Comparison of instrumented anterior interbody fusion with instrumented circumferential lumbar fusion

Posterior lumbar interbody fusion (PLIF) restores disc height, the load bearing ability of anterior ligaments and muscles, root canal dimensions, and spinal balance. It immobilizes the painful degenerate spinal segment and decompresses the nerve roots. Anterior lumbar interbody fusion (ALIF) does the same, but could have complications of graft extrusion, compression and instability contributing to pseudarthrosis in the absence of instrumentation. The purpose of this study was to assess and compare the outcome of instrumented circumferential fusion through a posterior approach [PLIF and posterolateral fusion (PLF)] with instrumented ALIF using the Hartshill horseshoe cage, for comparable degrees of internal disc disruption and clinical disability. It was designed as a prospective study, comparing the outcome of two methods of instrumented interbody fusion for internal disc disruption. Between April 1994 and June 1998, the senior author (N.R.B.) performed 39 instrumented ALIF procedures and 35 instrumented circumferential fusion with PLIF procedures. The second author, an independent assessor (S.M.), performed the entire review. Preoperative radiographic assessment included plain radiographs, magnetic resonance imaging (MRI) and provocative discography in all the patients. The outcome in the two groups was compared in terms of radiological improvement and clinical improvement, measured on the basis of improvement of back pain and work capacity. Preoperatively, patients were asked to fill out a questionnaire giving their demographic details, maximum walking distance and current employment status in order to establish the comparability of the two groups. Patient assessment was with the Oswestry Disability Index, quality of life questionnaire (subjective), pain drawing, visual analogue scale, disability benefit, compensation status, and psychological profile. The results of the study showed a satisfactory outcome (score30) on the subjective (quality of life questionnaire) score of 71.8% (28 patients) in the ALIF group and 74.3% (26 patients) in the PLIF group (P>0.05). On categorising Oswestry Index scores into "excellent", "better", "same", and "worse", we found no difference in outcome between the two groups: 79.5% (n=31) had satisfactory outcome with ALIF and 80% (n=28) had satisfactory outcome with PLIF. The rate of return to work was no different in the two groups. On radiological assessment, we found two nonunions in the circumferential fusion (PLIF) group (94.3% fusion rate) and indirect evidence of no nonunions in the ALIF group. There was no significant difference between the compensation rate and disability benefit rate between the two groups. There were three complications in ALIF group and four in the PLIF (circumferential) group. On the basis of these results, we conclude that it is possible to treat discogenic back pain by anterior interbody fusion with Hartshill horseshoe cage or with circumferential fusion using instrumented PLIF.     

Posterior lumbar interbody fusion using cages, combined with instrumented posterolateral fusion: a study of 75 cases

Posterior lumbar interbody fusion (PLIF) with cages can be combined with decompression of the spinal canal and with instrumented posterolateral fusion (IPLF) with pedicle screws, through a single posterior incision. The authors wanted to assess retrospectively the clinical and radiological outcome of PLIF + IPLF performed by the senior author. Between July 1997 and December 2003, 75 patients underwent PLIF with cages and IPLF with transpedicular instrumentation, for either degenerative disc disease, stenosis, spondylolisthesis or post-discectomy syndrome. The clinical outcome was evaluated according to the criteria of Kirkaldy-Willis. Flexion/extension radiographs and CT-scans were obtained in cases where there was any doubt about the fixation/fusion status. The mean age was 48.7 years (range: 30 to 75). The mean duration of follow-up was 29.17 months (range: 12 to 67). The clinical outcome was excellent or good in 85.3% of the patients. There were 4/75 patients (5.3%) who failed to return to their original occupation. Four posterolateral fusions were uncertain, but all anterior fusions succeeded: thus circumferential fusion was obtained in 71 out of 75 cases, or 94.6%. Three patients sustained a neurological complication, but only one was left with a partial drop foot. The results were comparable with similar studies. Therefore the authors recommend further use of PLIF + IPLF in painful lumbar degenerative spinal disease where conservative management has failed.     

