Abstract Background context The 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. Purpose To provide an evidence-based educational tool to assist spine specialists in the diagnosis and treatment of lumbar disc herniation with radiculopathy. Study design Systematic review and evidence-based clinical guideline. Methods This 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. Results Twenty-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. Conclusions The 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.
Abstract Background context The evidence-based clinical guideline on the diagnosis and treatment of degenerative lumbar spinal stenosis by the North American Spine Society (NASS) provides ...evidence-based recommendations to address key clinical questions surrounding the diagnosis and treatment of degenerative lumbar spinal stenosis. The guideline is intended to reflect contemporary treatment concepts for symptomatic degenerative lumbar spinal stenosis as reflected in the highest quality clinical literature available on this subject as of July 2010. The goals of the guideline recommendations are to assist in delivering optimum efficacious treatment and functional recovery from this spinal disorder. Purpose Provide an evidence-based educational tool to assist spine care providers in improving quality and efficiency of care delivered to patients with degenerative lumbar spinal stenosis. Study design Systematic review and evidence-based clinical guideline. Methods This report is from the Degenerative Lumbar Spinal Stenosis Work Group of the NASS's Evidence-Based Clinical Guideline Development Committee. The work group consisted of multidisciplinary spine care specialists trained in the principles of evidence-based analysis. The original guideline, published in 2006, was carefully reviewed. 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 published since the search performed for the original guideline. The relevant literature was then independently rated by a minimum of three physician reviewers 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 arrived at 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 key clinical questions were assessed, addressing issues of natural history, diagnosis, and treatment of degenerative lumbar spinal stenosis. The answers are summarized in this document. The respective recommendations were graded by the strength of the supporting literature that was stratified by levels of evidence. Conclusions A clinical guideline for degenerative lumbar spinal stenosis has been updated using the techniques of evidence-based medicine and using the best available clinical evidence to aid both practitioners and patients involved with the care of this condition. The entire guideline document, including the evidentiary tables, suggestions for future research, and all references, will be available electronically at the NASS Web site ( www.spine.org ) and will remain updated on a timely schedule.
Background Context The North American Spine Society's (NASS ) Evidence-Based Clinical Guideline for the Diagnosis and Treatment of Adult Isthmic Spondylolisthesis features evidence-based ...recommendations for diagnosing and treating adult patients with isthmic spondylolisthesis. The guideline is intended to reflect contemporary treatment concepts for symptomatic isthmic spondylolisthesis as reflected in the highest quality clinical literature available on this subject as of June 2013. NASS' guideline on this topic is the only guideline on adult isthmic spondylolisthesis accepted in the Agency for Healthcare Research and Quality's National Guideline Clearinghouse. Purpose The purpose of the guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for adult patients with isthmic spondylolisthesis. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition. Study Design Guideline summary review Methods This guideline is the product of the Adult Isthmic Spondylolisthesis Work Group of NASS' Evidence-Based 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 multi-disciplinary 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 guidelines were submitted to an internal peer review process and ultimately approved by the NASS Board of Directors. Upon publication, the Adult Isthmic Spondylolisthesis guideline was accepted into the National Guidelines Clearinghouse (NGC) and will be updated approximately every 5 years. Results Thirty-one 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. Conclusions The 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 isthmic spondylolisthesis. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flow chart, suggestions for future research and all of the references, is available electronically on the NASS website at https://www.spine.org/Pages/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx and will remain updated on a timely schedule.
