Spinal stenosis surgery in Sweden 1987-1999.
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Despite being recognised for many years as a clinical diagnosis, no exact definition of spinal stenosis has yet been agreed, leading to difficulties in interpreting and comparing studies of the incidence, prevalence and treatment. This study presents the first analysis of national data to be reported. It is a retrospective population-based national register study, aimed at analyzing surgical interventions in patients with lumbar spinal stenosis, patient characteristics, subsequent development, and case fatality rate, based on Swedish national data for 1987-1999. Complete follow-up data were obtained of incidence and type of spinal stenosis surgery, rate of multiple operations, mortality, underlying causes of death, length of hospital stay, and case fatality rate by linkage of the National Inpatient Register and Swedish Death Register. The study cohort consisted of 10,494 patients. Laminectomy was performed in 89%, and additional fusion in 11%. The mean annual rate of operations was 9.7 per 100,000 inhabitants, the annual number of operations performed increased from 4.7 to 13.2 per 100,000 inhabitants per year. The case fatality rate within 30 days after surgery was 3.5 per 1000 operations. Cardiovascular disease was the most common cause of death (46%). Relative risk of dying within 30 days of admission was doubled in men, and for fusion surgery, and increased four fold in patients older than 80 years. The relative risk of dying decreased during the study period. The results show that spinal stenosis surgery in Sweden has increased, and is associated with a low risk. Within an ageing group of patients, mortality has declined. (+info)
Vascular injury during a lumbar laminectomy.
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A lumbar laminectomy is a common and routine operation. Damage to abdominal vascular structures during surgery is a relatively infrequent complication; however, when it does occur, it is sudden and life-threatening. We herein report on 2 cases of abdominal vascular injury which occurred during lumbar microdiscectomies. The first case was a 34-year-old man. A bloody surgical field was noted 45 min into the operation along with an increase in heart rate and a decrease in blood pressure. After fluid resuscitation and an ephedrine injection, his vital signs stabilized. The patient was then sent to the surgical intensive care unit for observation. An emergent abdominal computer tomography scan revealed right retroperitoneal hematoma, and an urgent exploratory laparotomy was performed to check for bleeding and to remove the hematoma. The second case was a 61-year-old woman with recurrent disc herniation. The operation was proceeding smoothly for 90 min, when a large amount of fresh blood suddenly gushed out. Her blood pressure immediately dropped to that of a state of shock. The patient was turned back to a supine position, and an emergent laparotomy was done to repair the injured vessels. Both patients had uneventful recoveries. (+info)
Pseudomeningoceles are uncommon complications of lumbar surgery. They are encapsulated cerebrospinal fluid collections developing extradurally as a consequence of incidental dural tears. They are typically located in the paraspinal compartment and occasionally reach the subcutaneous space. We describe the case of a patient in whom a postlaminectomy pseudomeningocele developed over a 10-year period within the L5 spinous process and remained completely encircled within its bony boundaries. The surgical implications of this finding are discussed. (+info)
Schwann cell invasion of the conus medullaris: case report.
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As Schwann cells possess regenerative capabilities there is intense interest concerning their role in central nervous system (CNS) regeneration. We report on a case of an intramedullary schwannoma involving the conus medullaris and spinal cord above it. We discuss the possible origin of these cells and the mechanisms by which these cells may invade the CNS. We offer imaging and discuss experimental studies to support our hypothesis. This case concerns a 48-year-old man, who presented with a 6-month history of bilateral lower extremity weakness. Magnetic resonance imaging (MRI) revealed an intramedullary tumour extending from the conus to T11. At operation, following laminectomy and durotomy, a schwannoma was dissected free from the conus. Total gross resection of tumour was achieved. The patient made an uneventful and full recovery. This case shows that Schwann cells can invade the CNS. Manipulation of the transitional zone astrocytic barrier may offer a potential avenue for Schwann cells to enter the CNS in pathological states. (+info)
Use of the World Wide Web to implement clinical practice guidelines: a feasibility study.
