Cervical epidural steroid injections for symptomatic disc herniations

OBJECTIVES: Cervical disc herniations are a common cause of radicular pain from nerve root impingement and may necessitate surgical decompression to alleviate symptoms. The use of cervical epidural injections has not been studied in detail. The objective of this retrospective study was to examine the efficacy of cervical epidural steroid injections for the treatment of symptomatic herniated cervical discs. METHODS: Patients with herniated cervical discs without myelopathy that had failed conservative management and were otherwise surgical candidates were offered a trial of cervical epidural injections. The results and benefits of the injections were examined as well as the incidence of proceeding to surgical intervention. RESULTS: Of the 70 treated patients, 44 (63%) had significant relief of their symptoms and did not wish to proceed with surgical treatment. Of the 26 patients who underwent surgical decompression, 92% had successful resolution of their symptoms. The nonsurgical and surgical groups were similar in terms of gender, preinjection symptoms, or number of injections. However, significant differences between the two groups were found with regard to age (P<0.05) and time from initial consultation to initial injection (P<0.05). With an average of 13-month follow-up, 45 (65.3%) patients reported a good/excellent result per Odom criteria. In addition, 53 (75%) would attempt cervical epidural steroid injections again in the future. No complications were noted in our series. CONCLUSIONS: Cervical epidural injections are a reasonable part of the nonoperative treatment of patients with symptomatic cervical disc herniations. The success rates appear to be very similar to prior studies of lumbar epidural injections for symptomatic lumbar disc herniations. It appears that a large percentage of the patients may obtain relief from radicular symptoms and avoid surgery for the follow-up period up to 1 year. In addition, patients older than 50 years and those who received the injections earlier, less than 100 days from diagnosis, seemed to have a more favorable outcome.     

Cost and use of conservative management of lumbar disc herniation before surgical discectomy

Background ContextLumbar discectomy is one of the most common spine surgical procedures. With the exception of true emergencies (eg, cauda equina syndrome), lumbar discectomy is usually performed as an elective procedure after a prudent trial of nonoperative treatment. Although several studies have compared costs of definitive operative or nonoperative management of lumbar disc herniation, no information has been published regarding the cost of conservative care in patients who ultimately underwent surgical discectomy.PurposeThe purpose of this study was to determine the financial costs (and relative distribution of those costs) associated with the nonoperative management of lumbar disc herniation in patients who ultimately failed conservative care and elected to undergo surgical discectomy.Study DesignThis is a retrospective database review.Patient SampleThe sample comprises patients within the database who underwent lumbar discectomy.Outcome MeasuresThe outcome measures were frequency of associated procedures and the costs of those procedures.Materials and MethodsA search was conducted using a commercially available online database of insurance records of orthopedic patients to identify all patients within the database undergoing lumbar discectomy between 2004 and 2006. Patients were identified by American Medical Association Current Procedural Terminology code. The associated charge codes for the 90-day period before the surgery were reviewed and categorized as outpatient physician visits, imaging studies, physical therapy, injection, chiropractic manipulation, medication charges, preoperative studies, or miscellaneous charges. The frequency of each code and the percentage of patients for whom that code was submitted to the insurance companies were noted, as were the associated charges.ResultsIn total, 30,709 patients in the database met eligibility criteria. A total of $105,799,925 was charged during the 90 days preoperatively, an average of $3,445 per patient. Average charge for discectomy procedure was $7,841. Charges for injection procedures totaled $16,211,246 or 32% of total charges, diagnostic imaging $15,648,769 (31%), outpatient visits $6,552,135 (13%), physical therapy visits $5,723,644 (11%), chiropractic manipulation $1,177,406 (2%), preoperative studies $426,976 (0.8%), medications $263,039 (0.5%), and miscellaneous charges $1,177,371 (2%).ConclusionsCharges for preoperative care of patients with lumbar disc herniation are substantial and are split almost evenly between diagnostic charges (outpatient visits, imaging, laboratory studies, and miscellaneous) and therapeutic charges (injections, physical therapy, chiropractic manipulation, and medications). Although a large number of patients will ultimately require surgical intervention, given that many patients will improve with nonoperative therapy, a trial of conservative management is appropriate. Additional studies to identify patients who may ultimately fail nonoperative treatment and would benefit from early discectomy would be beneficial.     