Laparoscopic splenectomy: analysis of 60 consecutive cases

The purpose of the study was to analyze the results of 60 patients who were candidates for laparoscopic splenectomy. Over the period from May 1994 to May 2001, 60 patients were candidates for splenectomy. Laparoscopy was contraindicated in 3 cases because of ASA III and marked splenomegaly (2 cases) and previous gastric resection (1 case). The procedure was indicated for benign disease in 38 cases and for malignant disease in the remainder. Fifty-three procedures were completed laparoscopically (92.9%). Conversion proved necessary in 4 patients (6.7%) due to large incisional hernia, perisplenic abscess, bleeding of major splenic vessels at the hilum and marked splenomegaly (2 cases of lymphoma). The mean operative time was 200 min for the malignancies and 110 min for the benign conditions (P < 0.05). Major morbidity occurred in 5 cases (8.7%). No deaths were registered. The mean postoperative hospital stay was 7.5 days for patients with malignancies and 5.2 days for patients with benign disease (P < 0.05). Laparoscopic splenectomy was safe and effective in patients with benign disease, even in cases of marked splenomegaly. The morbidity rate was significantly higher in lymphoma patients than in patients with benign haematological disorders.     

Minimally invasive transforaminal lumbar interbody fusion: Results of 23 consecutive cases

Background:

The use of minimally invasive surgical (MIS) techniques represents the most recent modification of methods used to achieve lumbar interbody fusion. The advantages of minimally invasive spinal instrumentation techniques are less soft tissue injury, reduced blood loss, less postoperative pain and shorter hospital stay while achieving clinical outcomes comparable with equivalent open procedure. The aim was to study the clinicoradiological outcome of minimally invasive transforaminal lumbar interbody fusion.

Materials and Methods:

This prospective study was conducted on 23 patients, 17 females and 6 males, who underwent MIS-transforaminal lumbar interbody fusion (TLIF) followed up for a mean 15 months. The subjects were evaluated for clinical and radiological outcome who were manifested by back pain alone (n = 4) or back pain with leg pain (n = 19) associated with a primary diagnosis of degenerative spondylolisthesis, massive disc herniation, lumbar stenosis, recurrent disc herniation or degenerative disc disease. Paraspinal approach was used in all patients. The clinical outcome was assessed using the revised Oswestry disability index and Macnab criteria.

Results:

The mean age of subjects was 55.45 years. L4-L5 level was operated in 14 subjects, L5-S1 in 7 subjects; L3-L4 and double level was fixed in 1 patient each. L4-L5 degenerative listhesis was the most common indication (n = 12). Average operative time was 3 h. Fourteen patients had excellent results, a good result in 5 subjects, 2 subjects had fair results and 2 had poor results. Three patients had persistent back pain, 4 patients had residual numbness or radiculopathy. All patients had a radiological union except for 1 patient.

Conclusion:

The study demonstrates a good clinicoradiological outcome of minimally invasive TLIF. It is also superior in terms of postoperative back pain, blood loss, hospital stay, recovery time as well as medication use.     

Lumbosacral fusion by standing H-graft technique

Summary Fusion of the lumbosacral spine was carried out on 44 patients. A modification of the standing H-graft technique was used in 41 of the patients. The operative diagnosis was degeneration of the lumbosacral spine in nearly two-thirds of the cases and spondylolisthesis in about one-third. Operations for low back or sciatic pain had previously been performed on 17 patients. The duration of postoperative bed rest ranged from one to six weeks; a lumbosacral corset was used at least for six weeks postoperatively. The average stay in hospital was 52 days. Complications occurred in five cases.The operative results of 40 patients were evaluated on the basis of a follow-up examination performed on average 3.6 years after operation. Nearly half the patients with radiologically successful fusions had a good subjective improvement and about one-fourth had returned to their previous or corresponding occupations. The operative result was at least fair in about half the patients, assessed by a measure of the patients' subjective improvement and working capacity. In the non-fusion group (six cases) the operative results were exclusively poor. Age over 40 years, long-standing preoperative disability and previous back operations proved prognostic factors for poor results.Assessed from functional radiographs, 63% of two-segment fusions and 95% of one-segment fusions were successful.The operative technique appeared simple and suitable for fusions of one spinal segment, but the value of the lumbosacral fusion in the treatment of low back pain seemed doubtful because of the great proportion of poor clinical results even following technically successful fusions.

