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Biomedical subjects

R G Fessler

Publications and source records attributed to R G Fessler.

At least 19 recordsLinked to original sources
PubMed1998

Review: complications of surgery for thoracic disc disease.

BACKGROUND: Thoracic discectomy has evolved over the last 60 years from resection through standard laminectomy, to posterolateral procedures to open thoracotomy and finally thoracoscopy. Comparison of relative morbidity and mortality between these approaches is now possible. METHODS: Peer-reviewed publications reporting clinical data relating to thoracic discectomy, and which provided sufficient information to enable adequate assessment of mortality and morbidity were reviewed. These articles were determined via review of the results of MedLine searches and articles gathered through compilation of references from those articles. RESULTS: Articles reviewed spanned a period of over 60 years. Surgical procedures used for thoracic discectomy included laminectomy, pediculectomy, costotransversectomy, lateral extracavitary, transverse arthropediculectomy, anterolateral thoracotomy, and thoracoscopy. Complications included death, paralysis, paresis, loss of bowel and/or bladder control, pulmonary embolism, pneumonia, atelectasis, compression fracture, infection, pleural tear, bowel obstruction, and anesthesia dolorosa. Mortality dropped to nearly zero after development of anterior and posterolateral approaches. Morbidity seems relatively similar between most procedures other than laminectomy. Not enough procedures have been reported using thoracoscopy to adequately assess its morbidity. CONCLUSION: Comparison of relative rates of morbidity and mortality between surgical approaches to thoracic discectomy suggest that laminectomy does not provide adequate access for the safe removal of these lesions. Choice of approach among the alternatives should be based on the evacuation of the herniated fragment and experience of the surgeon. Thoracoscopy, although promising, has not had sufficient time for evaluation of morbidity to make definite statements regarding its safety.

Diskectomy↗
PubMed1997

Primary reconstruction for spinal infections.

Primary reconstruction using bone grafts and instrumentation for spinal infections remains controversial. Between 1991 and 1993, 27 infections of the spinal column were treated at the Department of Neurosurgery of the University of Florida. Of the 27 cases 20 (six cervical, eight thoracic, and six lumbar spine) required surgical debridement and spinal reconstruction to maximize eradication of the infection and maintenance of spinal alignment. All of the cervical and lumbar cases were caused by bacterial infections, and two of eight thoracic cases were caused by tuberculous infections. Spinal arthrodesis was performed in all cases: interbody grafts were used in 18 procedures and posterolateral onlay grafts in 14. Interbody grafts were autologous in 10 cases (six rib and four iliac crest) and allograft in eight (six fibular and two humerus). All of the posterolateral onlay grafts were autologous (three rib and 11 iliac crest). Spinal instrumentation was used in 15 cases: four with Caspar plates and 11 with posterior segmental fixation (five hook/rod constructs and six screw/rod constructs). Seventeen of 20 patients achieved improved clinical status postoperatively and 18 of 20 showed radiographic evidence of bone fusion. Antibiotic drugs were administered parenterally for an average of 6 weeks followed by a 3-month course of oral antibiotic medications. Tuberculous infections were treated for 1 year with antibiotic therapy. The average follow-up period was 37 months from surgery and 31 months after completion of treatment with antibiotic drugs. The authors conclude that primary arthrodesis and instrumentation can be performed in acute spinal infections; however, successful management depends on aggressive debridement of infectious foci and prolonged treatment with parenteral antibiotic drugs.

Adult↗
PubMed1997

Lateral extracavitary approach to the thoracic and thoracolumbar spine.

Twenty-nine patients with anterior spinal cord compression underwent decompression and fusion through a laterally based approach to the thoracic and thoracolumbar spine. The lateral extracavitary approach allows access to the vertebral bodies as well as the posterior elements through a single incision. This approach was chosen for patients who had complicating medical conditions that made staged procedures less desirable. Ten men and 19 women with an average age of 53 years were studied. Diagnoses included post-traumatic deformity, metastatic disease, osteomyelitis, and primary neoplasms. Twenty-three patients had frank neurologic loss preoperatively, and 28 patients had significant medical comorbidities as evidenced by American Society of Anesthesiology classes II, III, and IV. One patient died postoperatively from pneumonia, which developed in a lung with metastatic disease, and two patients developed seromas that subsequently became infected. The average intensive care unit stay was less than 2 days. Patients remained intubated for an average of 13 hours after surgery. In this population of medically compromised patients with difficult spinal disease, the lateral extracavitary approach provided an effective means of one-stage treatment. Patients tolerated the procedure, and cardiopulmonary complications were minimal. This approach is most appropriate in patients who require posterior stabilization in conjunction with anterior stabilization.

