Extreme lateral interbody fusion for the treatment of adult degenerative scoliosis

Extreme lateral interbody fusion (XLIF; NuVasive Inc., San Diego, CA, USA) is a minimally invasive lateral transpsoas approach to the thoracolumbar spine. Though the procedure is rapidly increasing in popularity, limited data is available regarding its use in deformity surgery. We aimed to evaluate radiographic correction using XLIF in adults with degenerative lumbar scoliosis. Thirty consecutive patients were followed for an average of 14.3 months. Interbody fusion was completed using the XLIF technique with supplemental posterior instrumentation. Plain radiographs were obtained on all patients preoperatively, postoperatively, and at most recent follow-up. Plain radiographic measurements of coronal Cobb angle, apical vertebral translation, segmental lordosis, global lordosis, disc height, neuroforaminal height and neuroforaminal width were made at each time point. CT scans were obtained for all patients 1 year after surgery to evaluate for fusion. There was significant improvement in multiple radiographic parameters from preoperative to postoperative. Cobb angle corrected 72.3%, apical vertebral translation corrected 59.7%, neuroforaminal height increased 80.3%, neuroforaminal width increased 7.4%, and disc height increased 116.7%. Segmental lordosis at L4–L5 increased 14.1% and global lordosis increased 11.5%. There was no significant loss of correction from postoperative to most recent follow-up. There was an 11.8% pseudoarthrosis rate at levels treated with XLIF. Complications included lateral incisional hernia (n = 1), rupture of anterior longitudinal ligament (n = 2), wound breakdown (n = 2), cardiac instability (n = 1), pedicle fracture (n = 1), and nonunion requiring revision (n = 1). XLIF significantly improves coronal plane deformity in patients with adult degenerative scoliosis. XLIF has the ability to correct sagittal plane deformity, although it is most effective at lower lumbar levels.     

Developmental psychological aspects of scoliosis treatment

The diagnosis and treatment of idiopathic adolescent scoliosis can have significant psychological consequences for affected individuals.

This article aims to provide an overview of the current state of empirical knowledge concerning the psychosocial aspects of scoliosis in adolescence. These research results are set against experience gained from practical work.

Adolescence, as a sensitive phase of a young person's development, requires a special degree of adaptation in the event of a chronic illness.

For scoliosis patients this means, for instance, facing up to cosmetic impairments and subjectively significant physical defects. Cognitively the patient must come to terms with a commitment of time-consuming, confining, and sometimes uncomfortable treatment for a condition that does not always cause physical symptoms and to achieve success which is not necessarily defined as an improvement in the state of health.

Scoliosis is a risk factor for impairment of the quality of life of children and adolescents.

Its impact is particularly marked if brace-wearing is indicated. Particular attention needs to be paid to aspects of brace compliance.

Support for patients within the context of in-patient rehabilitative treatment has proved to be both necessary and helpful. Here, within the setting of psychological group sessions and individual discussions, the possibility exists for preventing psychosocial impairment.     

脊柱侧弯合并椎管内病变的一期手术治疗

目的探讨一期手术治疗脊柱侧弯合并椎管内病变的有效性和安全性。方法与结果共6例脊柱侧弯合并椎管内病变患者均完成一期手术治疗,手术成功率为100%。手术时间(470.83±136.20)min,术中出血量1350(625,2150)ml,融合椎体节段(11.00±2.76)个;术后冠状位侧凸角度(19.60±5.94)°,矢状位后凸角度(25.80±10.87)°,均较术前改善(P=0.007,0.005);脊髓拴系行脊髓拴系松解术,表皮样囊肿、节细胞胶质瘤和椎管内脂肪瘤行椎管内病变切除术,脊髓空洞症不予特殊处理;无神经功能缺损恶化;术后下肢肌力增高,肌张力降低;排尿障碍改善。术后住院(8.83±3.31)d,无一例出现感染、脑脊液漏、脊柱内固定失败、椎弓根螺钉和钛棒断钉断棒等手术相关并发症,无一例死亡。术后随访(7.50±1.22)个月,均无神经功能缺损恶化、迟发性感染和假关节形成,均未出现矫形丢失。结论一期手术可以安全、有效地治疗脊柱侧弯合并椎管内病变,术后神经功能改善,通过截骨可以获得良好的矫形效果。     

