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Thomas W. Sadler, Ph.D.
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Because the nerve is myelinated by oligodendrocytes and perhaps is more sensitive than Schwann cell myelin to irradiation, it was hypothesized that a stronger radiobiologic effect would occur at this portion of the nerve kaiser allergy shots san jose buy prednisolone visa. Normal nerves were irradiated with a 4-mm collimator to maximum doses of 80 or 100 Gy allergy testing via blood order prednisolone 20 mg without prescription. Traditionally, it has involved imaging definition of the thalamic target, placement of an electrode into the thalamus, physiologic recording and stimulation at the target site, and creation of a lesion or provision of electrical stimulation allergy symptoms at night and morning purchase prednisolone without prescription. Radiosurgical thalamotomy by definition avoids placement of an electrode and evaluation of the physiologic response allergy testing utah buy line prednisolone. The challenges inherent in choosing the best possible ablative target by imaging alone are significant allergy treatment for 4 year old buy discount prednisolone 40mg online. Because of the absence of electrophysiologic information, inability to stop the lesion during surgery, and latency until a clinical response occurs, most surgeons perform radiosurgery primarily in patients with advanced age or medical disorders in which electrode placement would be associated with higher risk allergy forecast long island buy 20mg prednisolone overnight delivery. The median time to improvement was 2 months, consistent with data from previous animal experiments. They used a dose range of 110 to 165 Gy but achieved better results at higher doses. Such high doses may exert effects on a larger surrounding tissue volume of kinesthetic tremor cells (outside the sharply defined necrotic volume), which translates into tremor reduction and overcomes any limitations in target selection. Young and coworkers reported that 88% of 27 patients who underwent radiosurgical thalamotomy for tremor (120 to 160 Gy) became tremor free or "nearly" tremor free. Eighteen patients (69%) improved in both action tremor and writing scores, and an additional six (23%) improved in action tremor scores. Thirteen patients (50%) had either no or only slight intermittent tremor in the affected extremity, and 90% had some degree of clinically significant improvement in tremor. Although the enhancing lesion created in one patient was unexpectedly large, complete resolution was seen on subsequent imaging. This finding indicated that the response was related to temporary changes in the blood-brain barrier and not to permanent radiation necrosis. Early results with larger target volumes using an 8-mm collimator were reported by Lindquist and colleagues. To that end, several surgeons have evaluated the use of radiosurgery for medial thalamotomy and for pallidotomy, procedures in which the usefulness of physiologic recording or stimulation was initially less clear. B,Theimagetaken6months after Gamma Knife radiosurgery (single 4-mm collimator,150-Gymaximumdose)showsawell-circumscribed lesionwithperipheralcontrast enhancementsurroundingalow-signalregion. Some investigators then performed Gamma Knife pallidotomy under image guidance alone as an alternative to electrode techniques. Rand and coauthors reported their preliminary results after radiosurgical pallidotomy and noted relief of contralateral rigidity in four of eight patients. Friedman and associates reported on four patients after Gamma Knife pallidotomy (180 Gy), with improvement in just one patient. In contrast to the thalamus, where small radiosurgical lesions appeared consistent, pallidotomy lesions may be more variable because of effects on perforating arteries that supply that region of the basal ganglia. They enrolled nine patients with bone metastases and pain controlled well by morphine, a Karnofsky Performance Scale score higher than 40, and no previous radiation therapy. All patients became pain free within a few days after radiosurgery, and the pain relief was maintained as long as they lived. This strategy of pituitary gland-stalk ablation for pain control also showed a good initial response (87. The initial use of an 8-mm collimator resulted in excessive edema, so these authors recommended the use of only 4-mm isocenters. A series of patients from Brown University and the University of Pittsburgh have been presented at national meetings. Since the case report by Leksell in 1968 and the larger series by Steiner and coworkers in 1980, little has been written. The second patient underwent bilateral radiosurgery spaced 2 months apart and became pain free. Young and associates performed medial thalamotomy for the treatment of chronic noncancer pain in patients who had failed comprehensive medical, surgical, and behavioral therapies. Again, they advocated caution when using volumes larger than those obtained with a single 4-mm isocenter and when using doses higher than 160 Gy. Bilateral lesions were created with two 4-mm isocenters to produce an oval volume in the ventral capsule at the putaminal midpoint. There was no morbidity after the procedure, and all returned immediately to baseline function. We believe that this technique should be evaluated further in patients with severe and disabling behavioral disorders. The observation that brain irradiation (via radiation therapy or radiosurgery) could lead to cessation of seizures has spurred several groups to work in this field despite the lack of a consistent approach to defining the target volume. In 1985, Barcia-Salorio and coauthors reported on 6 patients with epilepsy who underwent low-dose radiosurgery. Radiosurgery (a 10-mm collimator to deliver an estimated 10-Gy dose) was performed with a cobalt unit coupled to a stereotactic localizer. They hypothesized that this low radiation dose provided a specific effect on epileptic neurons without inducing tissue necrosis. In 1994 they provided a long-term analysis in a series of 11 patients who received doses ranging from 10 to 20 Gy. Five patients had complete cessation of seizures, and an additional 5 were improved. We used the kainic acid model of hippocampal epilepsy in the rat and were able to stop seizures and improve animal behavior. More recently, radiosurgery has been of value in patients with gelastic or generalized seizures related to hypothalamic hamartomas. Gamma Knife radiosurgery was used to create a conformal volume of radiation for the amygdala and hippocampus. This approximate 7-cc volume represented the largest functional target irradiated to that time. They delivered a margin dose of 25 Gy to the 50% isodose line, a dose that later caused target necrosis. The first patient became seizure free immediately and the second after a latency of almost 1 year. A recently published longer term evaluation with 8-year mean follow-up (margin dose of 24 Gy) found that 9 of 16 patients were seizure free. The optimal target may include both the amygdala and hippocampus, but the total target volume remains debated. Target volume helps