An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spondylolisthesis

Background ContextThe objective of the North American Spine Society (NASS) evidence-based clinical guideline on the diagnosis and treatment of degenerative lumbar spondylolisthesis is to provide evidence-based recommendations on key clinical questions concerning the diagnosis and treatment of degenerative lumbar spondylolisthesis. The guideline is intended to address these questions based on the highest quality clinical literature available on this subject as of January 2007. The goal of the guideline recommendations is to assist the practitioner in delivering optimum, efficacious treatment of and functional recovery from this common disorder.PurposeTo provide an evidence-based, educational tool to assist spine care providers in improving the quality and efficiency of care delivered to patients with degenerative lumbar spondylolisthesis.Study DesignSystematic review and evidence-based clinical guideline.MethodsThis report is from the Degenerative Lumbar Spondylolisthesis Work Group of the NASS Evidence-Based Clinical Guideline Development Committee. The work group was comprised of multidisciplinary spine care specialists, all of whom were trained in the principles of evidence-based analysis. Each member participated in the development of a series of clinical questions to be addressed by the group. The final questions agreed on by the group are the subject of this report. A literature search addressing each question and using a specific search protocol was performed on English language references found in MEDLINE, EMBASE (Drugs and Pharmacology) and four additional, evidence-based, databases. The relevant literature was then independently rated by at least three reviewers using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final grades of recommendation for the answer to each clinical question were arrived at via face-to-face meetings among members of the work group using standardized grades of recommendation. When Level I–IV evidence was insufficient to support a recommendation to answer a specific clinical question, expert consensus was arrived at by the work group through the modified nominal group technique and is clearly identified as such in the guideline.ResultsNineteen clinical questions were formulated, addressing issues of prognosis, diagnosis, and treatment of degenerative lumbar spondylolisthesis. The answers to these 19 clinical questions are summarized in this document. The respective recommendations were graded by the strength of the supporting literature that was stratified by levels of evidence.ConclusionsA clinical guideline for degenerative lumbar spondylolisthesis has been created using the techniques of evidence-based medicine and using the best available evidence as a tool to aid practitioners involved with the care of this condition. The entire guideline document, including the evidentiary tables, suggestions for future research, and all references, is available electronically at the NASS Web site (www.spine.org) and will remain updated on a timely schedule.     

An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy

Background contextThe objective of the North American Spine Society's (NASS) Evidence-Based Clinical Guideline for the Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy is to provide evidence-based recommendations to address key clinical questions surrounding the diagnosis and treatment of lumbar disc herniation with radiculopathy. The guideline is intended to reflect contemporary treatment concepts for symptomatic lumbar disc herniation with radiculopathy as reflected in the highest quality clinical literature available on this subject as of July 2011. The goals of the guideline recommendations are to assist in delivering optimum efficacious treatment and functional recovery from this spinal disorder.PurposeTo provide an evidence-based educational tool to assist spine specialists in the diagnosis and treatment of lumbar disc herniation with radiculopathy.Study designSystematic review and evidence-based clinical guideline.MethodsThis guideline is a product of the Lumbar Disc Herniation with Radiculopathy Work Group of NASS' Evidence-Based Guideline Development Committee. The work group consisted of multidisciplinary spine care specialists trained in the principles of evidence-based analysis. A literature search addressing each question and using a specific search protocol was performed on English-language references found in Medline, Embase (Drugs and Pharmacology), and four additional evidence-based databases to identify articles. The relevant literature was then independently rated using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final recommendations to answer each clinical question were developed via work group discussion, and grades were assigned to the recommendations using standardized grades of recommendation. In the absence of Level I to IV evidence, work group consensus statements have been developed using a modified nominal group technique, and these statements are clearly identified as such in the guideline.ResultsTwenty-nine clinical questions were formulated and addressed, and the answers are summarized in this article. The respective recommendations were graded by strength of the supporting literature, which was stratified by levels of evidence.ConclusionsThe clinical guideline has been created using the techniques of evidence-based medicine and best available evidence to aid practitioners in the care of patients with symptomatic lumbar disc herniation with radiculopathy. The entire guideline document, including the evidentiary tables, suggestions for future research, and all the references, is available electronically on the NASS Web site at http://www.spine.org/Pages/PracticePolicy/ClinicalCare/ClinicalGuidlines/Default.aspx and will remain updated on a timely schedule.     

Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of low back pain

Background contextThe North American Spine Society's (NASS) Evidence Based Clinical Guideline for the Diagnosis and Treatment of Low Back Pain features evidence-based recommendations for diagnosing and treating adult patients with nonspecific low back pain. The guideline is intended to reflect contemporary treatment concepts for nonspecific low back pain as reflected in the highest quality clinical literature available on this subject as of February 2016.PURPOSEThe purpose of the guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for adult patients with nonspecific low back pain. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition.Study designThis is a guideline summary review.MethodsThis guideline is the product of the Low Back Pain Work Group of NASS’ Evidence-Based Clinical Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members utilized NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guideline was submitted to an internal and external peer review process and ultimately approved by the NASS Board of Directors.ResultsEighty-two clinical questions were addressed, and the answers are summarized in this article. The respective recommendations were graded according to the levels of evidence of the supporting literature.ConclusionsThe evidence-based clinical guideline has been created using techniques of evidence-based medicine and best available evidence to aid practitioners in the diagnosis and treatment of adult patients with nonspecific low back pain. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flowchart, suggestions for future research, and all of the references, is available electronically on the NASS website at https://www.spine.org/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx     

Degenerative lumbar spinal stenosis: an evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis.

BACKGROUND CONTEXT: The objective of the North American Spine Society (NASS) evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (DLSS) is to provide evidence-based recommendations to address key clinical questions surrounding the diagnosis and treatment of DLSS. The guideline is intended to reflect contemporary treatment concepts for symptomatic DLSS as reflected in the highest quality clinical literature available on this subject as of April 2006. The goals of the guideline recommendations are to assist in delivering optimum, efficacious treatment, and functional recovery from this spinal disorder. PURPOSE: To provide an evidence-based tool that assists practitioners in improving the quality and efficiency of care delivered to patients with DLSS. STUDY DESIGN/SETTING: Evidence-based clinical guideline. METHODS: This report is from the Spinal Stenosis Work Group of the NASS Clinical Guidelines Committee. The work group comprised medical, diagnostic, interventional, and surgical spinal care specialists, all of whom were trained in the principles of evidence-based analysis. In the development of this guideline, the work group arrived at a consensus definition of a working diagnosis of lumbar spinal stenosis by use of a modification of the nominal group technique. Each member of the group formatted a series of clinical questions to be addressed by the group and the final list of questions agreed on by the group is the subject of this report. A literature search addressing each question and using a specific literature search protocol was performed on English language references found in MEDLINE, EMBASE (Drugs and Pharmacology), and four additional, evidence-based, databases. The relevant literature to answer each clinical question was then independently rated by at least two reviewers using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Any discrepancies in evidence levels among the initial raters were resolved by at least two additional members' review of the reference and independent rating. Final grades of recommendation for the answer to each clinical question were arrived at in face-to-face meetings among members of the work group using the NASS-adopted standardized grades of recommendation. When Levels I to IV evidence was insufficient to support a recommendation to answer a specific clinical question, expert consensus was arrived at by the work group through the modified nominal group technique and is clearly identified as such in the guideline. RESULTS: Eighteen clinical questions were asked, addressing issues of prognosis, diagnosis, and treatment of DLSS. The answers to these 18 clinical questions are summarized in this document along with their respective levels of evidence and grades of recommendation in support of these answers. CONCLUSIONS: A clinical guideline for DLSS has been created using the techniques of evidence-based medicine and using the best available evidence as a tool to aid both practitioners and patients involved with the care of this disease. The entire guideline document including the evidentiary tables, suggestions for future research, and all references is available electronically at the NASS Web site (www.spine.org) and will remain updated on a timely schedule.     