Advanced reconstructive endovascular techniques for the treatment of cerebral aneurysms

Endovascular treatment of cerebral aneurysms with detachable coils has now been proven to be a superior alternative to open microsurgery in terms of disability-free survival 1 year following treatment. Despite this, recurrence due to recanalization of these aneurysms in 10-20% of patients after coiling is still the main drawback of the endovascular technique. In the last 5 years, access devices and endovascular tools based on new concepts, materials and endovascular reconstruction techniques that go beyond simply coiling have been described for cerebral aneurysm treatment, especially for more complicated broad-necked, fusiform and large/giant aneurysms. In this article, we review our recent experience in the treatment of complex cerebral aneurysms by means of multiple novel endovascular techniques for arterial reconstruction.     

The treatment of scoliosis in duchenne muscular dystrophy

There are not, as yet, clear indications for the surgical management of scoliosis in Duchenne muscular dystrophy (DMD), taking into account the varying severity of the clinical course. Monitoring the vital capacity can be most important for the indication and timing of surgery. In some cases, delaying surgical intervention with conservative management using spinal braces and wheelchair inserts can permit the restrictive lung syndrome to advance to the point that surgery will be contraidicated. Ten such patients conservatively treated for an average of 5 years exhibited perhaps a slower progression but ultimately an advanced deformity. From a second group of five carefully selected and surgically treated patients, indications for spinal surgery were reviewed. Surgical intervention should be prophylatically undertaken when there is high risk of a rapidly evolving curve with a severe restrictive lung syndrome.     

Posterolateral lumbar fusion versus transforaminal lumbar interbody fusion for the treatment of degenerative lumbar scoliosis

This study compares the safety and efficacy of posterolateral lumbar fusion (PLF) and transforaminal lumbar interbody fusion (TLIF) in the treatment of degenerative lumbar scoliosis (DLS). Forty DLS patients with Cobb angles of 20–60 degrees were randomized into either the PLF or TLIF treatment group, and were followed up for 2–5 years. Operating time, intraoperative blood loss, clinical outcomes, complications and imaging were compared between the two groups. There were significant differences between the PLF and TLIF treatment groups in operative time (187.8 ± 63.5 minutes and 253.2 ± 57.6 minutes, respectively; p = 0.002) and intraoperative blood loss (1166.7 ± 554.1 mL and 1673.7 ± 922.4 mL, respectively; p = 0.048). The occurrence rates of early complications in the two groups were 11.1% and 26.3%. The recovery rates of the lumbar lordotic angle and spinal sagittal balance were significantly different (36.7% versus 62.5% and 44.8% versus 64.1%, respectively). In various domains of the Scoliosis Research Society-22 (SRS-22) questionnaire, the scores for pain and satisfaction with the treatment showed significant differences between PLF and TLIF group (p = 0.033 and p = 0.006, for pain and satisfaction respectively), and the TLIF group showed better outcomes than the PLF group. There were no significant differences in the recovery rates in the Cobb angle and the spinal coronal balance, function, self-image, or mental health scores. Although TLIF increases the surgical trauma and occurrence of complications, it helps to improve lumbar lordosis and sagittal balance and shows better clinical outcomes. For patients without significant loss of lumbar lordosis and with good spinal sagittal balance preoperatively, PLF is still an option.     