determine dose selection, including the dose received by regional structures such as the brainstem or optic tract. Finally, investigators need to determine whether the balance between seizure response and morbidity is acceptable, particularly in comparison to surgical resection. Current issues that remain important for epilepsy radiosurgery include dose selection (necrotizing versus non-necrotizing), localization methods for nonlesional epilepsy, the target volume necessary for irradiation, and the expected short- and long-term outcomes. It is not known what kind of tissue effect is required to stop the generation or propagation of seizures. Others have used doses as high as 100 Gy, which causes target necrosis and regional brain edema. If focal hippocampal (or any other brain tissue) irradiation can eliminate seizures without the need for complete tissue destruction, radiosurgery may become an important therapy for patients with intractable epilepsy. At the same time we await improvements in tools for localization of the seizure focus. Pollock and Kondziolka first irradiated the sphenopalatine ganglion in a patient with sphenopalatine neuralgia by using an 8-mm collimator and maximum dose of 90 Gy. They found prompt relief of vasomotor symptoms but a latency of several months in relief of pain. Does increased nerve length within the treatment volume improve trigeminal neuralgia radiosurgery Glycerol rhizotomy versus Gamma Knife radiosurgery for the treatment of trigeminal neuralgia: an analysis of patients treated at one institution. Histologic effects of trigeminal nerve radiosurgery in a primate model: Implications for trigeminal neuralgia radiosurgery. Stereotactic radiosurgery for trigeminal neuralgia: A multi-institution study using the gamma unit. Stereotactic radiosurgery for primary trigeminal neuralgia: state of the evidence and recommendations for future reports. Subnecrotic stereotactic radiosurgery controlling epilepsy produced by kainic acid injection in rats. Gamma Knife surgery for idiopathic trigeminal neuralgia performed using a far-anterior cisternal target and a high dose of radiation. Radiosurgical treatment of trigeminal neuralgia: evaluating quality of life and treatment outcomes. Prospective controlled trial of Gamma Knife surgery for essential trigeminal neuralgia. CyberKnife radiosurgery for trigeminal neuralgia treatment: A preliminary multicenter experience. Bilsky n Yoshiya Yamada Metastatic spine disease represents a significant source of morbidity in the cancer population. Therapy is aimed at reducing pain, maintaining or improving neurological status, stabilizing the spine, and achieving local tumor control. Traditionally, the principal modalities used to treat spinal metastases are radiation therapy and surgery, although hormonal therapy, immunotherapy, and chemotherapy are playing increasingly large roles for selected tumors. The wide application of technologic advances in both surgery and radiation therapy over the past 5 years has improved patient outcomes. Surgical advances include the application of posterolateral approaches to the spine,1 pedicle screw fixation, and percutaneous augmentation of the vertebral body with cement. Because of the steep dose gradient, radiation techniques such as imageguided intensity modulation radiotherapy can deliver high-dose radiation within millimeters of the spinal cord. Patients were excluded from analysis for early death (10%) or failure to initiate steroids at the time of radiation therapy (8%) for a total of 205 evaluable patients. Overall, 89% of pretreatment ambulatory patients maintained ambulation, whereas just 60% regained ambulation. In the group that recovered ambulation, 70% had radiosensitive tumor histologies, but radioresistant histologies responded poorly. For example, breast carcinoma had an 80% response rate versus a 20% rate for hepatocellular carcinoma. Additionally, patients with favorable tumor histology had a more durable response of 10 to 16 months, in contrast to unfavorable tumors, which had a response lasting just 1 to 3 months. All 3 who recovered in the radiation arm crossed over to the surgical arm in keeping with the intention-to-treat paradigm. Tumor has variable intensity on T2-weighted images, which is not useful for tumor delineation; however, T2-weighted axial images provide the best assessment of spinal canal impingement and spinal cord compression. As opposed to brain metastases, vertebral body tumors are thought to have an infiltrative penumbra through the entire bone. Dose escalation to treat spinal metastases has been limited by knowledge of spinal cord tolerance. Spinal cord toxicity is related to the absolute dose, fractionation schedule, and length of spinal cord irradiated. Cord Dmax is currently defined at Memorial Sloan-Kettering Cancer Center as 14 Gy to the spinal cord or 16 Gy to the cauda equina. Based on the linear quadratic equation, radioresistant tumors are predicted to respond better to radiation given at higher dose per fraction. Although cell killing is primarily dependent on disruption of mitosis, additional factors may affect tumor response, such as apoptosis and damage to stromal cells. Experimental evidence suggests that high-dose single-fraction radiation therapy greater than 8 to 10 Gy activates the acid sphingomyelinase pathway and causes endothelial apoptosis and disruption of blood vessels. Photon delivery of cytotoxic tumoral doses within normal tissue tolerance is accomplished by using micromultileaf collimation with inverse treatment planning to deliver image-guided intensity modulation radiotherapy or by using robotic technology to guide the photon beams. A number of devices have been developed to immobilize patients and provide image-guided patient setup and isocenter verification. Regardless of the technology used, target delineation and tumor contouring are essential for successful treatment. Failure to contour any part of the tumor or spinal cord may result in tumor progression or spinal cord injury, respectively. A small number of centers are also exploring the use of 18F-fluorodeoxyglucose positron emission tomography to precisely identify the tumor target. The patient was treated by androgen deprivation and had risingprostate-specificantigenlevels. The patient was treated with 24-Gy stereotactic radiosurgery with the maximal dose to a single voxel on the spinal cord being less than 14Gy. To avoid radiation myelopathy, one would have to underdose at the margin of the spinal cord and thereby risk progression at the site demanding the highest degree of tumor control. Conversely, delivering a cytotoxic dose to the margin of the dura risks spinal cord injury. This is broadly defined as movement-related pain, in contradistinction to biologic pain, which is night or morning pain that resolves with steroids and frequently with radiation therapy. Patients with occipitocervical tumors additionally demonstrate pain with lateral rotation of the head, often in association with occipital neuralgia. Counterintuitively, thoracic instability is often worse in recumbency because patients straighten an unstable kyphosis. Finally, lumbar instability is often manifested as mechanical radiculopathy or severe radicular pain on axial loading. Radiographic criteria in the occipitocervical spine include fracture subluxation greater than 5 mm or 3.