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BACKGROUND: Important efforts have been invested in the past few years in the development of quality clinical guidelines. However, the means for the effective dissemination of guidelines to practicing physicians have not been determined. Several studies have examined the possibilities offered by the World Wide Web (the Web), but studies examining the implementation of clinical guidelines in actual practice are clearly lacking. OBJECTIVE: This study assessed the potential of the Web to implement clinical practice guidelines in actual clinical settings. It also documents the obstacles perceived by the physicians in their use of guidelines on the Internet to determine the role that the Web can play in the implementation of guidelines in practice. METHODS: Two guidelines were developed using a standardized panel method and made available via the Web. One concerned indications for low-back surgery and the other dealt with indications for upper and lower digestive endoscopies. To identify obstacles to their use in clinical practice, 20 physicians were asked to consult the guidelines during consultations with patients. Answers were collected using 3 different questionnaires. RESULTS: Questionnaires were completed for consultations involving 213 patients. Less than 50% of the physicians have direct access to the Internet in their examination room. For 75%, the use of the guidelines was easy and the time required to consult them acceptable (3.4 minutes on average, or 12% of the time spent with the patient). The fear that use of such guidelines might interfere with the physician-patient relationship was mentioned as a reason for not consulting the guidelines for 27 consultations. Taking into account their experience with the Web, 75% of the physicians considered that the Web has a great or very-great potential for the dissemination of guidelines and 78% indicated that they would use such guidelines if they became generally available for clinical questions that concerned them. Only 3 physicians had consulted guidelines on the Web prior to this study. CONCLUSIONS: The acceptance of use of clinical practice guidelines via the Web is high. The main limits to further use of such Web-based guidelines seem to be the lack of a computer connection in the physician's office or examining room and the fear that use of such guidelines might interfere with the physician-patient relationship. Though most participants appreciate the considerable potential of the Web for disseminating guidelines, only a small handful regularly use guidelines available on the Web. There are still numerous obstacles to the regular use of guidelines in clinical practice, some related to the physicians, others to the guidelines themselves. (+info)
Use of topically applied rt-PA in the evacuation of extensive acute spinal subdural haematoma.
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Spontaneous spinal subdural haematoma is a rare cause of spinal cord compression, usually confined to a few vertebral levels. When the haematoma extends over several spinal segments, surgical decompression is a major undertaking. Recombinant tissue plasminogen activator (rt-PA) has previously been used in a number of surgical procedures, but not in the setting of acute spinal subdural haematoma. A minimally invasive technique of decompression, using topical rt-PA, is presented in two patients with extensive spinal intradural haematoma. Two patients receiving long-term anticoagulation therapy presented with acute-onset back pain progressing to paraparesis. Magnetic resonance imaging of the spine demonstrated spinal subdural haematomas extending over 15 vertebral levels in one patient and 12 in the other. An angiography catheter was introduced into the subdural space through a limited laminectomy. Thrombolysis and evacuation of haematoma was then achieved by intermittent irrigation of the subdural space with rt-PA, followed by saline lavage. Postoperative imaging demonstrated satisfactory decompression in both patients. There was significant improvement of neurological function in one patient. Topical application of rt-PA for spinal subdural haematoma allows evacuation of the haematoma through a limited surgical exposure. Decompression of the subdural space by this minimally invasive technique may be advantageous over extensive surgery by minimising surgical exposure, reducing postoperative pain and risk of neuronal injury. This technique may be useful in patients presenting with compression extending over several vertebral levels or poor surgical candidates. (+info)
A 48-year-old man presented with idiopathic spinal cord herniation associated with calcified thoracic disc extrusion at the T7-8 intervertebral level, manifesting as Brown-Sequard syndrome at the thoracic level persisting for 20 years. Preoperative magnetic resonance imaging and computed tomography myelography revealed ventral displacement of the spinal cord and extrusion of a calcified disc at the T7-8 intervertebral level. At surgery, the spinal cord herniation at this level was released from the dura mater and carefully returned to the dural sac. An extruded calcified thoracic disc was found just below the dural defect at the same level. The development of idiopathic spinal cord herniation is associated closely with a defect in the ventral dura mater of unknown etiology. In our case, the etiology of the ventral dural defect was probably associated with the calcified thoracic disc extrusion. (+info)
Posterior approach to the degenerative cervical spine.
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Laminoplasty has been gradually accepted as a treatment for choice for cervical compression myelopathy. The historical perspective of laminoplasty is described. The aims of laminoplasty are to expand the spinal canal, to secure spinal stability, to preserve the protective function of the spine, and to preserve spinal mobility. Laminoplasty is indicated in myelopathic patients with a developmentally narrow spinal canal or multiple-level involvement combined with a relatively narrow canal. Several laminoplasty techniques and supplementary techniques are described, together with expected outcomes and complications of surgery. (+info)