 Infrequent (n = 31652) Frequent (n =1042) Persistent (n = 160) Demographics Mean age, y 52.1 c 56.9 a 56.8 Male, % 43.3 c 45.8 b 55.6 White, % 73.0 a 72.2 a 78.1 Unmarried, % 54.5 d 70.6 b 80.0 ...English speaking, % 89.1 a 87.0 b 93.8 Income, $ 55689.10 d 50044.65 a 49037.68 Less than high school education, % 53.7 a 49.4 a 56.3 Insurance    Medicare, % 28.2 d 48.9 a 53.1 Medicaid, % 11.0 d 18.9 c 28.1 Uninsured, % 4.5 a 3.5 a 3.1 Commercial, % 56.30 d 28.7 d 15.6 Chronic disease profile Coronary artery disease, % 9.1 d 19.6 a 25.0 Cerebrovascular disease, % 4.4 d 8.5 a 10.6 Peripheral vascular disease, % 3.6 c 8.5 a 8.1 Hypertension, % 28.8 c 35.5 a 40.0 Chronic obstructive pulmonary disease, % 20.9 d 39.0 a 45.0 Congestive heart failure, % 16.3 d 42.5 a 48.8 Diabetes, % 13.0 d 24.3 c 36.3 Chronic pain, % 2.2 d 10.0 d 20.6 Mean Charlson index, n 1.2 d 2.2 c 2.6 Behavioral health problems Depression, % 3.9 d 10.6 c 18.1 Bipolar disorder, % 4.8 d 12.9 b 18.8 Personality disorder, % 1.9 d 6.2 b 11.3 Posttraumatic stress disorder, % 2.6 d 9.1 c 16.3 Alcohol use disorder, % 6.8 d 20.8 d 36.9 Drug use disorder, % 5.8 d 21.8 d 38.8 Electronic prescriptions Narcotics, % 49.2 d 80.3 c 89.4 Benzodiazepines, % 35.9 d 70.4 d 84.4 Antipsychotics, % 10.5 d 39.2 d 58.8 Depression/anxiety, % 28.9 d 53.0 c 64.4 No. of prescriptions, n 14.0 d 24.2 d 27.8 Outpatient utilization Mean PCP seen, n 3.4 d 5.0 c 5.8 No-show rate to primary care appointments, % 8.6 d 15.0 d 20.4 Mean no. of primary care visits, n 9.8 d 14.9 b 17.5 Mean urgent care visits, n 2.4 d 3.7 b 4.4 Acute care utilization All hospitalizations, n per 1000 patient years 133.3 d 663.3 d 1293.8 Behavioral health hospitalizations, n per 1000 patient years 4.5 d 28.8 d 101.3 All ED visits, n per 1000 patient years 329.9 d 1525.5 d 3531.3 Behavioral health ED visits, n per 1000 patient years 18.5 d 121.9 d 447.5 Table Baseline characteristics of persistent frequent utilizers compared with frequent and infrequent utilizers in 2005 to 2007 Abbreviation: PCP, Primary care physician.
Abstract Background context A paucity of data exists studying outcomes of patients with syringomyelia undergoing spinal deformity correction. The literature does not stratify patients by syrinx size, ...which is likely a major contributor to outcomes. Purpose To compare differences in outcomes between patients with large (≥ 4mm) and small syrinxes (< 4mm) undergoing spinal deformity correction. Design Retrospective review Patient sample 28 patients (11 with large syrinx LS, ≥ 4mm and 17 with small syrinx SS, < 4mm). Outcome measures Radiographic, operative and neurophysiologic measures Methods We retrospectively reviewed 28 patients with syringomyelia who underwent spine deformity surgery with 2 year follow-up. Demographic, surgical, and radiographic data were collected and compared preoperatively and at 2 years. Results The LS group (11 patients) trended toward more left sided thoracic curves (36% vs. 18%, p=0.38) and was more likely to have had a Chiari decompression (45% vs. 12%, p=0.08). LS patients had larger preoperative major curves (LS=66° vs. SS=57°, p=0.05), more thoracic kyphosis (LS=42°, SS=24°, p<0.01) and greater rib prominences (LS=16°, SS=13°, p=0.04). LS patients had more levels fused (LS=12.2, SS=11.2, p=0.05), higher EBL (LS=1068cc, SS=832cc, p=0.04), and a trend toward less percent correction of the major curve (LS=57%, SS=65%, p=0.18). 4/11 LS patients (36%) did not have SSEPS, and one of these also did not have MEPS. Neuromonitoring changes occurred in 3/11 (27%) of the LS patients and in none of the SS, with no postoperative deficits. Conclusions Outcomes of patients with syringomyelia undergoing spine deformity surgery are dependent on the size of the syrinx. Those with large syringomyelia are fused longer with more EBL and less correction. Spine surgeons should be aware that these patients are more likely to have less reliable neuromonitoring, with a higher chance of experiencing a change.