On T2-weighted imaging, chordoma displays its characteristic high intensity signals as a result of the high water content within these tumors allergy fatigue discount prednisolone 5mg online. On histologic evaluation, chordomas display elongated cords of clear cells known as physaliphorous cells allergy forecast iowa city prednisolone 10 mg online. The cells contain intracytoplasmic vacuoles with a copious amount of mucin in both the intracellular and extracellular compartments allergy forecast michigan trusted prednisolone 10 mg. En bloc tumor excision is technically challenging but is associated with longer median disease-free survival than is the case with subtotal excision allergy medicine non drowsy over the counter prednisolone 40mg amex. The reported 5-year local control rate is below 20% after treatment with photon-based radiotherapy at doses of up to 40 to 60 Gy allergy medicine brands names purchase prednisolone canada. With wide resection, chordomas are slow-growing neoplasms, and patients generally have a favorable probability of 5-year survival allergy and asthma care buy 20mg prednisolone with amex. Although both radiation therapy and chemotherapy are ineffective in treating chondrosarcoma, they can be used for palliation when surgery is not an option. Chondrosarcoma Other than lymphoproliferative tumors, chondrosarcoma is the second most common primary vertebral column tumor, and it arises from the spine in up to 12% of all cases. Patients with chondrosarcoma seek medical attention in their fifth or sixth decades, often because of pain and neurological symptoms. Chondrosarcomas have a male preponderance and are 2 to 4 times more likely to occur in men than women. Radiographically, they resemble an osteolytic lesion with an associated soft tissue mass. Unlike chordomas, which tend to arise centrally within the vertebral body, chondrosarcomas generally arise in paracentral locations. They typically develop near the petroclival region in the skull base and near the sacroiliac joints in the pelvis. Primary osteosarcoma of the spine is rare and accounts for roughly 1% to 2% of osteosarcomas. About 70% to 80% of patients have neurological symptoms ranging from sensory deficits to motor paresis at the time of diagnosis. On radiography, osteosarcomas most commonly display dense mineralized matrix with osteoblastic changes. These tumors are generally large at initial evaluation, and invasion of the spinal canal by these tumors is common. However, in recent years, neoadjuvant and adjuvant chemotherapy in combination with radiotherapy has been used for the treatment of osteosarcoma with success. Long-term survival and cure are now possible with aggressive multimodality treatment consisting of surgery, chemotherapy, and radiotherapy. It is a tumor with a characteristic histologic appearance and chromosomal alteration. On cytogenetic analysis, it has a characteristic chromosomal translocation t(11;22)(q24;q12). Neoadjuvant radiation therapy and chemotherapy should be initiated in patients with large tumors, extensive extraspinal extension, or metastatic disease. In patients in whom en bloc excision is not possible, intralesional excision to debulk the majority of the tumor is acceptable. Adjuvant radiation therapy and chemotherapy are administered postoperatively and are required to achieve the most optimal oncologic control. With a contemporary multidisciplinary approach, long-term survival rates have improved from 5% to 20% to 50% to 80%. Patients with metastasis generally have a 5-year survival rate of just 10% to 15%. Chemotherapy and bone marrow transplantation are used in patients with systemic and advanced disease. In addition, these lymphoproliferative tumors are highly responsive to corticosteroids. Corticosteroids are administered to acutely symptomatic patients and are effective in improving pain and even neurological symptoms. Surgical intervention is reserved for patients with spinal instability, severe pain refractory to conservative treatment, and neurological deficits. Similar to the management of metastatic spine disease, circumferential decompression with stabilization is the ideal for patients with spinal canal compromise and neurological deficits or severe spinal instability. Chemotherapy is typically administered as an adjunct to surgical resection of malignant spinal tumors or to patients with systemic disease. In general, the response rate is worse with low-grade tumors than with highgrade tumors. The most common form of spinal radiation therapy is externalbeam ionizing radiation. However, radiation toxicity to the spinal cord is of great concern because of the proximity of the cord and the high radiation doses required to achieve adequate local tumor control. In addition, exposure of surrounding tissues leading to radiation-induced sarcoma is a concern for young patients with benign tumors. Recent advances in radiation therapy have improved the ability to deliver high-dose radiation therapy to tumors while limiting radiation exposure to the spinal cord and surrounding nonneoplastic tissues. Such advances include proton beam therapy and conformal radiation therapy such as intensity-modulated radiation therapy and other stereotactic radiosurgery techniques. Currently, data are still limited on the long-term efficacy of these advanced radiotherapy techniques for the management of primary spinal tumors, but current and future clinical studies incorporating these therapeutic modalities will be extremely valuable. Plasmacytoma/MultipleMyeloma the most common primary malignant tumors that arise from the vertebral column are plasmacytoma and multiple myeloma. Although they are lymphoproliferative tumors and are considered systemic tumors, plasmacytoma and multiple myeloma generally arise within the bone marrow of the vertebral column. The estimated incidence of multiple myeloma is 5 to 7 new cases per 100,000 persons per year, and 19,920 new cases are expected to be diagnosed in the United States in 2008. The abnormal proliferation of plasma cells within the spine causes destruction of the bony architecture and results in secondary osteoporosis. Multiple myeloma occurs more frequently in men than in women, and its peak incidence is in the sixth or seventh decade of life. Radiographs often demonstrate "punched-out" or osteolytic lesions and areas of decreased mineralization. In addition, serum and urine electrophoresis should be performed to evaluate for the presence of an abnormal or excessive amount of immunoglobulins. In cases of plasmacytoma, en bloc spondylectomy followed by radiotherapy can be considered, but such treatment is highly controversial. These tumors are very radiosensitive, and good local control and long-term survival can be achieved with radiotherapy alone. In a study of 206 patients, Knobel and coworkers found that the 5-year probability of progression from solitary plasmacytoma to multiple myeloma was 51% and the median time to progression was 21 