Estimating the final outcome of brace treatment for idiopathic thoracic scoliosis at 6-month follow-up

Objective: The study was conducted on the possibility of predicting the final outcome of bracing for idiopathic scoliosis at a follow-up period of 6 months. Methods: In a retrospective study, 62 adolescent female patients with right thoracic scoliosis (20–40° Cobb angle) treated with a brace were examined. A new compliance score was developed. The sample was divided into four groups based on compliance (compliance score) and initial correction (half-year after start bracing): group A, good compliance/high initial correction; group B, good compliance/low initial correction; group C, bad compliance/high initial correction; group D, bad compliance/low initial correction. The final outcome (1 year after weaning) was defined as successful if a curve correction of at least 5° was achieved. The influence of factors on final outcome was analysed by ANOVA. Differences between continuous data were analysed by a two-sample Wilcoxon test.?Results: The overall final outcome was not successful (thoracic curve ?3°). However, the average outcome of the compliant group was successful (?5°), while no success was achieved without good compliance (+5°). High initial correction of more than 40% (p?<?0.002) and good compliance (p<?0.004) were of significant impact for the outcome. Patients showing good compliance and high initial correction presented a successful outcome of 7° Cobb angle.?Conclusion: Compliant patients with a high initial correction can expect a final correction of around 7°, while compliant patients with low initial correction may maintain the curve extent. Bad compliance is always associated with curve progression.     

New neuromodulation techniques for treatment resistant depression

Abstract

In the treatment of depression, when pharmacotherapy, psychotherapy and the oldest brain stimulation techniques are deadlocked, the emergence of new therapies is a necessary development. The field of neuromodulation is very broad and controversial. This article provides an overview of current progress in the technological advances in neuromodulation and neurostimulation treatments for treatment-resistant depression: magnetic seizure therapy; focal electrically administered seizure therapy; low field magnetic stimulation; transcranial pulsed electromagnetic fields; transcranial direct current stimulation; epidural cortical stimulation; trigeminal nerve stimulation; transcutaneous vagus nerve stimulation; transcranial focussed ultrasound; near infra-red transcranial radiation; closed loop stimulation. The role of new interventions is expanding, probably with more efficacy. Nowadays, still under experimentation, neuromodulation will probably revolutionise the field of neuroscience. At present, major efforts are still necessary before that these therapies are likely to become widespread.

• Key points

• There is a critical need for new therapies for treatment resistant depression.

• Newer therapies are expanding. In the future, these therapies, as an evidence-based adjunctive treatments, could offer a good therapeutic choice for the patients with a TRD.

• The current trend in the new neuromodulation therapies is to apply a personalised treatment.

• These news therapies can be complementary.

• That treatment approaches can provide clinically significant benefits.

     

Physical exercises as a treatment for adolescent idiopathic scoliosis. A systematic review

Our purpose was, through an extensive and systematic review of the literature, to verify the effectiveness of physical exercises in the treatment of adolescent idiopathic scoliosis. We performed a search of different databases (Medline, Cochrane Library, Embase, Cinhal), and a hand-search of the non-indexed pertinent literature, and found 11 papers: none of the studies was randomized, six were prospective, seven were controlled, and two compared their results to historical controls; one paper had both a prospective design and a concurrent control group. The methodological quality of the retrieved studies was reviewed and found to be very poor. With one exception, the published studies demonstrated the efficacy of physical exercises in reducing both the rate of progression or the magnitude of the Cobb angle at the end of treatment. However, being of poor quality, the literature failed to provide solid evidence for or against the efficacy of physical exercises in the treatment of adolescent idiopathic scoliosis. Nevertheless, considering that exercises could also be proposed on the basis that benefits rather than to avoid progression have been shown in the literature, and that the results contained in published studies here reviewed suggest an effect on the primary goal of preventing progression, there is a basis for discussion of this option with patients and their families, which in turn allows decisions to be made according to their preferences.     