Increased signal intensity of the spinal cord on magnetic resonance images in cervical compressive myelopathy. Does it predict the outcome of conservative treatment?

STUDY DESIGN: Correlation between a lesion of the spinal cord that elicits increased signal intensity (ISI) on magnetic resonance images (MRIs) and the outcome of conservative treatment for cervical compressive myelopathy was retrospectively investigated. OBJECTIVE: To investigate whether ISI could predict the outcome of conservative treatment for cervical compressive myelopathy. SUMMARY OF BACKGROUND DATA: It is unknown whether ISI is related to the outcome of conservative treatment for cervical compressive myelopathy. METHODS: Fifty-two patients with mild cervical myelopathy underwent conservative treatment with a cervical brace. The compressive lesions were spondylosis in 29 patients, disc herniation in 12, and an ossification of the longitudinal ligament in 11. They also underwent MRI (1.5 T), and ISI was evaluated on T2-weighted sagittal and axial images. The ISI areas were classified as focal or multisegmental. Thirty-nine patients underwent follow-up MRI after a mean interval of 2 years, 4 months. The transverse area of the spinal cord was also measured on T2-weighted axial images. The outcome of conservative treatment was assessed using the Japanese Orthopedic Association Score (JOA score). Patients showing either an improvement in the JOA score or with a JOA score of 15 or more were considered to have a satisfactory outcome. RESULTS: The average JOA score was 14.0 +/- 1.4 (range, 10-16) before conservative treatment and 14.4 +/- 1.9 (range, 10-17) at follow-up. The average gain in the JOA score was 0.4 points +/- 1.9 (range, -5 to +6). The outcome was satisfactory in 36 patients (69%). An area of ISI was observed in 34 patients (65%) before treatment (24 focal and 10 multisegmental). A satisfactory outcome was obtained in 78% of the patients without ISI, in 63% of those with focal ISI, and in 70% of those with multisegmental ISI. No statistically significant difference was seen among these three groups in the percentages of patients with satisfactory outcome, JOA scores before and after treatment or transverse spinal cord area. Of the 39 patients who were re-examined by MRI, 28 showed an area of ISI. The ISI regressed in five patients (18%). Satisfactory outcome was obtained in all 5 patients with regression of ISI, in 16 (70%) of the 23 patients without regression of ISI, and in 10 (91%) of the 11 patients without ISI apparent on the the first images (difference, not significant). CONCLUSIONS: Increased signal intensity was not related to a poor outcome of conservative treatment or severity of myelopathy in the patients with mild cervical myelopathy.     

Therapeutic value of gastrografin in adhesive small bowel obstruction after unsuccessful conservative treatment: a prospective randomized trial

OBJECTIVE: To assess the therapeutic value of Gastrografin in the management of adhesive small bowel obstruction after unsuccessful conservative treatment. SUMMARY BACKGROUND DATA: Gastrografin is a hyperosmolar water-soluble contrast medium. Besides its predictive value for the need for surgery, there is probably a therapeutic role of this contrast medium in adhesive small bowel obstruction. METHODS: Patients with clinical evidence of adhesive small bowel obstruction were given trial conservative treatment unless there was suspicion of strangulation. Those who responded in the initial 48 hours had conservative treatment continued. Patients showing no clinical and radiologic improvement in the initial 48 hours were randomized to undergo either Gastrografin meal and follow-through study or surgery. Contrast that appeared in the large bowel within 24 hours was regarded as a partial obstruction, and conservative treatment was continued. Patients in whom contrast failed to reach the large bowel within 24 hours were considered to have complete obstruction, and laparotomy was performed. For patients who had conservative treatment for more than 48 hours with or without Gastrografin, surgery was performed when there was no continuing improvement. RESULTS: One hundred twenty-four patients with a total of 139 episodes of adhesive obstruction were included. Three patients underwent surgery soon after admission for suspected bowel strangulation. Strangulating obstruction was confirmed in two patients. One hundred one obstructive episodes showed improvement in the initial 48 hours and conservative treatment was continued. Only one patient required surgical treatment subsequently after conservative treatment for 6 days. Thirty-five patients showed no improvement within 48 hours. Nineteen patients were randomized to undergo Gastrografin meal and follow-through study and 16 patients to surgery. Gastrografin study revealed partial obstruction in 14 patients. Obstruction resolved subsequently in all of them after a mean of 41 hours. The other five patients underwent laparotomy because the contrast study showed complete obstruction. The use of Gastrografin significantly reduced the need for surgery by 74%. There was no complication that could be attributed to the use of Gastrografin. No strangulation of bowel occurred in either group. CONCLUSIONS: The use of Gastrografin in adhesive small bowel obstruction is safe and reduces the need for surgery when conservative treatment fails.     