months. In addition, an important indication for surgery is to achieve complete tumor resection for local tumor control and, ultimately, cure or long-term disease control. Treatment of primary spinal tumors is often dictated by the histology of the tumor, its location, and the extent of tumor invasion. For selected malignant tumors, neoadjuvant or adjuvant radiation therapy and chemotherapy are required to achieve the best oncologic outcome. Neoadjuvant therapy can significantly reduce the bulk of the tumor to decrease the magnitude of surgery and improve the prospect of achieving wide en bloc resection. In primary sarcomas from extraspinal sites, long-term tumor control, progression-free survival, and the potential for cure have been shown to correlate with the ability to perform marginal, wide, or radical en bloc tumor resection. Over the recent decades, evidence is accumulating that en bloc spondylectomy for primary spinal tumors can impart a higher local tumor control rate, longer disease-free survival, and possible cure of chordomas and chondrosarcomas specifically. In en bloc spondylectomy, the vertebral body is typically removed in a single piece, and the posterior arch is removed separately as a single piece. Spondylectomy was first described by Stener in 1971,182 and since then, various reports have supported improved local tumor control rates and diseasefree survival with spondylectomy. In this procedure, en bloc spondylectomy with anterior and posterior spinal reconstruction is performed through an all-posterior approach. Although the assumption is that en bloc resection of a spinal tumor removes the lesion in its entirety, it does not equate with the classic en bloc radical resection of extremity tumors because of the presence of the neural elements and spinal cord within the lesion, which may often be spared. Therefore, the extent of spinal tumor resection should instead be designated "marginal," "wide," or "radical" en bloc resection. In contrast, marginal en bloc resection involves removal of the tumor with dissection along the pseudocapsule but no entrance into the tumor. In wide en bloc resection, a continuous layer of surrounding healthy tissue is removed along with the tumor. Radical en bloc resection requires removal of the tumor along with the entire anatomic compartment of the tumor origin. It is not possible in the spine, given that it would require removal of the entire spine compartment from the skull base to the coccyx. The ability to accomplish marginal or wide en bloc resection of primary spinal tumors is largely based on tumor location and extension. In addition, the vertebra is divided into five layers ranging from the paravertebral extraosseous region to intradural involvement. Finally, the longitudinal extent of the tumor is defined by the number of spinal segments involved. Accordingly, neoplasms that are confined within the vertebral body or the posterior arch can be excised via marginal or wide en bloc resection. Moreover, tumors located eccentrically with unilateral pedicle or transverse process involvement (or both) and small paraspinal extension can be excised via marginal or wide en bloc resection with the sagittal resection technique. There is also risk for spinal cord ischemia with manipulation and sacrifice of segmental vessels. Finally, after completion of the spondylectomy, there is complete disconnection of the spine with spinal instability, which requires a well-planned reconstruction. Moreover, despite meticulous effort to remain extralesional, there is still the inherent risk of tumor contamination of the field during pediculotomy. However, the use of a fine-threaded T-saw has been shown to decrease the risk for tumor contamination during pediculotomy in an animal model. Such structures include the dura, neural elements, major vessels, paraspinal musculature, and visceral organs. Tumor involvement in these structures may limit the ability to achieve wide or marginal excision of the tumor without significant risk. In these cases, intralesional or piecemeal resection can be performed for subtotal tumor removal. Benign primary spinal tumors can be managed conservatively or treated surgically with complete resection. Malignant primary spinal tumors are generally treated surgically with tumor excision. Unlike the management of metastatic spinal tumors, the goal of treatment of a primary spinal tumor is to achieve lasting local tumor control for long-term survival or possible cure. The most advanced and optimal surgical treatment to achieve this goal is wide tumor excision with en bloc spondylectomy or en bloc sacrectomy. Several clinical studies have demonstrated improved local tumor control and overall survival rates with these aggressive surgical treatments. En bloc tumor excision should be the first-line treatment of aggressive or invasive benign primary spinal tumors and almost all malignant primary spinal tumors. In cases in which en bloc tumor excision is not possible, subtotal tumor excision followed by adjuvant radiation therapy or chemotherapy (or both) is a viable alternative. Giant cell tumor of the pelvis and sacrum: 17 cases and analysis of the literature. As patients survive longer as a consequence of improvements in cancer treatments, metastases to the spine are affecting quality of live as well as survival. Historically, the treatment of spinal metastatic disease was palliative radiation, but newer surgical techniques have demonstrated superiority in many cases to radiation alone. In this chapter, we review the various epidemiologic, diagnostic, and treatment issues involved in caring for the patient with metastatic spinal disease. Pain usually precedes neurological signs of spinal cord compression by a prolonged period. It is often described as a dull, constant ache that is notably worse at night (nocturnal pain) or early in the morning. This is thought to be related to venous engorgement of the tumor causing increasing mass effect on surrounding pain-sensitive structures, such as the periosteum, dura, nerve roots, cauda equina, or spinal cord. The pain is usually located at the diseased site, but sometimes it can be referred to other regions such as the interscapular area and shoulders for cervical with thoracic involvement and the sacroiliac and iliac crest regions with lumbar disease. Mechanical pain is the result of destruction of the vertebrae to the point that there is enough structural abnormality causing instability. This pain is increased by standing, increased activity, and coughing and decreased by assuming a supine position, similar to the pain experienced with traumatic instability. Spinal cord compression results from any one or a combination of four processes: direct compression from an enlarging soft tissue mass, pressure caused by fracture and retropulsion of bony fragments into the canal, severe kyphosis following vertebral collapse, and, rarely, extension of a paraspinal tumor through the intervertebral foramen. Neurological symptoms are usually gradually progressive, but alternatively may occur rapidly and present as a neurological emergency. Neurological symptoms can broadly be divided into radicular and myelopathic, the features of which depend on the level and extent of disease. Myelopathy often presents as a gait disturbance, followed by spasticity, generalized weakness, sensory loss, and autonomic dysfunction. Bowel and bladder dysfunction, which may be present on initial evaluation, is rarely unaccompanied by other symptoms. When it does appear as the only symptom, the lesion is most likely at the level of the conus medullaris.
Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves allergy forecast salt lake city cheap 40mg prednisolone otc. Patient selection for lumbar arthroplasty and arthrodesis: the effect of revision surgery in a controlled, multicenter, randomized study allergy medicine recall purchase prednisolone 10mg amex. Effects of Charite artificial disc on the implanted and adjacent spinal segments mechanics using a hybrid testing protocol allergy symptoms 1dpo buy discount prednisolone 5 mg. It is applied as a two-part in situ curable polyurethane and an expandable polyurethane balloon, which is inserted into the disk space after the nucleus has been removed allergy testing maine discount prednisolone 10mg without a prescription. The balloon is then injected under pressure with the flowable polymer that conforms to the shape and size of the disk space allergy testing pittsburgh generic prednisolone 5 mg fast delivery. The flowable polymer cures, creating a firm but pliable implant with shock absorption capability allergy under eye swelling prednisolone 5 mg lowest price. Challenges include maintaining an even stress distribution and lack of shock absorption. The major weakness revolves around a lack of anchor to the end plates, which predisposes to subsidence and expulsion. Effect of age on clinical and radiographic outcomes and adverse events following 1-level lumbar arthroplasty after a minimum 2-year follow-up. Guidelines for the performance of lumbar fusion for degenerative disease of the lumbar spine. Results of the prospective, randomized, multicenter Food and Drug Administration investigational device exemption study of ProDisc-L total disc replacement versus circumferential fusion for the treatment of 1-level degenerative disc disease. The authors stated that this group of patients with sciatica more closely resembled patients with chronic back pain, with symptoms disproportionate to anatomic findings. Thus, the contained disk herniation with radicular and/ or diskogenic symptoms remains a difficult clinical entity to treat with standard discectomy. Both radiculopathy and diskogenic lumbago can be attributed to tears within the annulus fibrosus. For more than 50 years, open discectomy has been the "gold standard" for disk decompression in the treatment of sciatica. Despite the success of discectomy, complications from the open procedure include: reherniation in up to 10% of patients, epidural fibrosis, loss of height, instability, and residual back pain. Advantages of these treatments include minimal scarring, avoidance of canal structures, and short hospital times. This section will briefly discuss some of these methods, with an emphasis on nucleoplasty, which perhaps has the greatest promise. The following section will address the concept of dynamic stabilization, a related but separate topic in the treatment of motion preservation lumbar spine surgery. As the trends within surgery have shifted to minimally invasive, reductionist methods, the concept of definitive percutaneous treatment of disk disease has become increasingly attractive. In general terms, nucleoplasty is a technique in which intervertebral disk material is typically removed, rather than inserted, via a percutaneous route. The lumbar levels below the conus medullaris are the primary targets, in particular, L4-5 and L5-S1, and rarely L3-4. However, an understanding of all of these treatment options is relevant to the field. Patients with contained fragments and less than 6-mm herniation have been shown to respond poorly to diskectomy. The technique uses chymopapain for enzymatic lysis of the nucleus and was first described by Lyman Smith in 1964. Multiple recent studies have reported success rates of 85% or greater in a carefully selected population. In a typical protocol, 4000 U of chymopapain dissolved in 1 to 2 mL of saline is injected into the center of the symptomatic disk. The enzyme may potentially dissolve annular structures; there is no additional aspiration of lysate. Complications include back stiffness (up to 50%) and pain that can last for weeks. The treatment consists of radiofrequency ablation of the annulus fibrosus in a controlled manner. The probe is heated to a temperature required for coagulation of nerve endings and contraction of collagen. If the space is even partially decompressed, radiculopathy can improve from a reduction in volume, which may not be radiographically evident. Thus the process is effective only in select patients who still have an intact annulus fibrosus without large or free fragments. Discography can be helpful in distinguishing annular fissures from intact external fibers and true extrusions. Relief of intradiscal pressure may also decrease leaching of inflammatory mediators, thereby alleviating both chemical and mechanical causes of diskogenic pain. In general, exclusion criteria include greater than 50% loss of disk height, sequestered disk herniation, greater than one third canal occupation, spinal instability or fracture, morbid obesity, infection, or spinal stenosis from osteophytic disease. Typically patients will have a 6-month or greater history of symptoms, with exacerbations under loading conditions that increase the pressure and diameter of the disk. Decompression and subsequent scar formation may reinforce the annulus with a fibrous scar, facilitate closure of radial tears, and contribute to stabilization. Alternative strategies for lumbar diskectomy: intradiscal electrothermy and nucleoplasty. The technique involves insertion of a mechanical (automated) probe to perform a nucleotomy via a "suction and cutting" mechanism. Then, a rounded-tip aspiration probe with a side port is passed into the disk space. Disk material is sheared off by the pneumatically driven guillotine effect of the sharp inner cannula. Suction aspiration of nuclear material is stopped when there is blood return or decreased flow. Iatrogenic fragment herniation is a rare complication (<1%), which may occur from annular weakening or direct pressure of the probe. The decompression is performed by advancing the wand in ablation mode to create a channel from the posterolateral annulus to the anteromedial annulus. The entire radiofrequency ablation process requires 2 to 3 minutes and results in disk volume reduction of 10% to 20%. A bilateral approach may be used for maximal nucleus pulposus removal or for centrally herniated disks. Postoperatively, patients may be discharged on the day of the procedure or the following day. Side effects and complications include local needle site pain, transient paresthesias, and increased back pain and muscle spasms in a minority of patients. Large series reported symptomatic improvements for both low back and sciatic