椎弓根钉系统治疗特发性脊柱侧凸的临床应用

学术背景：近些年来胸段置入椎弓根钉技术广泛普及,使得椎弓根钉系统在治疗特发性脊柱侧凸中起到越来越关键的作用。 目的：了解椎弓根钉系统在治疗特发性脊柱侧凸的应用。 检索策略：由该论文的研究人员应用计算机检索Pubmed数据库1997-01/2007-01的相关文献, 检索词为“pedicle screw, IS”并限定文章语言种类为English。同时计算机检索中国期刊全文数据库1997-01/2007-01的相关文献,检索词“椎弓根钉,特发性脊柱侧凸”,并限定文章语言种类为中文。共检索到116篇文献,对资料进行初审,纳入标准：椎弓根钉系统的特点和治疗特发性脊柱侧凸相关的文献。排除标准：重复研究,Meta分析。 文献评价：文献的来源主要是对椎弓根钉系统治疗特发性脊柱侧凸的研究。所选用的30篇文献中,3篇为综述,其余均为临床或基础实验研究。 资料综合：特发性脊柱侧凸多为三维平面的复杂畸形,现代脊柱侧凸治疗的目的是达到脊柱三维畸形矫正。椎弓根螺钉提供了贯穿脊柱三柱的强大控制力,并把矫形棒和脊椎连接起来,不仅作用力强、牢固可靠,而且还同时具有对脊柱的去旋转、节段撑开、节段加压和水平矫正等功能,可更有效的发挥对脊柱的三维矫正作用。 结论：椎弓根钉系统治疗特发性脊柱侧凸是安全可靠的,此外椎弓根钉系统提供了确实的三维矫形,并能够保留部分活动能力。     

Minimally invasive scoliosis surgery for adolescent idiopathic scoliosis using posterior mini-open technique

The purpose of this study aimed to analyze and evaluate the radiologic and clinical outcomes of minimally invasive scoliosis surgery (MISS) for correcting adolescent idiopathic scoliosis (AIS) using the mini-open technique. Thirty-four AIS patients who underwent MISS using the mini-open technique for deformity correction. Using two to four 3-centimeter-long skin incisions (mini-open) and tubular retractors, we performed screw fixations, rod assembly, rod derotation maneuver (RD), and bone graft. For thoracoplasty, four to six ribs were resected using the same incisions. Correction was attempted using rod translation and RD maneuvers. Radiological outcomes and clinical outcomes (SRS-22) were evaluated. Mean preoperative Cobb’s angle was 61.3° and curve flexibility (major curve) was 26.1%. This angle was corrected to 21.6° with a correction rate of 65.2% (P < 0.001). The coronal balance was not changed significantly. Sagittal vertical axes were corrected from −3.5 mm to 8.6 mm (–22 to 36.3 mm) (P = 0.009). Thoracic kyphosis angles and lumbar lordosis angles were not changed significantly but the values were within normal range. Each score of self-image in the SRS-22 questionnaire as well as the total score were improved significantly (P < 0.001). In conclusion, the MISS for correcting AIS using the mini-open technique showed comparable radiologic and clinical outcomes with fewer complications in patients with non-rigid scoliosis with Cobb’s angle between 50° and 80°. Long-term results of this novel MISS using the mini-open technique could further strengthen the rationale for adopting this technique for curve correction in selected cases of AIS.     

Playing for time: temporizing techniques in the treatment of multiple personality disorder

The treatment of multiple personality disorder (MPD) is often a prolonged and grueling enterprise, which imposes taxing demands upon the therapist and the patient alike. It becomes quite important to pace the therapy, lest the already beleaguered patient become both acutely and chronically overwhelmed. The majority of the extant literature on the use of hypnosis for the treatment of MPD addresses the processes of accessing the alters, abreacting traumata, arranging reconciliations among the alters, and facilitating integration. This communication discusses the necessity of titrating the amount of discomfort the patient must endure against the patient's resources and capacity to achieve mastery and self-efficacy. Several hypnotherapeutic techniques for offering respite and temporary asylum are explained and illustrated: alter substitution, the provision of sanctuary, distancing maneuvers, bypassing time, bypassing affect and/or memory, attenuating affect and/or memory retrieval, and rearranging the configuration of the alters by bartering or "shuffling the deck."     