Resorption of thoracic disc herniation. Report of 2 cases

The authors describe 2 cases of thoracic disc herniation, resulting in acute myelopathy without bladder dysfunction or progressive muscular weakness; the herniated disc apparently resorbed without surgical intervention. Thoracic disc herniations are less frequent than cervical or lumbar disc herniations and are usually associated with severe neurological deficits. In these 2 cases, the herniated discs exhibited marked decreases in size, corresponding to a favorable clinical outcome within a few months after the initiation of conservative treatment with prostaglandin E(1) and/or steroids in conjunction with physical therapy. The authors conclude that thoracic herniated discs are capable of undergoing natural resorption and that conservative treatment could be indicated, even in the presence of moderate myelopathy, when the myelopathy is not accompanied by bladder dysfunction or progressive muscular weakness.     

Management of severe traumatic brain injury by decompressive craniectomy

OBJECTIVE: The beneficial effect of decompressive craniectomy in the treatment of head trauma patients is controversial. The aim of our study was to assess the value of unilateral decompressive craniectomy in patients with severe traumatic brain injury. METHODS: We retrospectively investigated 49 patients who underwent decompressive craniectomy. Intracranial pressure, cerebral perfusion pressure, therapy intensity level, and cranial computed tomographic scan features (midline shift, visibility of ventricles, gyral pattern, and mesencephalic cisterns) were evaluated before and after craniectomy. The gain of intracranial space was calculated from cranial computed tomographic scans. Patient outcome was graded using the Glasgow Outcome Scale. RESULTS: Thirty-one patients (63.3%) underwent rapid surgical decompression within 4.5 +/- 3.8 hours after trauma; in 18 patients (36.7%), delayed surgical decompression was performed 56.2 +/- 57.0 hours after injury. Patients younger than 50 years or patients who underwent rapid surgical decompression had a significantly better outcome than older patients or patients who underwent delayed surgical decompression. Craniectomy significantly decreased midline shift and improved visibility of the mesencephalic cisterns. The state of the mesencephalic cisterns correlated with the distance of the lower border of the craniectomy to the temporal cranial base. Alterations in intracranial pressure, cerebral perfusion pressure, and therapy intensity level were not significant. The overall mortality of the patients corresponded to the reports of the Traumatic Coma Data Bank (1991). CONCLUSION: Although there was a significant decrease in midline shift after craniectomy, this did not translate into decompressive craniectomy demonstrating a beneficial effect on patient outcome.     

Relationships between outcomes of conservative treatment and magnetic resonance imaging findings in patients with mild cervical myelopathy caused by soft disc herniations.