Abstract Background Post-operative pain following transforaminal lumbar interbody fusion (TLIF) is a barrier to early mobility. Intraoperative local infiltration of anesthetic agents is standard ...practice to alleviate post-operative pain. Liposomal formulations may prolong the action of these anesthetic agents. The purpose of this study was to investigate the role of liposomal bupivacaine in post-operative pain control in patients undergoing unilateral, single level TLIF. Methods From a cohort of 74 patients, half received non-liposomal local anesthetic (Group C) and half received liposomal bupivacaine (Group LB) via local infiltration. Both groups received a standard post-operative analgesia regimen. Demographic information, post-operative pain scores (visual analog scale), analgesic consumption, length of stay, and complications were retrospectively collected. Results The area under the curve (AUC) of cumulative pain scores was significantly lower in the LB group between 0 and 12 hours (15.0 ± 15.6 versus 45.6 ± 21.1, p=.003) and between 12 and 24 hours (37.6 ± 20.6 versus 48.4 ± 24.9, p=.05) after surgery. Significantly fewer narcotic equivalents were consumed in the LB group between 12 and 24 hours (16.0 ± 13.4 mg versus 24.1 ± 19.7 mg IV morphine equivalents, p=.04. Length of stay was significantly shorter in the LB group than in the control group (3.1 ± 0.9 days versus 4.3 ± 1.3 days, p < .001). Conclusions Liposomal bupivacaine may be a useful adjunct during unilateral TLIF for decreasing pain and narcotic consumption in the first 24 hours after surgery and may also decrease overall length of stay.
Pediatric iatrogenic spinal deformity Hwang, Steven W; Riesenburger, Ron I; Benzel, Edward C
Neurosurgery clinics of North America,
10/2007, Volume:
18, Issue:
4
Journal Article
Peer reviewed
This article reviews current published literature regarding pediatric iatrogenic spinal deformity, with particular emphasis on the cervical spine. The results of published series reporting the ...incidence, etiology, age, risk factors, surgical techniques, and treatment options are summarized. Iatrogenic deformity resulting from radiation therapy and a variety of surgical procedures are addressed.
Magnesium is neuroprotective in animal models of stroke, and findings of small clinical pilot trials suggest potential benefit in people. We aimed to test whether intravenous magnesium sulphate, ...given within 12 h of stroke onset, reduces death or disability at 90 days.
2589 patients were randomised within 12 h of acute stroke to receive 16 mmol MgSO
4 intravenously over 15 min and then 65 mmol over 24 h, or matching placebo. Primary outcome was a global endpoint statistic expressed as the common odds ratio for death or disability at day 90. Secondary outcomes were mortality and death or disability, variously defined as Barthel score less than 95, Barthel score less than 60, and modified Rankin scale more than 1. Predefined subgroup analyses were for the primary endpoint in patients in whom treatment commenced within 6 h versus after 6 h, ischaemic versus non-ischaemic strokes, and cortical stroke syndromes versus non-cortical strokes. Intention-to-treat and efficacy analyses were done.
The efficacy dataset included 2386 patients. Primary outcome was not improved by magnesium (odds ratio 0·95, 95% CI 0·80–1·13, p=0·59). Mortality was slightly higher in the magnesium-treated group than in the placebo group (hazard ratio 1·18, 95% CI 0·97–1·42, p=0·098). Secondary outcomes did not show any treatment effect. Planned subgroup analyses showed benefit of magnesium in noncortical strokes (p=0·011) whereas greater benefit had been expected in the cortical group.
Magnesium given within 12 h of acute stroke does not reduce the chances of death or disability significantly, although it may be of benefit in lacunar strokes.
The mission of the National Spherical Torus Experiment (NSTX) is to prove the principles of spherical torus physics by producing high-β
t
plasmas that are noninductively sustained and whose current ...profiles are in steady state. The NSTX will be one of the first ultralow-aspect-ratio tori (R/a ≤ 1.3) to operate at high power (P
input
up to 11 MW) to produce high-β
t
(25 to 40%), low-collisionality, high-bootstrap-fraction (≤70%) discharges. Both radio-frequency and neutral beam heating and current drive will be employed. Built into the NSTX is sufficient configurational flexibility to study a range of operating space and the resulting dependences of the confinement, micro- and magnetohydrodynamic stability, and particle- and power-handling properties. NSTX research will be carried out by a nationally based science team.