A case study evaluation of the effects of different techniques for the treatment of anomia

Abstract

This study sought to demonstrate the relative effects of different techniques for treatment of the severe anomia of a 67 year-old aphasic woman. Both a semantic and a word form problem underlaid the anomia. A single subject approach was employed with an alternating treatment design to contrast four therapy conditions and two control conditions. Condition 1 involved semantic matching tasks and word form training (mentally visualising the written word, naming with the help of the first letter), condition 2 involved semantically unrelated matching tasks and word form training, condition 3 involved semantic matching tasks, condition 4 involved semantically unrelated matching tasks. In the two control conditions, the patient was only provided with the opportunity to try to name the pictures. With the first therapy condition, the criterion for the termination of therapy was reached. Moreover, there were overall significant differences between the different conditions. Some maintenance of the effects of therapy were observed two days later. No generalisation to untreated items was observed, although the patient seemed to be better at identifying the first syllables of words when naming. These results demonstrate that techniques which are designed for remediating particular anomic problems are a better means of therapy than techniques which are not.     

Guidelines for the use of magnetic resonance techniques in monitoring the treatment of multiple sclerosis

Because of the major difficulties in measuring clinical end points in multiple sclerosis (MS) treatment trials, there has been much enthusiasm for using magnetic resonance imaging (MRI) findings as an alternative outcome. To provide international consensus guidelines for the use of MRI in MS clinical trials, a task force of the US National MS Society was convened. The recommendations of the task force are presented in this review. Given the high sensitivity for detecting pathological activity in relapsing-remitting and secondary progressive MS, monthly T2-weighted and gadoliniumenhanced brain MRI is an excellent tool for short-term exploratory trials of new agents where it serves as the primary end point; in particular, failure to demonstrate a reduction in lesion activity avoids the time, cost, and risks of a larger clinical end point study. However, conventional MRI findings have a limited correlation with disability in established MS. The primary end point of a definitive trial should therefore be clinical, although serial MRI at 6- to 12-month intervals is a useful secondary end point in providing an index of pathological progression. In trials of patients presenting with clinically isolated syndromes suggestive of MS, MRI findings can be used in the entry criteria, and as a secondary outcome measure, but conversion to clinically definite MS should be the primary outcome. The pathological substrates of irreversible disability are demyelination and axonal loss. Putative magnetic resonance markers for these processes include decreased N-acetylaspartate on proton magnetic resonance spectroscopy, decreased magnetization transfer ratios, hypointensity on T1-weighted images, and loss of short T2 water fractions, some of which relate more closely to disability than conventional MRI findings. Further technical developments should lead to more accurate quantitation, greater pathological specificity, and stronger clinical correlations.     

半脊椎所致先天性脊柱侧凸三维矫形有限元模拟分析*☆

背景：对于半脊椎切除后长、短节段和前、后路固定矫形的选择,主要根据医生的临床经验。国内外对于半脊椎所致先天性脊柱侧凸的建模和研究尚未见报道。 目的：运用有限元法模拟半脊椎所致先天性脊柱侧凸三维矫形,分析半脊椎切除后不同固定方式的矫形效果和生物力学特点。 方法：通过有限元软件,利用基于CT图像建立的个体化半脊椎所致先天性脊柱侧凸三维有限元模型,仿真模拟半脊椎切除、前路或后路螺钉固定三维矫形技术,输出选择前路或后路固定矫形,以及不同节段固定的矫形结果。 结果与结论：顺利完成了模拟操作,半脊椎切除后,后路固定矫形效果好于前路固定矫形,特别是对后凸角的矫正,矫正率均大于50%;后路短节段固定矫形与长节段固定矫形在对脊柱侧后凸矫形效果上相差不大,差异值小于5°。针对该患者的个体化有限元模拟试验表明,在半脊椎切除后,后路短节段固定矫形为较好的治疗方案,能减少固定节段,并可获得满意的矫正率。     