pain of between 50% and 80% as much as 1 year posttreatment. The principles of percutaneous discectomy apply to nucleoplasty patient selection. It is important to consider not only whether the herniation is contained, but also the degree of disk degeneration. Chen and coworkers measured intradiscal pressures postnucleoplasty in a cadaver model,28 demonstrating that nucleoplasty was largely ineffective at reducing pressures in highly degenerative disks. The clinical implication is that older patients with more calcified disks or patients with smaller disk spaces may not respond well to nucleoplasty. Older patients are less likely to have radial fissures in the annulus because of decomposition of mucoid matrix,58 making nucleoplasty potentially less successful for diskogenic pain in this group. More recent European studies have continued to report the safety and efficacy of nucleoplasty in nonplacebo controlled cohorts. However, Gerszten and coworkers49 found mixed results in an outcomes study on a smaller longitudinal cohort of 67 patients. In conclusion, coblation nucleoplasty is probably the most promising treatment option among the variety of minimally invasive intradiscal therapies. Coblation minimizes thermal damage or irritation to adjacent tissues, which LaserDiscectomy Intradiscal laser discectomy is another method that works via reduction of intradiscal pressures. Between 1100 to 1200 J of energy from the laser vaporizes a portion of the nucleus pulposus. Laser-induced steam can be seen in the disk space afterward if it is not removed via the cannula, but this has not resulted in complications. The catheter creates a low thermal plasma field in which there is minimal thermal injury to adjacent tissue. Chen and coworkers found that the annulus, end plates, and neural elements were histologically normal at the level of the procedure in a cadaver study. Dynamic Stabilization the concept of dynamic stabilization rests on intervertebral motion preservation or restoration to the normal biomechanical limits of the healthy spine. The indications for posterior dynamic stabilization are still not completely defined. An example would be a patient with grade I spondylolisthesis and lumbar spinal stenosis at the same level. This patient might be considered for fusion if extensive facet joint resection for neural decompression was performed. Regarding the 1-year outcomes, the primary indication was leg symptoms greater than lower back pain, spondylolisthesis, and canal stenosis. Patients were treated at a single level and were randomized to either instrumented fusion with semirigid pedicle screw fixation and iliac crest autograft or Dynesys. The overall clinical outcomes were similar in the fusion group compared with the Dynesys group. Radiographic study demonstrated a more than 50% reduction in flexion-extension movement at 24 months in the Dynesys group. The rate of screw loosening was similar in both groups as well (approximately 5%). Indications As with most successful surgeries, patient selection is critical to a good result. The indication for use of the system as a fusion adjunct is to supplement onlay bone placement to promote solid arthrodesis. In this application, Dynesys can be used in cases of gross instability and pars interarticularis fractures. Surgeons have used this system to augment spinal levels with early degenerative disk disease, minimal instability, iatrogenic instability, recurrent disk rupture, lower back pain, facet disease, and other indications. Although the full range of efficacy and indications is not known, it is generally recommended that the system be used only in patients with adequate bone quality who have no evidence of infection, pars interarticularis fractures, or severe instability. In both fusion and nonfusion cases, the screws are placed in a lateral-to-medial direction starting lateral to the facet joint in the trough formed by the lateral facet joint and the medial transverse process. We try to use a special pedicle probe, which creates a large enough hole in the pedicle to obviate the need for tapping. The screws are placed and driven into the bone as far as possible to reduce the profile of the system and to improve the relationship of the instrumentation to the preoperative instantaneous axis of rotation. The use of solid rods is straightforward and similar to many other commercially available lumbar instrumentation systems. The distance between the pedicle screw heads is measured and a polyurethane bumper is cut to length. The bumper is placed over the cable, and the cable is advanced into the next pedicle screw. Tension is placed across the pedicle screws with a tensioning device and the cable is clamped in place. The process is repeated on the other side of the spine and at the other levels as determined by the surgeon. When used as a fusion adjunct, the surgeon may place bone on the transverse processes for arthrodesis. We generally put patients in lumbar braces for a period of time after surgery and monitor the system radiographically at 6, 12, 16, 52, and 104 weeks. Most require insertion of the pedicle screws followed by placement of the motion-preserving or stabilizing device. The standard technique is relatively straightforward and translational from pedicle screw placement for lumbar fusion. The selected patient is positioned on the operating room table in a prone position. Dissection is performed to the proximal (medial) aspect of the transverse process in cases of nonfusion and to the tips of the transverse processes for fusion cases. The ultimate robustness of the implanted system can, unfortunately, only be assessed in the long term in vivo. There are few randomized multicenter trials upon which to base firm clinical recommendations and guidelines. Major concerns with the systems are those of robustness and preservation of the bone-screw interface. Early information suggests that the systems are safe and at least as efficacious as lumbar fusion in highly selected patients. The ultimate acceptance of these systems will require further study and clinical experience. A prospective analysis of magnetic resonance imaging findings in patients with sciatica and lumbar disc herniation. Immediate biomechanical effects of a lumbar posterior dynamic stabilization above a circumferential fusion. A randomized, double-blind, controlled trial: intradiscal electrothermal therapy versus placebo for the treatment of chronic discogenic low back pain.