Adolescent↗
PubMed1996

Prospective, multicenter study of spinal cord stimulation for relief of chronic back and extremity pain.

STUDY DESIGN: This prospective, multicenter study was designed to investigate the efficacy and outcome of spinal cord stimulation using a variety of clinical and psychosocial outcome measures. Data were collected before implantation and at regular intervals after implantation. This report focuses on 70 patients who had undergone 1 year of follow-up treatment at the time of data analysis. OBJECTIVES: To provide a more generalizable assessment of long-term spinal cord stimulation outcome by comparing a variety of pain and functional/quality-of-life measures before and after management. This report details results after 1 year of stimulation. SUMMARY OF BACKGROUND DATA: The historically diverse methods, patient selection criteria, and outcome measures reported in the spinal cord stimulation literature have made interpretation and comparison of results difficult. Although short-term outcomes are generally consistent, long-term outcomes of spinal cord stimulation, as determined by prospective studies that assess multidimensional aspects of the pain complaint among a relatively homogeneous population, are not well established. METHODS: Two hundred nineteen patients were entered at six centers throughout the United States. All patients underwent a trial of stimulation before implant of the permanent system. Most were psychologically screened. One hundred eighty-two patients were implanted with a permanent stimulating system. At the time of this report, complete 1-year follow-up data were available on 70 patients, 88% of whom reported pain in the back or lower extremities. Patient evaluation of pain and functional levels was completed before implantation and 3, 6, 12, and 24 months after implantation. Complications, medication usage, and work status also were monitored. RESULTS: All pain and quality-of-life measures showed statistically significant improvement during the treatment year. These included the average pain visual analogue scale, the McGill Pain Questionnaire, the Oswestry Disability Questionnaire, the Sickness Impact Profile, and the Back Depression Inventory. Overall success of the therapy was defined as at least 50% pain relief and patient assessment of the procedure as fully or partially beneficial and worthwhile. Using this definition, spinal cord stimulation successfully managed pain in 55% of patients on whom 1-year follow-up is available. Complications requiring surgical intervention were reported by 17% (12 of 70) of patients. Medication usage and work status were not changed significantly. CONCLUSIONS: This prospective, multicenter study confirms that spinal cord stimulation can be an effective therapy for management of chronic low back and extremity pain. Significant improvements in many aspects of the pain condition were measured, and complications were minimal.

Adult↗
PubMed1996

Percutaneous lumbosacral fixation and fusion: anatomic study and two-year experience with a new method.

This anatomic and clinical study describes a transsacral, percutaneous approach for fixation and fusion of the L5-S1 disc. A tunnel is created into the L5-S1 disc from this approach, permitting disc removal, bone grafting, and placement of two nine-millimeter diameter titanium screws into the body of L5. There were no complications referable to screw placement, and eight of nine patients had successful fusion.

Adult↗
PubMed1994

Posterolateral approach to intradural extramedullary thoracic tumors.

Six ventrally located intradural thoracic tumors were successfully resected through the posterolateral approach. This approach allows direct visualization of the ventral and dorsal boundaries of the tumor with minimal manipulation of the spinal cord. Compared to the traditional laminectomy, the operative time is increased but visualization of the tumor and spinal cord is markedly improved. Compared to the transthoracic approach, the posterolateral approach has fewer potential complications and eliminates the necessity of vertebrectomy. Neurological improvement occurred in all six patients. It is believed that this approach offers significant advantages for the treatment of ventrally located intradural thoracic tumors, and should be considered an alternative to the transthoracic approach.

Adult↗
PubMed1993

The perioperative use of corticosteroids and bupivacaine in the management of lumbar disc disease.