Thoracoscopic sympathectomy for palmarhyperhidrosis: effects on pulmonary function

Palmar hyperhidrosis, probably caused by an over-reactivity of sympathetic nerves passing through the second and the third thoracic sympathetic ganglia (T2 & T3 ganglia), can only be cured by sympathectomy. Such sympathetic denervation may also alter pulmonary function. Previous studies have shown that open sympathectomy can cause significant deterioration in pulmonary function, however, the surgical procedure itself may contribute to the change. Recently thoracoscopic sympathectomy has been developed as a minimally invasive but effective treatment for palmar hyperhidrosis. In order to investigate the effect of sympathectomy, pulmonary function was compared before and four weeks after operation in 20 patients. Forced vital capacity (FVC) (-2.3%), forced expiratory volume in one second (FEV1) (-6.1%), and FEV1/FVC (-4.6%) were all slightly but significantly decreased four weeks after thoracoscopic sympathectomy. Also the instantaneous forced expiratory flow at 75%, 50% and 25% of the FVC (Vmax25, Vmax50, Vmax75) in flow-volume curves were decreased (-1.6%, -8.4%, and -20% respectively). Therefore, thoracoscopic sympathectomy minimises pulmonary restrictive effects but allows subclinical small airway obstructive effects to become more evident.     

胸腔镜下单孔胸交感神经链切断术治疗原发性手汗症

目的探讨电视胸腔镜下单孔胸交感神经链切断术治疗原发性手汗症的疗效和安全性。方法 2009年4月至2011年12月,80例原发性手汗症患者在胸腔镜下单孔操作,分别行T2～T5不同节段交感神经链切断术,术中持续监测双手掌温以判断手术疗效,随访症状缓解情况、有无复发以及代偿性出汗情况。结果全组病例手术均获成功,平均手术时间为(49.8±4.2)min,术后患者手掌多汗症状消失,双手转为干燥温暖状,双手掌皮肤温度均较术前显著升高(P<0.05),无严重并发症发生。77例患者随访1～32月,平均16.8月。1例单手手汗复发,已再次手术治愈。发生代偿性多汗38例(47.5%),其中中度出汗2例,轻度出汗36例。行单纯T3、T4或联合T3+T4胸交感神经链切断者代偿性多汗发生率为42.6%(29/68);余节段切断者代偿性多汗发生率为75.0%(9/12)。结论胸腔镜下单孔胸交感神经链切断术治疗手汗症具有操作简单、安全有效、创伤小等特点,值得临床推广。     

The use of exercises in the treatment of scoliosis: an evidence-based critical review of the literature

The loss of flexibility in a spinal curvature defines it as a structural spinal deformity; a curvature sufficiently mobile to resolve with a change in posture is a non-structural or ‘functional’ scoliosis which is within the normal limits of movement for a human spine. It, therefore, seems logical that exercise-based therapies designed to improve and/or maintain flexibility and range of motion of the spine and thorax would be useful in the treatment of scoliosis. Recognition of the importance of maintaining flexibility of the thoracic spinal column to avoid scoliosis-associated pulmonary dysfunction made the use of exercise-based therapies a topic of clinical interest in ancient Greece. In recent years, successful prevention of polio epidemics has resulted in a stable change in patient populations such that most individuals diagnosed with scoliosis do not suffer from irreversible central nervous system compromise. As a result, realistic opportunities to examine the role of exercise in treatment of scoliosis are available for the first time in history. A growing body of evidence from independent sources is consistent with the hypothesis that exercise-based approaches can be used effectively to reverse the signs and symptoms of spinal deformity and to prevent progression in children and adults.