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Biomedical subjects

S C Stein

Publications and source records attributed to S C Stein.

At least 19 recordsLinked to original sources
PubMed1996

Laparoscopic L5-S1 diskectomy: a cost-effective, minimally invasive general surgery--neurosurgery team alternative to laminectomy.

Laparoscopic L5-S1 diskectomy (LLD) is a promising new technique for managing disabling pain from herniated lumbar disks. It is unknown, however, whether the clinical results of LLD are superior to those of traditional laminectomy (LAM). This study was undertaken, therefore, in order to compare LLD and LAM in the management of L5-S1 disk herniation unresponsive to conservative treatment measures. Clinical records of 22 patients who underwent 23 LLD procedures and of 23 LAM patients were reviewed with respect to demographics and median age, operative blood loss, operative time, hospital stay, and time of rehabilitation to work/normal activity, as well as postoperative morbidity, recurrent symptoms, long-term functional status, and inhospital patient charges. Two LLD patients had undergone LAM previously, and one had a percutaneous microdiskectomy. All LLD patients had relief of disk pain immediately after surgery. Morbidity after LLD included transient brachial plexus neuropraxia (1), urinary retention (1), and rectus hematoma (1). No LAM complications were reported. Among LLD patients, compared with LAM, median age (34.5 years versus 40 years), estimated blood loss (12 mL versus 68 mL), hospital length of stay (1 day versus 3 days), time to normal activity (17 days versus 79 days) and mean inhospital patient charges ($5,737 +/- 283 versus $7,762 +/- 662) were reduced significantly (P < 0.05). LLD operating time was significantly longer than LAM (210 versus 160 minutes median, P < 0.01). With a median follow-up time of 11.0 months (range, 2 to 23 months) all LLD patients had returned to normal activity, whereas 7 of the LAM group (30%) remained disabled (P < 0.01). Sixty-eight per cent of LLD patients were pain-free during follow-up, compared with 39 per cent of the LAM group (P < 0.05). Sixty-four per cent of LLD patients and 57 per cent of the LAM group needed postoperatively physical therapy. One LLD and 4 LAM patients required reoperation, by LLD and LAM, respectively, for recurrent disk herniation. LLD is a safe, cost-effective, minimally invasive operation for managing disabling L5-S1 disk herniation. Compared with LAM, LLD reduces blood loss, length of stay, rehabilitation time, and patient charges, and improves long-term functional and pain-free status. LLD should be considered as an alternative to LAM for patients with herniated L5-S1 intervertebral disks unresponsive to conservative management.

Adult↗
PubMed1995

Laparoscopic laser lumbar diskectomy. Operative technique and case report.

Approximately 300,000 patients each year in the United States undergo laminectomy for disabling lumbar disc herniation. Post-laminectomy hospitalization is 3-7 days and convalescence may be prolonged. As an alternative to laminectomy, we have developed a technique for performing L5-S1 lumbar diskectomy laparoscopically. Using an anterior approach, the intervertebral disc space is opened and the diskectomy is performed under direct videolaparoscopic imaging. After pneumoperitoneum is established, the patient is placed in a steep Trendelenburg position. The small bowel is retracted cephalad and the colon is moved to the left. The iliac vessels are identified visually and by Doppler probe, and the presacral space is dissected in the midline to expose the L5-S1 disc. In the case presented, the disc annulus was opened with the Nd:YAG contact laser, and diskectomy was performed under direct videolaparoscopic vision using standard neurosurgical instruments modified for laparoscopy. The posterior longitudinal ligament can be visualized directly to define the posterior limits of the completed diskectomy. In the case described, pain relief was confirmed immediately after the procedure. The patient was discharged after 2 hospital days, and returned to normal activity in 8 days.

Adult↗
PubMed1995

Delayed and progressive brain injury in children and adolescents with head trauma.

We performed serial CT scans on 351 children and adolescents with serious closed-head injury. Delayed or progressive lesions were encountered in 145 (41%). The occurrence of such delayed cerebral injuries correlated with the severity of the initial head trauma, with the presence of major extracranial injury and with studies of coagulopathy on admission. The presence of delayed cerebral injury had a profound influence on survival and recovery from head trauma, especially when the initial severity of the head injury was taken into account. We conclude that serial CT scans provide a reliable means of diagnosing and following the progress of delayed cerebral injury in the pediatric population.

Adolescent↗
PubMed1995

The Head Injury Severity Scale (HISS): a practical classification of closed-head injury.

The authors introduce a two-dimensional scale for rating closed-head injury, the Head Injury Severity Scale (HISS). This system is based on a five-interval severity classification (minimal through critical), determined primarily by the initial post-resuscitation Glasgow Coma Scale score. The second dimension is predicated on the presence or absence of complications, appropriate for each severity interval. The outcomes of almost 25,000 patients with head injury encountered at our institution over a 7-year period were evaluated. We discovered that adding a complication dimension to each severity category resulted in significant outcome differences and effectively divided patients into groups with very different risks, prognosis and treatment requirements. The HISS is proposed as a framework on which further research can be done to guide care to predict outcome and to perform audits on head-injured patients.