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Treatment varies, depending on the type of pain, degree of slippage, and segmental instability allergy medicine dosage for dogs prednisolone 20mg lowest price. Surgical decompression with instrumentation and fusion is the mainstay for advanced disease allergy forecast new braunfels tx buy prednisolone 10 mg online. Most pathologic vertebral column fractures cause acute localized pain without neurological deficits allergy forecast vancouver wa cheap prednisolone 40mg with visa. External bracing may help relieve pain in the acute phase of a vertebral fracture and should be discontinued when the symptoms resolve allergy medicine help sore throat order prednisolone 5 mg online. Surgery is reserved for fractures resulting in gross deformity, instability, or neurological impairment allergy treatment in vellore discount 5mg prednisolone fast delivery. The extensive list of metabolic bone diseases is covered in other chapters; most are managed medically allergy symptoms anus buy cheap prednisolone 5 mg. Osteoporosis can be primary, which is idiopathic, or secondary, which is a result of endocrinopathies, neoplastic diseases, hematologic disorders, mechanical disorders, biochemical collagen disturbances, or nutritional aberrations. Osteomalacia, a metabolic bone disease characterized by inadequate mineralization of newly formed osteoid, results from a deficiency of or resistance to vitamin D, intestinal malabsorption, acquired or hereditary renal disorders, intoxication with heavy metals (aluminum and iron), and other assorted causes. Malignant degeneration occurs in 1% to 10% of patients; the most common malignant tumor in pagetic bone is osteogenic sarcoma. The clinical presentation involving the spine includes local pain, vertebral fractures, or entrapment of nerve roots. Treatment is multidisciplinary, with surgery reserved for instability or progressive neurological deficits. The clinical presentation and treatment of these diseases are variable and are discussed in other chapters. Deformities are classified according to cause, location, magnitude, and direction, and they represent another potential cause of spine and radicular pain. Adult lumbar scoliosis, defined as a Cobb angle greater than 10 degrees, increases with age and is not uncommon in those older than 60 years. Although the exact cause of the pain is unclear, back pain was present in 86% of adult patients with lumbar scoliosis in one large series. Most cases of minor (Cobb angle < 20 degrees) lumbar scoliosis are managed medically. Degenerative deformities in the sagittal plane are common in the elderly and often remain asymptomatic or are associated with mild axial skeletal pain. Surgical intervention for degenerative scoliosis, kyphosis, and lordosis is reserved for progressive deformity, severe pain, segmental instability, and neurological deficits. A patient complaining of spine or radicular pain after trauma is considered to have a fracture or ligamentous injury until proved otherwise. These pathologic conditions include infections, tumors, inflammatory disorders, and metabolic diseases that destroy or weaken the vertebral body and lead to fracture under normal physiologic loads. Acute disk herniation and spinal hemorrhage should be included in the differential diagnosis of acute localized pain. To formulate a differential diagnosis, one must define the time course of the neurological deficit, along with the pattern of pain, the presence of motor and sensory dysfunction, and the existence of bowel or bladder malfunction. This begins by obtaining a comprehensive history of symptom onset, characteristics, location, and aggravating and alleviating conditions. As previously discussed, thorough medical, family, and social histories elucidate conditions associated with neuronal diseases. The physical examination should include a detailed neurological examination searching for brain, brainstem, spinal cord, peripheral nerve, and muscle involvement, because dysfunction in any part of the nervous system can masquerade as spinal cord disease. Defining the location and distribution of a neurological deficit is extremely important for diagnosis and localization of the pathologic lesion. The single most important finding indicative of focal spinal cord pathology is a segmental spinal level below Metabolic Disorders Metabolic disorders can affect bone mineralization or density and many predispose patients to benign pathologic fractures. Frequently, patients with metabolic disorders present with systemic symptoms and signs of the disease before the discovery of any spine pathology. Focal neurological deficits in the anatomic distribution of a nerve root are extremely accurate for localizing pathology to the spinal cord or segmental nerve roots. In diffuse disease in which the neurological deficit cannot be localized, the pattern of sensory and motor involvement is the basis of the differential diagnosis, but this is less reliable for differentiating spinal cord pathology from central and peripheral neurological disease or from primary muscular pathology. Upper motoneuron pathology results from spinal, brainstem, or brain pathologic processes. Diffuse muscle weakness and atrophy may be the result of spine and peripheral nerve disease, neuromuscular junction failure, or a pure muscular illness. Localizing diffuse neurological deficits to the spinal cord requires knowledge of specific spine disease presentations, combined with laboratory investigations, electrophysiologic studies, and radiographic imaging. When the physical examination cannot localize the disease, electrophysiologic studies assist in identifying and characterizing the pathologic process. Electromyography, nerve conduction studies, and somatosensory evoked potentials can differentiate primary muscular, peripheral nerve, spine, and brainstem pathology. Laboratory investigations, electrophysiologic evaluation, and radiologic imaging may be diagnostic, or the diagnosis may require biopsy of a pathologic lesion. Cervical radicular arteries may also provide segmental cervical arterial supply to the spinal cord. Segmental branches of the aorta and internal iliac arteries supply the thoracic and lumbar spinal cord. The most important segmental vessel, the artery of Adamkiewicz, typically arises from the left side of aorta between the T10 and L3 spinal segments. The spinal cord between these main vascular systems is relatively vulnerable to ischemia, particularly in the midthoracic (T4-6) region of the spinal cord. Caisson disease, or decompression sickness, infrequently causes spinal cord infarction as a result of nitrogen bubbles after diving. Fibrocartilaginous embolism after trauma may occlude a spinal artery, with resultant spinal cord ischemia and infraction. It consists of motor paralysis, dissociated sensory loss, and paralysis of sphincter function. The most common causes of spontaneous epidural or subdural hematoma include bleeding diathesis, anticoagulant therapy, and vertebral body tumor. Spontaneous spinal epidural hematomas occur more commonly than subdural hematomas, and their pathogenesis is thought to involve the epidural venous plexus. Patients with a history of trauma and newonset neurological deficits need to be evaluated for a spinal column or neural axis injury. Without a history of trauma, acute paresis or paralysis of the extremities is most likely related to spinal cord infarction or spinal hemorrhage. Neurological evaluation usually reveals motor and sensory deficits below the level of vascular cord injury, allowing the clinician to localize the segmental level of the lesion. With the clinical history and the pattern of neurological deficit, a logical differential diagnosis can be deduced and is discussed in the sections that follow. Subacute, Progressive Neurological Deficit Subacute, progressive