STUDY DESIGN: A retrospective follow-up study of conservatively treated patients with mild cervical myelopathy caused by cervical soft disc herniation. OBJECTIVE: To investigate the outcome of conservative treatment for patients with mild myelopathy caused by cervical soft disc herniation and to evaluate usefulness of magnetic resonance findings in the prediction of the outcomes. SUMMARY OF BACKGROUND DATA: Recent studies on conservative treatment for cervical soft disc herniation have focused mainly on radiculopathy, and not on myelopathy. METHODS: Twenty-seven patients with mild cervical myelopathy secondary to cervical soft disc herniation were treated conservatively for more than 6 months by cervical bracing and restriction of daily activities. Of the 27 patients, 17 patients (Group A) underwent conservative treatment only and it was associated with improvement in their neurologic deficits, while the other 10 patients (Group B) ultimately underwent decompression surgery because of neurologic deterioration. Comparisons between the two groups were made in regard to JOA scores, patient satisfaction, and magnetic resonance findings, including location of the disc herniation (focal or diffuse in the sagittal plane, median or paramedian in the axial plane). RESULTS: The JOA scores were 13.6 +/- 1.6 in Group A and 14.1 +/- 1.6 in Group B before treatment, 14.9 +/- 1.0 and 12.9 +/- 2.1, respectively, at 3 months, and 16.2 +/- 0.8 and 16.0 +/- 1.2, respectively, at the final follow-up. The JOA scores at 3 months were significantly lower in Group B than in Group A. Satisfaction with the results of treatment at the final follow-up was reported by 77% of the patients in Group A and 90% in Group B. Focal-type herniation was present in 47% of the patients in Group A and 70% in Group B, while median-type herniation was diagnosed in 77% in Group A and 30% in Group B. Follow-up magnetic resonance imaging of the patients in Group A showed spontaneous regression of a herniated mass in 10 patients (59%). Diffuse-type herniations were more likely to regress spontaneously than focal-type herniations (78% vs. 37%). CONCLUSIONS: Conservative treatment is an effective treatment option for mild cervical myelopathy caused by cervical soft disc herniation. A good outcome can be expected in patients with a median-type and/or diffuse-type herniation on magnetic resonance imaging.     

Early endoscopic treatment of chylothorax develops after surgical treatment of lung cancer patients

Objective: Chylothorax which occasionally develops after surgical treatment of lung cancer is generally treated conservatively, and surgical treatment is limited to patients who do not respond well to conservative treatment. Subjects and Methods: Of the 941 lung cancer operation, 6 patients in whom Chylothorax developed after surgical treatment of lung cancer were evaluated for its characteristics and outcome. Results: Two patients underwent thoracoscopic treatment. The duration of drainage was shorter for the 2 patients undergoing chylothorax operation than for the 4 patients who underwent conservative treatment. The mean duration of hospitalization after surgical treatment of lung cancer was 24 days for the patients who underwent conservative treatment alone and 12.5 days for the patients who underwent chylothorax operation. conclusion: Patients in whom chylothorax develops after surgical treatment of lung cancer should promptly undergo operation when the volume of chylous fluid is not decreased by conservative treatment.     

Treatment of spontaneous intracerebral haemorrhage. A retrospective analysis of 74 consecutive cases with special reference to computertomographic data

The surgical treatment of spontaneous intracerebral haemorrhage (SIH) is still a matter of controversy, although most Neurosurgeons agree that surgery is indicated in selected cases. The introduction of computer tomography (CT) permits a more accurate determination of the localization, size and expansion of an intracerebral haemorrhage. The aim of this study is to evaluate the results of surgical and conservative therapy in selected cases and to search for parameters that could help to predict the outcome and facilitate the decision between surgery and conservative therapy. Seventy-four patients treated following SIH during the years 1976-1980 were analyzed. The decision for surgical treatment was made on the basis of the patient's conditions and the findings in the CT scan. Thirty-nine patients with mainly medium-sized haemorrhages underwent surgery and 35 were conservatively treated. The mortality after three months was 5/39 (13%) in the surgical and 7/35 (20%) in the conservative group. The volume of haemorrhage was significantly larger in the patients who died and 9/10 patients with a haematoma volume above 80 ml died. Five of these 10 were operated and the other 5 not and surgery seemed to be of little benefit to this group. Dilatation of the contralateral ventricle is another indicator of a bad prognosis. Long-term follow-up investigation was carried out 4-38 months after the initial treatment. Total mortality was 19 out of 68 patients that could be reached for late follow-up. Eleven patients (29%) were fully recovered and 16 had minor neurological deficits. There was no difference in late results between the surgical and the conservative groups, but the patients in the surgical group were generally in a worse condition and had larger haemorrhages that the others. The fact that the total mortality in this material is lower than in other conservatively treated series favours surgery in selected cases of SIH. The use of CT gives valuable information as to the prognosis and especially the volume of haemorrhage seems to be a good prognostic factor.     