An evidence-based clinical guideline for the use of antithrombotic therapies in spine surgery

Background contextThe objective of the North American Spine Society (NASS) Evidence-Based Clinical Guideline on antithrombotic therapies in spine surgery was to provide evidence-based recommendations to address key clinical questions surrounding the use of antithrombotic therapies in spine surgery. The guideline is intended to address these questions based on the highest quality clinical literature available on this subject as of February 2008. The goal of the guideline recommendations was to assist in delivering optimum, efficacious treatment with the goal of preventing thromboembolic events.PurposeTo provide an evidence-based, educational tool to assist spine surgeons in minimizing the risk of deep venous thrombosis (DVT) and pulmonary embolism (PE).Study designSystematic review and evidence-based clinical guideline.MethodsThis report is from the Antithrombotic Therapies Work Group of the NASS Evidence-Based Guideline Development Committee. The work group was composed of multidisciplinary spine care specialists, all of whom were trained in the principles of evidence-based analysis. Each member of the group was involved in formatting a series of clinical questions to be addressed by the group. The final questions agreed on by the group are the subject of this report. A literature search addressing each question and using a specific search protocol was performed on English language references found in MEDLINE, EMBASE (Drugs and Pharmacology), and four additional, evidence-based databases. The relevant literature was then independently rated by at least three reviewers using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final grades of recommendation for the answers to each clinical question were arrived at via Web casts among members of the work group using standardized grades of recommendation. When Level I to IV evidence was insufficient to support a recommendation to answer a specific clinical question, expert consensus was arrived at by the work group through the modified nominal group technique and is clearly identified as such in the guideline.ResultsFourteen clinical questions were formulated, addressing issues of incidence of DVT and PE in spine surgery and recommendations regarding utilization of mechanical prophylaxis and chemoprophylaxis in spine surgery. The answers to these 14 clinical questions are summarized in this article. The respective recommendations were graded by the strength of the supporting literature that was stratified by levels of evidence.ConclusionsA clinical guideline addressing the use of antithrombotic therapies in spine surgery has been created using the techniques of evidence-based medicine and using the best available evidence as a tool to assist spine surgeons in minimizing the risk of DVT and PE. The entire guideline document, including the evidentiary tables, suggestions for future research, and all references, is available electronically at the NASS Web site (www.spine.org) and will remain updated on a timely schedule.     

Antibiotic prophylaxis in spine surgery: an evidence-based clinical guideline for the use of prophylactic antibiotics in spine surgery

Background ContextThe objective of the North American Spine Society's (NASS) Evidence-Based Clinical Guideline on Antibiotic Prophylaxis in Spine Surgery is to provide evidence-based recommendations on key clinical questions concerning the use of prophylactic antibiotics in spine surgery. The guideline is intended to address these questions based on the highest quality clinical literature available on this subject as of December 2006. The goal of the guideline recommendations is to assist in delivering optimum, efficacious treatment to prevent surgical site infection.PurposeTo provide an evidence-based, educational tool to assist spine surgeons in preventing surgical site infections.Study DesignEvidence-based Clinical Guideline.MethodsThis report is from the Antibiotic Prophylaxis Work Group of the NASS's Evidence-Based Clinical Guideline Development Committee. The work group comprised multidisciplinary surgical spine care specialists, who were trained in the principles of evidence-based analysis. Each member of the group formatted a series of clinical questions to be addressed by the group. The final questions agreed upon by the group are the subjects of this report. A literature search addressing each question and using a specific search protocol was performed on English language references found in MEDLINE, EMBASE (Drugs and Pharmacology), and four additional, evidence-based, databases. The relevant literature was then independently rated by at least three reviewers using the NASS–adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final grades of recommendation for the answer to each clinical question were arrived at via Webcast meetings among members of the work group using standardized grades of recommendation. When Level I to Level IV evidence was insufficient to support a recommendation to answer a specific clinical question, expert consensus was arrived at by the work group through the modified nominal group technique and is clearly identified in the guideline.ResultsEleven clinical questions addressed the efficacy and appropriateness of antibiotic prophylaxis protocols, repeat dosing, discontinuation, wound drains, and special considerations related to the potential impact of comorbidities on antibiotic prophylaxis. The responses to these 11 clinical questions are summarized in this document. The respective recommendations were graded by the strength of the supported literature which was stratified by levels of evidence.ConclusionsA clinical guideline addressing the use of antibiotic prophylaxis in spine surgery has been created using the techniques of evidence-based medicine and the best available evidence. This educational tool will assist spine surgeons in preventing surgical site infections. The entire guideline document, including the evidentiary tables, suggestions for future research, and references, is available electronically at the NASS Web site (www.spine.org) and will remain updated on a timely schedule.     