Brain Damage, Chronic↗
PubMed1995

Laparoscopic lumbar diskectomy: preliminary report of a minimally invasive anterior approach to the herniated L5-S1 disk.

Approximately 300,000 patients each year in the United States undergo laminectomy for disabling lumbar disk herniation. Postlaminectomy hospitalization is 3-7 days and convalescence may be prolonged. As an alternative to laminectomy, we have developed a technique for performing L5-S1 lumbar diskectomy laparoscopically. Using an anterior approach, the intervertebral disk space is opened and the diskectomy is performed under direct videolaparoscopic imaging. After pneumoperitoneum is established, the patient is placed in a steep Trendelenburg position. The small bowel is retracted cephalad and the colon moved to the left. The iliac vessels are identified visually and by Doppler probe. Then the presacral space is dissected in the midline to expose the L5-S1 disk. The disk annulus is opened with the Nd:YAG contact laser (four cases) or the harmonic scalpel (three cases). Diskectomy is performed under direct videolaparoscopic vision using standard neurosurgical instruments modified for laparoscopy. The posterior longitudinal ligament can be visualized directly to define the posterior limits of the completed diskectomy. Laparoscopy lumbar diskectomy has been performed on seven patients (five male, two female). No perioperative complications occurred. All seven patients had immediate relief of back pain after laparoscopic lumbar diskectomy. Five patients were discharged the next day and two on the second postoperative day. L5-S1 laparoscopic lumbar diskectomy is feasible and safe. It may be an effective minimally invasive alternative to laminectomy.

Adult↗
PubMed1993

Delayed and progressive brain injury in closed-head trauma: radiological demonstration.

The importance of delayed or secondary brain insults in the eventual outcome of closed-head trauma has been documented in experimental models. To understand this phenomenon in the clinical setting, we studied a series of head-injured patients in whom multiple cranial computed tomographic (CT) scans were obtained. Patients whose follow-up CT studies revealed new intracranial lesions or worsening, compared with admission findings, were considered to have delayed cerebral injury. One hundred forty-nine (44.5%) of 337 consecutively studied patients developed delayed brain injury. There were highly significant associations (P < 0.001) between the appearance of delayed cerebral insults and the severity of the initial brain injury, the need for cardiopulmonary resuscitation in the field, the presence of coagulopathy at admission, and subdural hematoma on the initial CT scan. In addition, delayed injury was associated (P < 0.001) with higher mortality, slowed recovery, and poorer outcome at 6 months. Delayed brain injury was not significantly associated with patient age, sex, injury mechanism, associated injury, the need for endotracheal intubation in the field, early talking, CT abnormality other than intracranial hematoma, or type of residual neurological deficits. We used multiple regression analysis to explore the relationship between severity of injury, delayed insults, and outcome. As expected, the severity of the initial brain trauma contributed significantly to neurological outcome. The presence of delayed cerebral injury makes the outcome dramatically worse for each category of initial injury severity. The relationship between initial and secondary brain injury is discussed.

Adolescent↗
PubMed1992

Delayed brain injury after head trauma: significance of coagulopathy.

We reviewed the records of 253 patients with head injury who required serial computed tomographic (CT) scans; 123 (48.6%) developed delayed brain injury as evidenced by new or progressive lesions after a CT scan. An abnormality in the prothrombin time, partial thromboplastin time, or platelet count at admission was present in 55% of the patients who showed evidence of delayed injury, and only 9% of those whose subsequent CT scans were unchanged or improved from the time of admission (P less than 0.001). Among patients developing delayed injury, mean prothrombin time at admission was significantly longer (14.6 vs. 12.6 s, P less than 0.001) and partial thromboplastin time was significantly longer (36.9 vs. 29.2 s, P less than 0.001) than patients who did not have delayed injury. If coagulation studies at admission were normal, a patient with head injury had a 31% risk of developing delayed insults. This risk rose to almost 85% if at least one clotting test at admission was abnormal (P less than 0.001). We conclude that clotting studies at admission are of value in predicting the occurrence of delayed injury. If coagulopathy is discovered in the patient with head injury early follow-up CT scanning is advocated to discover progressive and new intracranial lesions that are likely to occur.

Adolescent↗
PubMed1992

Moderate head injury: a guide to initial management.