Surgical or conservative treatment for chronic rotator cuff calcifying tendinitis – a matched-pair analysis of 100 patients

Conservative or operative treatment for rotator cuff calcifying tendinitis was investigated in 100 patients in a matched-pair analysis. They were examined clinically and ultrasonographically 35–60 months after the initial visit. The mean Patte score was 91.8 for the patients who underwent surgical treatment and 81 for the ones who received conservative therapy (p < 0.004), while the age-related Constant-score was 103.4 and 95, respectively. Ultrasonography showed 28% calcifications in the surgical group, 18% newly formed and 10% that did not resolve after surgery. In the conservatively treated group, 33% calcifications were seen, of which 67% resolved. The number of rotator cuff ruptures was significantly higher in the conservative group. In the surgical group, 2% of partial tears and in the conservative group 5% of partial and 4% of complete cuff ruptures were found. Conservative treatment for calcifying tendinitis leads to less favourable pain results in the long term than surgical treatment. Surgery shortens the painful period and may reduce the number of future rotator cuff ruptures. Finally, the subjective functional outcome is significantly better after surgery. Received: 8 January 2000     

Occipital nerve electrical stimulation via the midline approach and subcutaneous surgical leads for treatment of severe occipital neuralgia: a pilot study

Persistent occipital neuralgia can produce severe headaches that may not be controllable by conservative or surgical approaches. We describe a case series of 6 patients who had chronic headaches over an average of 4.9 yr who underwent occipital nerve electrical stimulation lead implantation using a modified midline approach. The patients had received conservative and surgical therapies in the past including oral antidepressants, membrane stabilizers, opioids, occipital nerve blocks, and radiofrequency ablations. Significant decreases in pain visual analog scale (VAS) scores and drastic improvement in functional capacity were observed during the occipital stimulation trial and during the 3-mo follow-up after implantation. The mean VAS score changed from 8.66 +/- 1.0 to 2.5 +/- 1.3 whereas pain disability index improved from 49.8 +/- 15.9 to 14.0 +/- 7.4. Our midline approach has several advantages compared with the submastoid approach used elsewhere. There is only one small midline incision over the upper neck and the strain on the lead extension occurs only with flexion and is minimal with lateral flexion and rotation, which contributes to overall stability of this system.     

Comparative analysis of chest tube thoracostomy and video-assisted thoracoscopic surgery in empyema and parapneumonic effusion associated with pneumonia in children

BACKGROUND: Controversy exists regarding the optimal management strategy for children having empyema or parapneumonic effusion as a complication of pneumonia. We hypothesized that video-assisted thoracoscopic surgery (VATS)-assisted drainage of pleural fluid and debridement of the pleural space is superior to a chest tube alone in the management of these patients. We further identified predictive factors-namely, presentation, radiographic findings, antibiotic usage, and pleural fluid features-that could predict the need for VATS rather than primary chest tube drainage. METHODS: Forty-nine pediatric patients with pneumonia complicated by parapneumonic effusion or empyema treated at the Children's Hospital of Pittsburgh (1997-2003) were divided into three groups according to the therapy instituted: Primary chest tube, chest tube followed by VATS, or primary VATS. The groups were analyzed in terms of demographics and outcome, as judged by pleural fluid analysis and hospital resource utilization. Demographic and outcome data were compared among groups using one-way analysis of variance and the Student t-test. RESULTS: All groups were similar with respect to demographics and initial antibiotic usage. Patients undergoing primary VATS had a higher initial temperature, whereas radiographic findings of mediastinal shift and air bronchograms were more likely to be found in patients who underwent primary chest tube placement. Patients undergoing primary VATS demonstrated a significantly shorter total stay and lower hospital charges than the other groups. Forty percent of children started on chest tube therapy failed even with subsequent VATS, necessitating a significantly longer hospital course (18 +/- 3 vs. 11 +/- 0.8 days; p < 0.05) and higher hospital charges ($50,000 +/- 7,000 vs. $29,000 +/- 1000) than those having primary VATS. CONCLUSIONS: Patients treated by primary VATS had a shorter stay and lower hospital charges than patients treated by chest tube and antibiotic therapy alone. There were no demographic, physiologic, laboratory, or chest radiographic data that predicted the selection of VATS as an initial treatment. These data suggest a strategy of primary VATS as first-line treatment in the management of empyema or parapneumonic effusion as a complication of pneumonia in pediatric patients.     