The introduction of microdiscectomy to lumbar spine surgery has resulted in a significant decrease in postoperative pain and length of hospital stay. Intraoperative application of long-acting local anesthetic agents has been used for many general and neurosurgical procedures for the management of postoperative pain. In addition, many surgeons routinely use intraoperative corticosteroids during lumbar discectomy to reduce traumatic nerve root inflammation. However, the efficacy of intraoperative long-acting local anesthetic agents and corticosteroids for reduction of postoperative discomfort has not been reported for lumbar discectomy. This study evaluated 32 patients at a university-based Veterans Administration hospital undergoing lumbar microdiscectomy. All 32 patients presented with radicular symptoms and had radiographic confirmation of a herniated nucleus pulposus. These patients were divided into three groups. Group 1 (12 patients) received 160 mg intramuscular Depo-Medrol (methylprednisolone acetate) and 250 mg intravenous Solu-Medrol (methyl-prednisolone sodium succinate) at the start of the operation. A macerated fat graft soaked in 80 mg Depo-Medrol was placed over the affected nerve root following discectomy. In addition, 30 ml of 0.25% bupivacaine was infiltrated into the paraspinal musculature at skin incision and during closure. Group 2 (10 patients) received 30 ml of 0.25% bupivacaine infiltrated into the paraspinal musculature at skin incision and at closure. In this group of patients, a saline-soaked fat graft was placed over the affected nerve root. Group 3 (10 patients) acted as a control group, undergoing lumbar microdiscectomy without corticosteroids or bupivacaine. Patients receiving bupivacaine and corticosteroids (Group 1) had a statistically significantly shorter hospital stay (1.4 days) compared to the control group (4.0 days) (p = 0.0004, Mann-Whitney U-test). Patients in Group 1 required less postoperative narcotic analgesia than the other groups. Finally, a larger percentage of patients in Group 1 reported complete relief of back and radicular pain on postoperative Day 1 compared to other groups. Postoperative complications and functional outcome were not different between the groups. These results indicate that the combination of long-acting anesthetic agents and corticosteroids can reduce postoperative discomfort and subsequently the length of postoperative hospital stay.

Adrenal Cortex Hormones↗
PubMed1993

Thoracic disc herniations.

Because of the protean nature of thoracic disc disease, surgeons should maintain a high order of suspicion of a thoracic disc herniation in the patient with unexplained localized back or torso pain and sensorimotor deficits. These patients should have MR imaging performed as a screening test, and, if suspicious for a thoracic disc herniation, confirmatory myelogram and postmyelogram CT imaging. Though the natural history is anecdotal, there appears to be a tendency for myelopathic symptoms and signs to be progressive, warranting surgical intervention. For radicular dysfunction or localized back pain, a conservative therapeutic plan is recommended. If intractable pain is demonstrated, and the diagnosis is certain, then surgical intervention is recommended. Once surgical intervention is recommended the surgical approach needs to be individualized according to the surgeon's skills and experience and the specifics of the patient's pathology. Appropriate surgical decision-making depends on an understanding of the variety of surgical options and their advantages and disadvantages, and an understanding of the biomechanical factors of the spine of the individual patient. Surgical concepts important to successful thoracic disc removal are (1) minimal spinal cord manipulation, (2) preservation of the neurovascular supply whenever possible, (3) minimal manipulation of the intercostal nerve, and (4) preservation of maximal bony and ligamentous attachments allowable for adequate exposure. Lastly it is recommended that the posterior longitudinal ligament be removed to ensure complete spinal cord decompression.

Adult↗
PubMed1992

Epidural lipomatosis in steroid-treated patients.

Epidural lipomatosis is a condition in which excess adipose tissue is deposited circumferentially about the spinal cord in the epidural space. It is most frequently seen in patients on chronic steroid treatment for a variety of medical problems and can present as nonspecific back pain, radiculopathy, or frank spinal cord compression. Diagnosis and treatment have generally relied on multi-level decompressive laminectomy after myelography and computed tomography. The immunocompromised state and the reported postoperative mortality (22%) of these patients, however, suggests that nonoperative therapy may be preferable whenever possible. Five cases of epidural lipomatosis are reported, and previous literature is reviewed for presentation, evaluation, and treatment of this condition.

Adult↗
PubMed1992

The influence of transoral odontoid resection on stability of the craniovertebral junction.

Twenty-seven cases of craniovertebral junction compression treated with transoral surgery were reviewed to assess the influences of pathological processes and surgical interventions on spinal stability. All patients presented with signs and symptoms of spinal-cord or brain-stem dysfunction. Pathology included rheumatoid arthritis in 11 patients, congenital osseous malformations in 11, spinal fractures in two, plasmacytoma in one, osteomyelitis in one, and a gunshot injury in one. Instability was defined as clear radiographic evidence of mobile subluxation in conjunction with clinical assessment. Of 19 patients (70%) requiring internal fixation, nine underwent upper cervical fusion and 10 had occipitocervical fusion. When instability occurred, all subluxations were at the C1-2 level. There were no occipito-atlantal subluxations. Eight patients (30%) had preoperative instability of the craniovertebral junction due solely to their pathology, 11 patients (40%) suffered instability after transoral surgery, and eight (30%) were without clinical or radiographic evidence of instability (mean follow-up period 14 months). Craniovertebral junction instability predominated among patients with rheumatoid arthritis: 91% required fusion and 45% presented with pre-existing instability. Among individuals with congenital osseous malformations, 45% required fusion and only one patient (9%) had pre-existing instability. Patients who required subsequent posterior decompression of a Chiari malformation were at risk for developing instability; three of four became unstable after posterior decompression. Transoral resection of the dens, the anterior arch of C-1, and the lower clivus does not fully destabilize the spine; however, this operation may potentiate incipient pathological instability. The primary determinants of instability are the extent of pathological bone destruction, ligamentous weakening, and operative bone removal. Long-term follow-up monitoring is needed after transoral surgery to detect cases of late instability.