An evidence-based clinical guideline for antibiotic prophylaxis in spine surgery

Background context

The North American Spine Society's (NASS) Evidence-Based Clinical Guideline on Antibiotic Prophylaxis in Spine Surgery provides evidence-based recommendations to address key clinical questions regarding the efficacy and the appropriate antibiotic prophylaxis protocol to prevent surgical site infections in patients undergoing spine surgery. The guideline is intended to address these questions based on the highest quality clinical literature available on this subject as of June 2011.

Purpose

Provide an evidence-based educational tool to assist spine surgeons in preventing surgical site infections.

Study design

Systematic review and evidence-based clinical guideline.

Methods

This guideline is a product of the Antibiotic Prophylaxis in Spine Surgery Work Group of NASS Evidence-Based Guideline Development Committee. The work group consisted of neurosurgeons and orthopedic surgeons who specialize in spine surgery and are trained in the principles of evidence-based analysis. A literature search addressing each question and using a specific search protocol was performed on English language references found in MEDLINE (PubMed), ACP Journal Club, Cochrane Database of Systematic Reviews Database of Abstracts of Reviews of Effectiveness, Cochrane Central Register of Controlled Trials, EMBASE (Drugs and Pharmacology), and Web of Science to identify articles published since the search performed for the original guideline. The relevant literature was then independently rated using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final recommendations to answer each clinical question were developed via work group discussion, and grades were assigned to the recommendations using standardized grades of recommendation. In the absence of Levels I to IV evidence, work group consensus statements have been developed using a modified nominal group technique, and these statements are clearly identified as such in the guideline.

Results

Sixteen clinical questions were formulated and addressed, and the answers are summarized in this article. The respective recommendations were graded by the strength of the supporting literature, which was stratified by levels of evidence.

Conclusions

The clinical guideline for antibiotic prophylaxis in spine surgery has been created using the techniques of evidence-based medicine and best available evidence to aid practitioners in the care of patients undergoing spine surgery. The entire guideline document, including the evidentiary tables, suggestions for future research, and all the references, is available electronically on the NASS Web site at http://www.spine.org/Pages/PracticePolicy/ClinicalCare/ClinicalGuidlines/Default.aspx and will remain updated on a timely schedule.     

Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS®) Society recommendations

BackgroundEnhanced Recovery After Surgery (ERAS) evidence-based protocols for perioperative care have led to improvements in outcomes in numerous surgical areas, through multimodal optimization of patient pathway, reduction of complications, improved patient experience and reduction in the length of stay. ERAS represent a relatively new paradigm in spine surgery.PurposeThis multidisciplinary consensus review summarizes the literature and proposes recommendations for the perioperative care of patients undergoing lumbar fusion surgery with an ERAS program.Study DesignThis is a review article.MethodsUnder the impetus of the ERAS® society, a multidisciplinary guideline development group was constituted by bringing together international experts involved in the practice of ERAS and spine surgery. This group identified 22 ERAS items for lumbar fusion. A systematic search in the English language was performed in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. Systematic reviews, randomized controlled trials, and cohort studies were included, and the evidence was graded according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Consensus recommendation was reached by the group after a critical appraisal of the literature.ResultsTwo hundred fifty-six articles were included to develop the consensus statements for 22 ERAS items; one ERAS item (prehabilitation) was excluded from the final summary due to very poor quality and conflicting evidence in lumbar spinal fusion. From these remaining 21 ERAS items, 28 recommendations were included. All recommendations on ERAS protocol items are based on the best available evidence. These included nine preoperative, eleven intraoperative, and six postoperative recommendations. They span topics from preoperative patient education and nutritional evaluation, intraoperative anesthetic and surgical techniques, and postoperative multimodal analgesic strategies. The level of evidence for the use of each recommendation is presented.ConclusionBased on the best evidence available for each ERAS item within the multidisciplinary perioperative care pathways, the ERAS® Society presents this comprehensive consensus review for perioperative care in lumbar fusion.     

Knee or Spine Surgery First? A Survey of Treatment Order for Patients With Concurrent Degenerative Knee and Lumbar Spinal Disorders

BackgroundTotal knee arthroplasty (TKA) and lumbar spine surgery have been reported to affect the outcomes of each other. There is insufficient evidence to guide the choice of treatment order for patients with both disorders that are equally symptomatic.MethodsFive clinical scenarios of concurrent, advanced, degenerative knee and lumbar spinal disorders were designed to survey surgeons’ choices of treatment order and rationale. The spinal disorder was consistently degenerative lumbar spinal stenosis, but the knee conditions varied to include (1) osteoarthritis (OA) with varus deformity, (2) OA with valgus deformity, (3) rheumatoid arthritis with a severe flexion contracture, (4) OA without deformity, and (5) bilateral OA with windswept deformities. The survey was distributed to selected clinical members of the Knee Society and Scoliosis Research Society in North America. The surgeons’ choices were compared among the 5 scenarios, and their comments were analyzed using text-mining.ResultsResponses were received from 42 of 74 (57%) knee arthroplasty surgeons and 55 of 100 (55%) spine surgeons. The percentages of knee arthroplasty surgeons recommending “TKA first” differed significantly among scenarios: 29%, 79%, 55%, 7%, and 81% for scenarios 1 through 5, respectively (P < .001). A similar pattern was noted for the spine surgeons.ConclusionFor patients with concurrent degenerative knee and lumbar spinal disorders, the severity and type of knee deformity influenced the preference of treatment order in both specialties. Severe valgus deformity and windswept deformities of the knee would drive the decision toward “TKA first.”     

Lumbar spinal epidural lipomatosis: A case report and review of the literature

IntroductionLumbar spinal epidural lipomatosis (SEL) is a rare condition defined by an excessive deposition of adipose tissue in the lumbar spinal canal. The objective of this case report is to document a clinical case of SEL presenting within a multidisciplinary spine clinic and to compare our clinical findings and management with the available literature.Case presentationA 51-year-old female presented at a spine clinic with low back pain, bilateral leg pain and difficulty walking. Magnetic resonance imaging of the lumbar spine showed evidence of severe central canal stenosis due to extensive epidural lipomatosis. She was initially advised to lose weight and undergo a 3-month course of physiotherapy. However, because of lack of improvement, she was scheduled for and underwent L4-S1 posterior spinal decompression and L4-L5 posterior spinal instrumented fusion. At 12-month follow-up, the patient reported no pain and retained the ability to walk regular distances without experiencing discomfort.DiscussionThis case report describes the conservative and surgical management of a case of lumbar spinal stenosis due to SEL. The therapeutic approach of patients with this condition is not standardized. As such, a discussion of the literature with respect to the diagnosis, clinical presentation, epidemiology, imaging appearance, risk factors, etiology, and management of SEL is also presented.     