Cost-effectiveness of intra-arterial thrombolytic therapy

We reviewed the clinical course of 23 patients who received 24 intra-arterial infusions of either streptokinase or urokinase to treat 14 arteries and ten arterial grafts that were occluded due to primary thrombosis (22) or artery-artery embolism (two). Time from symptom onset to treatment was one to 28 days (mean, 11 days). Five infusions (21%) were completely successful since symptoms were eliminated without subsequent operation. Seven infusions (29%) were partially successful since thrombolysis aided, limited, or postponed subsequent surgery. Six infusions (25%) were failures since thrombolysis or clinical improvement did not occur and surgery was required. Six infusions (25%) were associated with thrombolytic complications that required urgent operation (less severe complications occurred in an additional 17% of cases [4/24]). Of the 19 patients without complete success after thrombolytic therapy, 16 underwent surgery during the same admission, two were not operable due to distal disease, and one declined operation. Of the 16 operations, 15 (94%) were successful in restoring graft or artery patency and achieving limb salvage, whereas one failed. In the 12 patients with failure or major complications of thrombolytic treatment, all had successful surgical outcome without morbidity. The actual mean cost of thrombolytic treatment was $8200 per patient and was comparable with the actual mean cost of subsequent surgical treatment in the 16 patients who required operation ($8900 per patient). The effective cost of thrombolytic and surgical treatment was calculated by dividing the actual costs by the proportion of successful cases. The effective cost of thrombolytic therapy per complete success was $39,200 and per complete or partial success was $16,500. This was significantly more than the effective cost of $9400 per complete success of surgical therapy.     

Long-term efficacy and compliance of MUSE for erectile dysfunction following radical prostatectomy: SHIM (IIEF-5) analysis

Baseline and follow-up data of 54 patients from a single surgical series (1998-2001), who used medicated urethral system for erection (MUSE) for the erectile dysfunction (ED) associated with radical prostatectomy (RP), were obtained. Patients were surveyed using the abridged five-item version of the International Index of Erectile Function (IIEF) questionnaire, commonly referred to as the Sexual Health Inventory of Men (SHIM), to determine presence and severity of ED and efficacy of ED treatment modalities. The mean patient age was 63.7+/-5.6 y and the mean follow-up period was 2.3+/-1.2 y. All patients experienced ED for at least 6 months after their surgery before starting MUSE therapy. Overall, 55% of the patients achieved and maintained erections sufficient for sexual intercourse while on MUSE and 48% continued long-term therapy with a mean use of 2.32+/-1.2 y. The mean presurgery SHIM score in these patients was 19.2+/-1.3, which decreased to 5.2+/-0.5 after surgery and increased to 16.3+/-1.3 after MUSE treatment. A total of 28 patients (52%) discontinued treatment after a mean use of 8+/-1.4 months. The reasons for discontinuation were insufficient erections (n = 16, mean SHIM score of 10.5+/-4.4), switch to other ED therapies (n = 4), natural return of erections (n = 4) and urethral pain and burning (n = 4). Excluding the patients (n = 8) who preferred other therapies and return of natural erections, the compliance to MUSE was 63%. There were no significant differences in the IIEF-5 responses between the patients who had a nerve-sparing technique (n=34) and those who did not (n = 20) or among patients who used different doses (250, 500 or 1000 microg) of MUSE. The results of the current trial indicate that MUSE is a successful treatment option in RP patients with established ED. It appears that a post-treatment SHIM score of > or = 16 defines a successful outcome with MUSE therapy.     

