herniation.
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We retrospectively analysed ten consecutive patients (age range 32-77 years) treated surgically from 1994 to 1999 for symptomatic thoracic disc herniation between the 6th and 12th thoracic discs. Clinically, eight patients had varying grades of back pain and eight patients had paraparesis. Radiography showed calcification in 50% of the herniated discs. Two patients had two-level thoracic disc herniation. Hemivertebrectomy followed by discectomy and fusion was carried out in all patients. Instrumentation with cages was performed in eight patients and bone grafting alone in two patients. The average follow-up was 24 months (range 13-36 months). Six patients had an excellent or good outcome, three had a fair outcome and one had a poor outcome. One patient had atelectasis, which recovered within 2 days of surgery. Another patient had developed complete paraplegia, detected at surgery by SSEPs, and underwent resurgery following magnetic resonance (MR) scan with complete corpectomy and instrumented fusion. At 2 years, she had a functional recovery. The patient with poor outcome had undergone a previous discectomy at T9/10. He developed severe back pain and generalised hyper-reflexia following corpectomy and fusion for disc herniation at T10/11. We advocate anterior transthoracic discectomy following partial corpectomy for symptomatic thoracic disc herniation between the 6th and 12th thoracic discs. This procedure offers improved access to the thoracic disc for an instrumented fusion, which is likely to decrease the risk of iatrogenic injury to the spinal cord. (+info)
Ho: Yag laser-assisted lumbar disc decompression: a minimally invasive procedure under local anesthesia.
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The morbidity associated with open procedures for lumbar intervertebral disc prolapse has led to the development of minimally invasive techniques. Ho: LADD (Laser-assisted disc decompression) is a very cost-effective minimally invasive procedure. The procedure is carried out under local anesthesia. The patient can be mobilized immediately after the surgery. The study involved 36 cases treated with Ho: LADD for contained lumbar intervertebral disc prolapse. 35 cases were available for follow-up. There was a 91.5% success rate and a minimal complication rate. All cases adhered to strict inclusion and exclusion criteria and were evaluated with the modified Macnab criteria for the assessment of postoperative results. (+info)
Primary and revision lumbar discectomy. A 16-year review from one centre.
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We present a review of 553 patients who underwent surgery for intractable sciatica ascribed to prolapsed lumbar intervertebral disc. One surgeon in one institution undertook or supervised all the operations over a period of 16 years. The total number of primary discectomies included in the study was 531, of which 42 subsequently required a second operation for recurrent sciatica, giving a revision rate of 7.9%. Factors associated with reoperation were analysed. A contained disc protrusion was almost three times more likely to need revision surgery, compared with extruded or sequestrated discs. Patients with primary protrusions had a significantly greater straight-leg raise and reduced incidence of positive neurological findings compared with those with extruded or sequestrated discs. These patients should therefore be selected out clinically and treated by a more enthusiastic conservative programme, since they are three times more likely to require revision surgery. (+info)