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Zusammenfassung Die dorsale Spondylodese der Lumbosakralregion wurde an 44 Patienten durchgeführt. Eine Modifizierung der stehenden H-Span-Technik wurde bei 41 Patienten angewendet. Lumbosakrale Degeneration war in fast zwei Drittel, Spondylolisthesis in etwa einem Drittel der Fälle die Operations-diagnose. Bei 17 Patienten waren bereits früher Operationen wegen Rückenschmerzen oder Ischiassyndrom durchgeführt worden. Die postoperative Bettruhe dauerte eine bis sechs Wochen. Nach der Operation wurde ein lumbosakrales Korsett mindestens sechs Wochen getragen. Der durchschnittliche Krankenhausaufenthalt betrug 52 Tage. In fünf Fällen kamen Komplikationen vor.Die Operationsergebnisse von 40 Patienten wurden auf Grund der Nachuntersuchung bewertet. Die Beobachtungszeit betrug im Durchschnitt 3,6 Jahre. Beinahe die Hälfte der Patienten mit röntgenologisch stabiler Fusion hatte ein gutes subjektives Endergebnis, und ein Viertel hatten ihre frühere oder eine entsprechende Arbeit wieder aufgenommen. Bei der Anwendung der subjektiven Symptome und der Arbeitsfähigkeit als Kriterien der Bewertung war das operative Resultat wenigstens mäßig bei etwa der Hälfte der Patienten. Bei den sechs Fällen, bei denen die stabile Fusion ausblieb, waren die Operationsresultate ausschließlich schlecht. Alter über 40 Jahre, langdauernde voroperative Arbeitsunfähigkeit und frühere Rücken-operationen becinträchtigten die Operationserfolge.Auf Grund der Bewertung funktioneller Röntgen-aufnahmen waren 63% der Versteifungen zweier Segmente und 95% der Versteifungen eines Segmentes erfolgreich.Die angewandte Operationstechnik erwies sich als einfach und angebracht für die Versteifung eines, aber nicht mehrerer Segmente. In der Behandlung von Kreuzschmerzen scheint aber der Wert der lumbosakralen Spondylodese fraglich zu sein, weil die klinischen Endergebnisse, selbst bei technisch erfolgreichen Fusionen, zum größten Teil schlecht waren.

     

指甲下肿瘤124例临床分析

目的 总结指甲下肿瘤的临床特点及诊疗方法.方法 对124例指甲下肿瘤临床资料进行分析,介绍治疗方法与疗效,以及常见的并发症.结果 指甲下肿瘤良、恶性均有,以良性多见,其中血管球瘤发病率最高;恶性肿瘤少见,为恶性黑色素瘤及鳞状上皮细胞癌.结论 指甲下肿瘤种类多,因指甲系统特殊的解剖与生理特点,应重视肿瘤的诊断与治疗.     

Functional outcome analysis: instrumented posterior lumbar interbody fusion for degenerative lumbar scoliosis

Purpose  

Although instrumented posterior lumbar interbody fusion (PLIF) has been becoming a popular and effective method for treating degenerative lumbar scoliosis, the clinical outcome is rarely reported. We retrospectively evaluated the clinical and radiographic outcomes in patients with degenerative lumbar scoliosis after instrumented PLIF.     

Acute appendicitis: An analysis of 417 consecutive cases

A statistical analysis of 417 consecutive cases of proved acute appendicitis is made.The distribution in sex, color and age groups is stated.An outline of the usual method of treatment is given.The signs, symptoms, temperature, pulse, respiration, duration of symptoms and use of cathartics are analyzed.At operation the McBurney incision is used almost exclusively when the diagnosis is certain. When drainage is employed, the tendency is to suture the peritoneum only.Wound infections, bacteriology and complications are presented.There were fourteen deaths or an incidence of 3.3 per cent in the entire series. There were no deaths in 300 unruptured cases; ten deaths out of seventy or an incidence of 14.2 per cent in the group with spreading peritonitis and four out of fortyseven or an incidence of 8.5 per cent in the group with abscess.A brief report of each case in which death occurred is given.     

Necrotizing pancreatitis: contemporary analysis of 99 consecutive cases

OBJECTIVE: To analyze the impact of a conservative strategy of management in patients with necrotizing pancreatitis, reserving intervention for patients with documented infection or the late complications of organized necrosis. SUMMARY BACKGROUND DATA: The role of surgery in patients with sterile pancreatic necrosis remains controversial. Although a conservative approach is being increasingly used, few studies have evaluated this strategy when applied to the entire spectrum of patients with necrotizing pancreatitis. METHODS: The authors reviewed 1,110 consecutive patients with acute pancreatitis managed at Brigham and Women's Hospital between January 1, 1995, and January 1, 2000, focusing on those with pancreatic necrosis documented by contrast-enhanced computed tomography. Fine-needle aspiration, the presence of extraintestinal gas on computed tomography, or both were used to identify infection. RESULTS: There were 99 (9%) patients with necrotizing pancreatitis treated, with an overall death rate of 14%. In three patients with underlying medical problems, the decision was made initially not to intervene. Of the other 62 patients without documented infection, all but 3 were managed conservatively; this group's death rate was 11%. Of these seven deaths, all were related to multiorgan failure. Five patients in this group eventually required surgery for organized necrosis, with no deaths. Of the 34 patients with infected necrosis, 31 underwent surgery and 3 underwent percutaneous drainage. Only four (12%) of these patients died, all of multiorgan failure. Of the total 11 patients who died, few if any would have been candidates for earlier surgical intervention. CONCLUSIONS: These results suggest that conservative strategies can be applied successfully to manage most patients with necrotizing pancreatitis, although some will eventually require surgery for symptomatic organized necrosis. Few if any patients seem likely to benefit from a more aggressive strategy.     