伴有“自溶”现象的腰椎椎间盘突出症的治疗探讨

目的 探讨对伴有“自溶”现象的腰椎椎间盘突出症的治疗策略。 方法 回顾2006年1月~2011年12月本院收治的腰椎椎间盘突出症患者34例,所有患者比较首次发病与入院前腰椎MRI检查发现均有突出椎间盘缩小的影像学表现。对其中15例行腰后路减压椎间植骨内固定术或髓核摘除术;19例采用卧床休息、腰围固定以及脱水、消炎镇痛等非手术治疗。采用Oswestry功能障碍指数（Oswestry disability index, ODI）、疼痛视觉模拟量表（visual analogue scale, VAS）评分及影像学检查评价治疗效果。 结果 手术组15例,手术切口均一期愈合,随访2~16个月,平均12.3个月。术前ODI为42.8±4.25,末次随访时为12.5±1.26,与术前比较差异有统计学意义（P＜0.01）。VAS评分术前为7.13±1.24分,末次随访时为1.45±0.86分, 与术前比较差异有统计学意义（P＜0.01）。非手术治疗组19例,治疗前ODI为27.9±3.61,末次随访时为10.5±6.4,治疗6个月后复查腰椎MRI平扫提示突出椎间盘完全消失者4例,部分消失者9例,无明显变化者6例。 结论 对于伴有“自溶”现象的腰椎椎间盘突出症患者应根据影像学及临床表现采用相应的治疗方法,可获得较满意的临床疗效。     

Types of lumbar herniated disc and clinical course

STUDY DESIGN: A retrospective study of different types of herniated discs and duration of symptoms in patients with lumbar disc herniation, and a trial of longer conservative treatment to reduce the number of operations. OBJECTIVE: To determine whether noncontained and contained herniated discs have different clinical courses and to evaluate the results of the clinical trial of longer and vigorous conservative treatment. SUMMARY OF BACKGROUND DATA: The possibility of a difference in clinical features between contained and noncontained disc herniation has been suggested previously. METHODS: In the first study, the medical history and intraoperative findings of 156 patients who had undergone herniotomy were reviewed. In the second study, conservative treatment of at least 2 months' duration was recommended for all patients with lumbar disc herniation. RESULTS: In the first study, patients with noncontained disc herniation had a shorter preoperative clinical course than those with contained disc herniation. It was rare for noncontained herniation to require surgery 4 months or more after the onset of symptoms. In the second study, the authors' protocol reduced the number of herniotomies required, especially the number of operations for the patients with noncontained disc herniation. CONCLUSIONS: The authors believe that patients with noncontained lumbar disc herniation can be treated without surgery, if these patients can tolerate the symptoms for the first 2 months.     

Spontaneous rupture of hepatocellular carcinoma: conservative management and selective intervention.

HYPOTHESIS: A conservative approach using selective intervention is better than an aggressive approach using nonselective intervention for ruptured hepatocellular carcinoma. DESIGN: Nonrandomized controlled trial. SETTING: A university hospital. PATIENTS AND INTERVENTIONS: From 1984 to 1990, an aggressive approach was adopted in which 29 and 8 of a total of 40 patients underwent surgical intervention or attempted transarterial embolization (TAE), respectively. From 1991 to 1997, a more conservative approach was used. The initial treatment for 72 patients was conservative with close monitoring. Additional hemostatic procedures consisting of TAE (n = 13) or surgical intervention (n = 9) were given, depending on the clinical progress, disease status, and liver function of the patients. MAIN OUTCOME MEASURES: In-hospital mortality, survival. RESULTS: In-hospital mortality rate was 62% (25 of 40 patients) in the first period and 51% (37 of 72 patients) in the second period. The respective median survival times were 7 and 12 days. If 36 patients with end-stage malignant neoplasms were excluded, the in-hospital mortality rate became 60% (18 of 30 patients) in the first period and 35% (16 of 46 patients) in the second period (P = .03, chi2 test). The respective median survival times became 8 and 72 days (P = .02, log rank test). In the second period, 7 (54%) of 13 patients who underwent TAE and 1 (11%) of 9 patients who underwent surgical intervention died within the same hospital admission (P = .07, Fisher exact test). CONCLUSIONS: Selective intervention was cost-effective and gave better results than an aggressive approach. When intervention was indicated for hemostasis, surgery seemed better than TAE although the difference was not statistically significant.     