腰椎退变性侧凸的治疗策略

目的探讨非手术治疗或腰椎后路减压、矫形固定、融合手术治疗由于椎间盘退变后继发小关节退变、椎管和神经根管容积变化以及脊柱失稳、畸形等病理改变导致的腰椎退变性侧凸患者的效果。方法2001年7月-2007年6月，治疗退变性腰椎侧凸患者56例，其中行非手术治疗5例。手术治疗51例。手术组患者平均年龄为63岁，腰椎侧凸Cobb角平均30°，采用腰椎后路减压，或辅助椎弓根螺钉矫形固定、后外侧融合或椎间融合治疗。结果56例均得到随访，平均随访时间为20个月，非手术治疗和手术患者均对治疗效果满意，生活质量提高，手术组矫正角度平均为15°，骨融合率达到95％，无神经损伤及翻修病例。结论腰椎退变性侧凸首选非手术治疗，如失败应根据患者情况遵循尽量采用有限内固定和融合的原则行手术治疗。     

Functional outcome of surgical treatment for multilevel lumbar spinal stenosis

Background?There is no consensus regarding the best treatment of patients with multilevel lumbar stenosis. We evaluated the clinical and radiological findings in 41 patients with complex degenerative spinal stenosis of the lumbar spine who were treated surgically.

Methods?Between 1997 and 2003, 41 patients suffering from degenerative lumbar spinal stenosis were included in a prospective clinical study. The spinal stenosis was multilevel in all patients and in 13 of them there was degenerative scoliosis, in 18 there was degenerative spondylolisthesis, and in 10 there was segmental instability. Plain radiographs, MRI and/or CT myelograms were obtained preoperatively. The patients were assessed clinically with the Oswestry disability index (ODI) and visual analog scale (VAS). Surgery included wide posterior decompression and fusion using a trans-pedicular instrumentation system and bone graft.

Results?After a mean follow-up of 3.7 (1–6) years, the patients' clinical improvement on the ODI and VAS was statistically significant. Recurrent stenosis was not observed, and 39 of 41 patients were satisfied with the outcome. 3 patients with improvement initially had later surgery because of instability.

Interpretation?The above-mentioned technique gives good and long lasting clinical results, when selection of patients is done carefully and when the spinal levels that are to be decompressed are selected accurately.     

A critical appraisal of clinical practice guidelines for the treatment of lumbar spinal stenosis

OBJECTIVEThe aim of the review was to appraise clinical practice guidelines and their recommendations for the treatment of lumbar spinal stenosis.METHODSPubMed, Medline, CINAHL, Embase, and Cochrane Central Register of Controlled Trials were searched up until 25/01/2020 for clinical practice guidelines on the management of lumbar spinal stenosis with a systematic process to generate recommendations and were publicly available.RESULTSTen guidelines were included, with a total of 76 recommendations for the treatment of lumbar spinal stenosis. Only 4 of the 10 guidelines were of satisfactory methodological quality according to the AGREE II instrument. Around three-quarters of recommendations (72.4%) were presented with poor evidence, with the remaining 21 presenting (27.6%) fair evidence. No recommendation presented good evidence. Recommendations were made on four types of interventions: surgery, injections, medications, and other nonsurgical treatments, with supporting evidence similar for all four treatment types. Positive recommendations were more common for injections (12/13=92.3%) and surgery (10/15=66%) than for nonsurgical treatments (6/21=28.6%) or medications (1/27=3.75%).CONCLUSIONSTen guidelines on the management of lumbar spinal stenosis were identified in the systematic review, but only four were of adequate methodological quality. While the evidence underpinning the various types of interventions was similar, guidelines tended to endorse surgery and injections but not nonsurgical interventions and medicines. These results support the need for greater rigor and inclusion of steps to minimize bias in the production of guidelines.     