Adolescent↗
PubMed1992

Transpedicular screw-rod fixation of the lumbar spine: operative technique and outcome in 104 cases.

A total of 104 patients underwent transpedicular spinal instrumentation using the Cotrel-Dubousset (71 cases) or the Texas Scottish Rite Hospital (33) screw-rod system. Surgery was performed for lumbar vertebral column instability secondary to fractures (28 cases), spondylolisthesis (29), tumors (four), vertebral osteomyelitis (two), or postoperative causes (41). Pseudoarthrodesis due to failure of a prior fusion was present in 37 cases. The 55 men and 49 women (mean age 47 years, range 18 to 87 years) all presented with severe back pain. Signs or symptoms of neural compression were noted in 96 patients. Surgery consisted of neural decompression, internal fixation, and autogenous iliac bone grafting. Spondylolistheses were fused in situ, without reduction; otherwise, major spinal deformities were corrected. A total of 516 pedicle screws were placed. The mean extent of fusion was 2.7 motion segments (range one to six motion segments). A 96% fusion rate was obtained with a mean follow-up period of 20 months. There were no operative deaths. Major complications included one spinal epidural hematoma, three isolated nerve root deficits (two transient, one permanent), and three wound infections (two deep, one superficial). Instrument failure eventually developed in 18 patients; nine were asymptomatic with a solid fusion and did not require further treatment and the other nine were symptomatic or had a pseudoarthrosis and required operative revision. Pedicle screw-rod fixation offers biomechanical advantages compared to other forms of internal fixation for the lumbar spine. It enables short-segment fixation with preservation of lumbar lordosis and adjacent normal motion segments. This technique provides a highly successful method to obtain arthrodesis, even with prior pseudoarthrosis.

Adult↗
PubMed1991

Lateral parascapular extrapleural approach to the upper thoracic spine.

The upper thoracic vertebrae are difficult to approach surgically because of the narrowing of the thoracic inlet, the proximity of the brachial plexus, and the parascapular shoulder musculature. A novel lateral parascapular extrapleural approach to the upper thoracic vertebrae is described. The parascapular shoulder musculature (trapezius, levator scapulae, and rhomboid muscles) is reflected off the spinous processes to the scapula as a musculocutaneous flap, preserving the neurovascular supply. The paraspinal musculature is mobilized and retracted, and the upper dorsal ribs are removed with caution to avoid injury to the C-8 and T-1 nerve roots. The rami communicantes are transected, and the sympathetic chain is displaced anterolaterally. The T2-4 vertebrae can be approached unobstructed. The T-1 nerve root obstructs posterolateral access to the T-1 vertebra, necessitating an inferolateral approach underneath the T-1 nerve root axilla. Four patients with compressive myelopathy from upper thoracic vertebral metastases underwent neural decompression, vertebral reconstruction, and posterior spinal fixation with this approach. Their postoperative neurological status was either unchanged or improved. Complications included radiographic pleural effusion and superficial wound dehiscence; one patient required posterior spinal reinstrumentation for progressive kyphosis. One patient developed pneumonia 7 days postoperatively which was unresponsive to appropriate treatment. It is believed that the anatomical limitations to this region have been overcome, and that excellent exposure of the T1-4 vertebrae for neural decompression and vertebral reconstruction can be performed safely. A major advantage is that posterior spinal fixation can be carried out simultaneously.

Female↗
PubMed1989

Superior sagittal sinus infection with Petriellidium boydii: case report.

A case of infection of the superior sagittal sinus with Petriellidium boydii is reported. This relatively common fungal pathogen rarely invades the central nervous system. Immunological compromise and poor personal hygiene seem to be common attributes shared by this patient and the 4 previous patients reported to have suffered invasion of the central nervous system by this organism. This report is unique in that it is the first demonstrating apparent hematogenous dissemination of this organism to the central nervous system.

Brain Diseases↗