Arthroscopic microdiscectomy.

Follow-up examinations performed a minimum of 2 years postoperatively showed that no neurovascular complications developed in 100 patients who underwent arthroscopic microdiscectomy for treatment of herniated discs at L3-4, L4-5, or L5-S1. By using a posterolateral approach, endoscopic control, and specially designed straight, upbiting, and deflectable forceps, it was possible to remove not only fragments located in the center of the nucleus, but also fragments that had migrated posteriorly and posterolaterally. Analysis of operative results by a modification of the Rush-Presbyterian-St. Luke's lumbar spine analysis system demonstrated that 88 of the patients attained excellent or good results and 12 attained poor or fair results. The outcome of surgery was not related to age, sex, or surgical level. The most common causes of an unsuccessful surgical outcome were lateral recess stenosis and sequestered fragments missed in the preoperative work-up.     

Acute type A aortic dissection complicated by aortic regurgitation: composite valve graft versus separate valve graft versus conservative valve repair

OBJECTIVE: To clarify the merits of various surgical approaches, we studied the outcome after composite valve graft versus separate valve and graft replacement versus conservative valve treatment with replacement of the ascending aorta in patients with acute type A aortic dissection complicated by aortic regurgitation. METHODS: Between 1967 and 1999, 123 patients (mean age 56 +/- 15 years) underwent composite valve graft replacement (n = 21), separate valve and graft replacement (n = 20), or conservative valve treatment (n = 82 [commissural resuspension in 46]); follow-up averaged 6.5 years (95% complete). RESULTS: The 30-day, 1-year, and 6-year survival estimates of 85% +/- 4%, 79% +/- 5%, and 69% +/- 5% (+/-1 standard error of mean), respectively, after conservative valve treatment were similar to 86% +/- 8%, 81% +/- 9%, and 65% +/- 16%, respectively, with composite valve graft replacement and better (but insignificantly so) than 70% +/- 10%, 70% +/- 10%, and 45% +/- 11%, respectively, with separate valve and graft replacement. The 6-year freedom from proximal reoperation was 95% +/- 3%, 89% +/- 10%, and 100% in conservative valve graft, separate valve and graft, and composite valve graft subgroups, respectively (P = not significant). Cox regression multivariable analysis identified that previous sternotomy (hazard ratio [or e(beta)] 95% confidence interval 1.4-10.9, P =.006), hypertension (0.99-2.9, P =.05), cardiac tamponade (1.1-4.0, P =.03), and stroke (1.7-7.0, P =.001) increased the hazard of death. No factors predicting a higher likelihood of late proximal reoperation were identified. CONCLUSIONS: In patients with acute type A aortic dissection and aortic regurgitation, there was no significant difference in overall survival or reoperation rates among these surgical approaches. We try to save the valve whenever possible unless the aortic root is pathologically dilated (eg, Marfan syndrome or annuloaortic ectasia) or destroyed by the dissection process, when composite valve graft or valve-sparing aortic root replacement is indicated.     

A prospective randomized trial of chemonucleolysis and conventional disc surgery in single level lumbar disc herniation.

The role of chemonucleolysis as an alternative to disc surgery is still disputed. The authors conducted a prospective randomized controlled trial of chemonucleolysis and conventional disc surgery involving 92 patients with L4-5 or L5-S1 disc herniation who failed to respond to conservative treatment. There were 46 patients in each group, matched for demographic, clinical characteristics, and co-interventions. Independent examiners assessed patients before treatment, at 6 weeks after, 3 months after, and 1 year after treatment. A comprehensive method of outcome assessment involving physiological outcome, functional outcome, cost outcome, and psychological outcome was employed. Nine chemonucleolysis patients and one disc surgery patient required additional surgery for failure of initial treatment (P less than 0.02). The outcomes at 6 weeks and at 3 months were better in the surgical group, but at 1 year the differences were not significant. The authors conclude that chemonucleolysis as a minimally invasive technique produces inferior short-term results and offers no advantage over conventional discectomy.