腰椎过伸位MRI在腰椎管狭窄诊断中的临床应用

目的：通过腰椎过伸位MRI检查,研究腰椎过伸位下椎管狭窄程度的变化,评估腰椎过伸位MRI扫描对腰椎管狭窄的诊断价值。方法：2018年9月至2020年2月,纳入26例腰椎管狭窄进行腰椎中立位和过伸位MRI扫描,男11例,女15例;年龄43~85（64.00±10.37）岁。由于6例患者在过伸位下诱发并加重了腰腿痛症状,无法采集到合格的MRI数据,最终完成检查共采集到20例患者的合格数据,采用Mimics 21.0医学图像处理软件测量腰椎管狭窄的相关诊断参数,统计分析其变化规律,评价过伸位下腰椎管的狭窄程度和神经受压情况。结果：腰椎管矢径及横截面积不随体位发生明显变化;硬膜囊矢径、盘黄间隙在过伸位时均有不同程度变小。结论：对于腰椎管狭窄的影像学诊断,腰椎过伸位MRI扫描可较好地补充常规中立位MRI检查,对腰椎管狭窄程度的临床诊断更具敏感性。     

Guía del carcinoma de células renales

ObjectivesThe European Association of Urology (EAU) Guideline Group for renal cell carcinoma (RCC) prepared this guideline to help urologists assess the evidence-based management of RCC and to incorporate the guideline recommendations into their clinical practice.MethodsThe re commendations provided in the current guideline are based on a systematic literature search using MedLine, the Cochrane Central Register of Controlled Trials, and publications and review articles.ResultsA Limited Number of prospective randomized studies are available with high-level evidence.Most publications concerning RCC are based on retrospective analyses, including some larger multicentre validation studies and well-designed controlled studies.ConclusionsIt must be stressed that the current guideline contains information for the treatment of an individual patient according to a standardized general approach. Updated recommendations concerning diagnosis, treatment, and follow-up can improve the clinical handling of patients with RCC.     

微创极外侧入路腰椎椎间融合术治疗退行性腰椎椎管狭窄症的初步应用和早期疗效分析

目的 研究微创极外侧入路腰椎椎间融合术(extreme lateral interbody fusion,XLIF)治疗退行性腰椎椎管狭窄症的早期疗效和安全性。方法 2013年10月~2014年3月本院收治退行性腰椎椎管狭窄症患者14例,均在微创通道下采用XLIF治疗。分别测量并分析术前、末次随访时患者疼痛视觉模拟量表(visual analogue scale, VAS)评分及Oswestry功能障碍指数(Oswestry disability index, ODI),椎间高度,椎间孔高度,椎间孔面积和盘黄间隙(关节下间隙),并通过X线片、CT、MRI等影像学资料进行整体评价。结果 所有患者手术顺利,术后随访6~13个月,患者均有不同程度的症状改善。5例患者术后出现短暂的右大腿外侧皮肤感觉异常和轻度髂腰肌肌力下降,均在术后2个月内恢复;1例大体重患者术后下床活动时出现持续性腰痛,给予延长卧床休息时间后症状改善。术后影像学显示所有患者椎管及神经根管减压效果满意,滑脱得到一定程度的复位。腰、腿痛VAS评分及ODI均较术前明显改善。术后测量椎间高度增加109.2%;椎间孔高度增加33.8%,症状侧椎间孔面积扩大41.4%,盘黄间隙平均增加2.3 mm。多项影像学评价指标均优于术前,差异有统计学意义(P< 0.01)。结论 微创XLIF应用于退行性腰椎椎管狭窄症的治疗,可以使患者早期得到良好的症状缓解和满意的影像学改善,值得临床推广与应用。但其远期疗效还需经过大样本长期的随访和研究。     