指甲下肿瘤124例临床分析

目的 总结指甲下肿瘤的临床特点及诊疗方法.方法 对124例指甲下肿瘤临床资料进行分析,介绍治疗方法与疗效,以及常见的并发症.结果 指甲下肿瘤良、恶性均有,以良性多见,其中血管球瘤发病率最高;恶性肿瘤少见,为恶性黑色素瘤及鳞状上皮细胞癌.结论 指甲下肿瘤种类多,因指甲系统特殊的解剖与生理特点,应重视肿瘤的诊断与治疗.     

Anatomy of the right liver lobe: a surgical analysis in 124 consecutive living donors

Bageacu S, Abdelaal A, Ficarelli S, ElMeteini M, Boillot O. Anatomy of the right liver lobe: a surgical analysis in 124 consecutive living donors.
Clin Transplant 2011: 25: E447–E454. © 2011 John Wiley & Sons A/S. Abstract: Background: Understanding anatomic variations of the right lobe is fundamental in adult to adult living donor liver transplantation. Methods: We analysed anatomy in 124 right liver (RL) donors. Results: Portal vein: normal anatomy was found in 85.5% donors. In 14.5% the main right portal vein (PV) was absent. Hepatic artery: single arterial inflow of the RL was identified in 96% of donors. In 4% two arterial stumps were found. Bile duct: classic anatomy was identified in 50.8% of donors; 9.7% had a trifurcation of the common bile duct; in 7.2% the right anterior and in 15.3% the right posterior bile duct opened into the left bile duct; one segmental bile duct opened directly into the common bile duct in 12.1% and two segmental bile ducts in 4.8%. Hepatic veins (HV): in 74.3% the right HV was the single outflow; in 24.2% significant accessory HV (>5 mm) were preserved, in 2.4% the middle HV was harvested. We found that patients with PV variations had high incidence of multiple bile ducts (88.9%) while patients with single right PV had lower incidence (42.4%) (p = 0.00026). Conclusion: While anatomic variations in the RL donor were common, no contraindication to RL harvesting was noted in this study.     

Renal oncocytoma: a clinicopathological analysis of 45 consecutive cases

OBJECTIVE: To evaluate the clinical behaviour and pathology of renal oncocytoma in a well-defined population over a 30-year period. PATIENTS AND METHODS: In a retrospective population-based study we assessed relevant clinical and pathological factors in 45 patients (31 men and 14 women) diagnosed with renal oncocytoma in Iceland between 1971 and 2000. Clinical presentation, pathology, survival and causes of death were evaluated. RESULTS: The age-standardized incidence was 0.3 per 100,000 per year for both men and women, the incidence of oncocytomas being 5.5% of renal cell carcinomas (RCCs) diagnosed during the same period in Iceland. Fourteen patients were diagnosed at autopsy for an unrelated disease. Of 31 living patients (mean age 70.5 years), seven were diagnosed incidentally (23%), and the others had presented with haematuria (32%), abdominal pain (29%), and weight loss (10%). All the patients had a radical nephrectomy, except for one with bilateral oncocytoma who had a partial nephrectomy. The mean (range) tumour size was 5.7 (0.9-12) cm. Eighteen patients (58%) were diagnosed at Tumour-Node-Metastasis stage I, 10 at stage II (32%) and three at stage III (10%), all of those at stage III having renal capsular penetration or tumour invasion into perirenal fat tissue (T3aN0M0). No patients were diagnosed with lymph node or distant metastasis. Two cases of coexisting RCC were detected. After a median follow-up of 8.3 years there were no recurrences or deaths from oncocytoma (100% disease-specific survival). The overall 5-year survival was 63%, with most patients dying from cardiovascular diseases or nonrenal cancers. CONCLUSIONS: In most cases renal oncocytoma behaves like a benign tumour; the long-term prognosis is excellent. Thus, in the present patients, radical nephrectomy could be regarded as an over-treatment and nephron-sparing surgery as more appropriate, especially in patients with small tumours. However, both coexisting RCC and perirenal fat invasion, a hallmark of malignant behaviour, might indicate that more radical surgery is warranted in some of these patients.