neurological deficits are defined by the clinical onset of neurological symptoms that worsen over the course of days to weeks. This clinical picture indicates an inflammatory spinal cord disease or a compressive spinal cord lesion. Painful subacute, progressive diseases are more likely caused by rapid compression and include tumors, vertebral infections with abscesses, and large herniated disks. Myelitic disorders usually manifest with subacute, progressive neurological deficits associated with systemic signs of infection but without a significant history of long-standing pain. Myelitis represents a nonhomogeneous group of inflammatory disorders related to viral, bacterial, fungal, and parasitic diseases or to noninfectious inflammatory lesions. Ischemia to the spinal cord is usually from the anterior spinal artery distribution and usually results from involvement of the segmental vessels rather than direct involvement of the artery. Spinal cord infarction may result from thromboembolic occlusion of spinal segmental arteries secondary to dissection, clamping, or severe atheroma of the aorta, and anterior cord syndrome is the typical clinical presentation. The midthoracic spinal cord is the most common affected level because it lies in a vascular watershed zone. When spinal cord infarction results from systemic hypotension, it can damage the lower thoracic and lumbosacral central gray matter. Clinical presentation may include the subacute onset of spine pain at the level of the inflammatory damage. A detailed neurological evaluation reveals motor or sensory deficits, or both, at or below the level of the lesion. The pattern and progression of these deficits provide evidence of the cause of the inflammatory process. Treatment includes acyclovir, which shortens the duration of acute pain and speeds healing but does not affect the incidence of postherpetic neuralgia. Disorder of sphincter control is usually an early sign, and sensory function in the lower extremities is variably affected. There are anecdotal reports of improvement after the intravenous administration of gammaglobulin. The enteroviruses have an affinity for anterior horn cells of the spinal cord and motor nuclei of the brainstem, whereas varicella-zoster virus prefers the dorsal root ganglion. When significant sensory and motor deficits are present, the cause of myelitis is rarely viral. In countries with successful vaccination programs, polio infections are rare and other enteroviruses are the most common causes of anterior poliomyelitis syndrome. The human gastrointestinal tract acts as a reservoir for the virus, and the main route of infection is fecal-oral contamination. In clinically apparent poliovirus infection, symptoms include listlessness, headache, fever, stiffness, aching muscles, sore throat, anorexia, nausea, and vomiting. Nervous system involvement includes irritability, restlessness, and emotional lability, which are often followed by paralysis. Paralytic poliomyelitis is secondary to the destruction of the anterior and intermediate horn cells in the spinal cord gray matter, and the distribution of paralysis is variable. The development of muscle weakness is variable and may occur rapidly over 48 hours or over a week or longer. Objective sensory loss is rare; urinary retention may occur acutely, but the problem seldom persists. Treatment of an acute poliovirus infection is supportive; most patients with paralytic poliomyelitis improve over 3 to 4 months after the infection the mortality rate associated with acute infection is 5% to 10%. There are approximately three to five cases per 1000 persons each year, and the incidence increases with age. Symptoms include an acute inflammatory reaction involving isolated spinal or cranial sensory ganglia, the posterior gray matter of the spinal cord, and the adjacent leptomeninges. Clinically, varicella-zoster infection is characterized by radicular pain, a vesicular cutaneous eruption, and, less often, segmental motor or sensory loss. Almost any dermatome can be involved, but the Bacterial, Fungal, and Parasitic Myelitis this category of disease includes myelitis due to Mycoplasma pneumoniae and Borrelia burgdorferi, pyogenic myelitis, tuberculous myelitis, and syphilitic myelitis. Lesions may involve both the spinal cord and meninges, or a spinal cord lesion may predominate. Any infection of the axial skeleton can produce an infection in the epidural space resulting in pain and fever, followed by radicular symptoms. If the infection is allowed to progress untreated, patients develop paraplegia or quadriplegia. Granulomatous infections of the epidural space or meninges may become symptomatic, with a more indolent clinical course and associated with a more subacute, progressive neurological deficit. The clinical symptoms and signs are almost indistinguishable from those of an epidural infection. Neurosyphilis may affect the spinal cord and most commonly causes tabetic neurosyphilis (tabes dorsalis); however, it may also produce syphilitic meningomyelitis or spinal meningovascular syphilis. Tabetic neurosyphilis usually develops 15 to 20 years after the onset of the infection, resulting from degeneration of the posterior columns of the spinal cord and the dorsal nerve roots. Other systemic signs of infection are usually present by the time tabes dorsalis presents; these include pupillary abnormalities in more than 90% of patients. The major symptoms of tabes dorsalis are lightning pains, ataxia, and urinary incontinence. Muscular power is fully retained, and the ataxia is related to the sensory deficit. In syphilitic meningomyelitis, there is a subpial loss of myelinated fibers and gliosis as a result of chronic fibrosing meningitis; gumma of the meninges or spinal cord is rare. Spinal meningovascular syphilis occasionally assumes the form of an anterior spinal artery syndrome. Other possible causes of inflammatory lesions of the spinal cord include tuberculous meningitis with spinal tuberculoma, schistosomiasis, spinal cord abscess, and sarcoid. The processes that produce chronic and progressive spinal cord dysfunction are associated with persistent spinal cord ischemia or slowly progressive spinal neuronal degeneration. Differentiating the different disease entities requires the usual detailed clinical history, neurological evaluation, laboratory investigation, electrophysiologic studies, and radiographic imaging. Congenital malformations may cause spinal cord tethering and blood flow abnormalities. Chronic, progressive spinal cord neuronal dysfunction may result from progressive neuronal degeneration, chronic myelitis, or intramedullary spinal cord tumors. Intramedullary tumors usually manifest with an insidious onset of pain, and chronic myelitis is usually associated with systemic symptoms and signs; in contrast, neuronal degenerative diseases are seldom associated with pain or systemic symptoms and signs. Noninfectious Inflammatory Myelitis A disordered immune response rather than an infectious agent produces noninfectious inflammatory myelitis. This immune reaction results in leukomyelitis with demyelination or necrosis of spinal cord tracts.