选择性神经根阻滞在腰椎有限手术中的应用

目的：总结选择性神经根阻滞在腰椎有限手术中的临床应用结果。方法：2008年1月至2012年10月,对68例多平面腰椎管狭窄症患者采用选择性神经根阻滞,其中男47例,女21例;年龄45～80岁,平均56岁。神经根阻滞后64例为阳性患者进行了腰椎有限手术,另4例封闭后症状减轻不明显为阴性,难以确定手术平面或引起症状的神经根,放弃了手术治疗。术后采用Macnab腰腿痛手术治疗评定标准进行疗效评定。结果：神经根阻滞操作过程顺利,未发生与神经根阻滞相关的并发症,术后无神经损伤并发症。术后随访16～45个月,平均32个月。术后根据Macnab腰腿痛手术治疗评定标准进行疗效评定,优44例,良18例,差2例。结论：对腰椎管狭窄症的手术治疗重点应放在压迫引起症状的部位,而对无症状的部位不做预防性减压操作。应用神经根阻滞能准确判断责任椎与疼痛源,提高腰椎有限手术的疗效。     

Hyperostotic lumbar spinal stenosis. A review of 12 surgically treated cases with roentgenographic survey of ossification of the yellow ligament at the lumbar spine

Although there is considerable literature concerning ossification of the posterior longitudinal ligament or the ligamentous flava (OPLL or OYL) in the cervical and thoracic spine, there are only a few references about OPLL or OYL in the lumbar spine. The authors have described lumbar spinal stenosis due to OPLL or OYL as hyperostotic lumbar spinal stenosis, and analyzed 12 surgically documented cases with this condition. The symptoms and signs of hyperostotic lumbar spinal stenosis are the same as those seen in degenerative lumbar spinal stenosis, but the degree of paraparesis is much more severe in hyperostotic lumbar spinal stenosis. Computed tomography scan imaging clearly demonstrates OPLL or OYL in the lumbar spine, although some lesions can be seen on the lateral view of a plain roentgenogram. The results of 12 surgical cases suggest that decompression laminectomy produces relief of symptoms. An analysis of 2,403 plain lumbar roentgenograms showed an incidence of 8.4% OYL in the lumbar spine, with frequent involvement of the upper and middle lumbar spine. A classification system of OYL in the lumbar spine has been developed. The entire spine should be examined before surgery on a patient with hyperostotic lumbar spinal stenosis because of a tendency to ossify spinal ligaments at other levels.     

Is lumbar stenosis associated with thoracic stenosis? A study of 1,072 human cadaveric specimens

Background contextTandem stenosis of the cervical and lumbar spine is known to occur in 5% to 25% of individuals with symptomatic neural compression in one region. However, the prevalence of concurrent lumbar and thoracic stenosis is not known. Whether this relationship is because of an increased risk of degenerative diseases in these individuals or because of the tandem presence of stenosis in lumbar and thoracic canal is unknown.PurposeTo determine the prevalence of concurrent lumbar and thoracic stenosis, and whether the presence of stenosis in the lumbar spine is associated with stenosis in the thoracic spine.Study designA morphoanatomic study of lumbar and thoracic cadaveric spines.MethodsOne thousand seventy-two adult skeletal specimens from the Hamann-Todd Collection in the Cleveland Museum of Natural History were selected. Canal area at each level was also calculated using a geometric formula. A standard distribution for each level was created, and values that were 2 standard deviations below mean were considered as being stenotic. Linear regression analysis was used to determine the association between the additive canal areas at all levels in the lumbar and thoracic spine and between the number of stenotic lumbar and thoracic levels. Logistic regression was used to calculate the odds ratios (OR) for concurrent lumbar and thoracic stenosis.ResultsThe prevalence of concurrent lumbar and thoracic stenosis is 1.42%. A positive association was found between the additive areas of all lumbar and thoracic levels (p<.01). No association, however, was found between the number of stenotic lumbar and thoracic levels (p=.7). Log regression demonstrated no significant association (OR <1) between stenosis in the lumbar and thoracic spine.ConclusionsThe stenosis of the lumbar spine is not associated with the thoracic stenosis. Thus, stenosis in lumbar and thoracic levels does not seem to be contributed by tandem stenosis.