The purpose of this study is to determine the initial treatment of patients who appear to have sustained moderate head injuries when first evaluated. The authors reviewed the records of 341 patients whose initial Glasgow Coma Scale (GCS) scores ranged from 9 to 12, as well as another 106 patients with GCS scores of 13. All patients underwent cranial computerized tomography (CT) at the time of admission. In 40.3% of these patients the CT scans were abnormal (30.6% had intracranial lesions), and 8.1% required neurosurgical intervention (craniotomies for hematoma in 12, elevation of depressed fractures in five, and insertion of intracranial pressure monitors in 19). Four patients died of their intracranial injuries. A similar incidence of lesions found on CT and at surgery suggests that an initial GCS score of 13 be classified with the moderate head injury group. Skull fractures were found to be poor indicators of intracranial abnormalities. These results suggest that all patients with head injury thought to be moderate on initial examination be admitted to the hospital and undergo urgent CT scanning. Patients with intracranial lesions require immediate neurosurgical consultation, surgery as needed, and admission to a critical-care unit. Scans should be repeated in patients whose recovery is less rapid than expected and in all patients with evidence of clinical deterioration; this was necessary in almost half of the patients in this group, and 32% were found to have progression of radiological abnormalities on serial CT scans.

Craniocerebral Trauma↗
PubMed1992

Mild head injury: a plea for routine early CT scanning.

We reviewed the records of 1538 mild head injury patients admitted during a 4 1/2-year period to the Southern New Jersey Regional Trauma Center. All patients had experienced brief loss of consciousness or amnesia, but had a normal or near normal neurologic examination on admission, with Glasgow Coma Scale (GCS) scores of 13-15 and no focal neurologic deficit. Routine urgent cranial CT scans were obtained on all patients, and correlations between skull fractures and intracranial lesions investigated. Two hundred sixty-five patients (17.2%) harbored 340 lesions on CT scans, of which 131 were fractures and 209 were intracranial abnormalities. Fifty-eight patients needed surgery for their intracranial lesions; 23 of them had no skull fractures. None of the 1339 patients without CT evidence of intracranial lesions deteriorated under observation. We conclude that clinical observation with or without skull x-ray films is inadequate to rule out potentially dangerous intracranial lesions in apparently mild head injuries. If there is a history of loss of consciousness or amnesia, an immediate CT scan is indicated. If the results of the CT scan are normal and there are no other indications for admission, these patients may be safely discharged.

Craniocerebral Trauma↗
PubMed1991

Is routine computed tomography scanning too expensive for mild head injury?

OBJECTIVE: To compare relative costs of treating mildly head-injured patients by routine admission or by using skull radiographs or cranial computed tomography (CT) scanning to screen patients for admission. DESIGN: Retrospective record review, hypothetical costs based on actual patient course and requirements. SETTING: Southern New Jersey Regional Trauma Center at Cooper Hospital/University Medical Center. PARTICIPANTS: 658 consecutive mildly head-injured patients admitted from 1986 to 1988. All were given cranial CT scans. MEASUREMENTS: Records were reviewed retrospectively and hypothetical costs were calculated based on actual length of hospitalization, surgical intervention, etc. These costs were compared for different treatment protocols. MAIN RESULTS: The average cost if every patient had been admitted for observation given skull radiographs, with CT scans done on those exhibiting skull fracture or later deterioration, was $1,207. If the CT scan had been used to identify patients with intracranial lesions and the others had been discharged, costs would have been almost 10% less. Had skull radiography been used to screen admissions, costs would have been 22% below those of routine CT scanning. However, these small savings are likely to be reduced by additional expenses related to missed intracranial lesions. CONCLUSIONS: Every patient with loss of consciousness or post-traumatic amnesia should have routine CT scanning. If the scan is normal and there are no other reasons for admission, the patients can be discharged safely from the emergency department. This represents optimal care from a medical standpoint and is justified from a cost-effectiveness point of view.

Adolescent↗
PubMed1991

Time of rehabilitation admission and severity of trauma: effect on brain injury outcome.

Outcome after traumatic brain injury, defined by the Glasgow Outcome Scale (GOS) and length of stay in acute rehabilitation, was measured in 59 patients admitted to an intensive rehabilitation program to examine the effects of severity of the initial brain injury, severity of multiple trauma, and length of stay in the acute care hospital. Severity of initial brain injury, best measured by length of coma, was the most significant predictor of GOS outcome. Length of acute hospitalization was a small, but significant, predictor of GOS. Severity of initial brain injury, length of acute hospitalization, and gender emerged as predictors of length of rehabilitation hospital stay. Although length of acute hospitalization is apparently affected by severity of brain injury, it adds significantly--more than severity of brain injury--to the prediction of length of rehabilitation.

Adolescent↗
PubMed1990

The value of computed tomographic scans in patients with low-risk head injuries.

The determination that a particular head injury is "mild" or "low-risk" is usually made on clinical grounds. Observation at home or in the hospital has been the usual treatment for such patients. A recent report of excessive mortality among these patients with low-risk head injuries in some hospital settings suggests the need for improvement in diagnostic criteria. Our study included 658 patients admitted to Cooper Hospital for a mild head injury, who had a Glasgow Coma Scale score of 13 to 15 on admission, and who experienced a brief loss of consciousness or amnesia after the injury. Their records and cranial computed tomographic (CT) scans on admission were reviewed to determine their subsequent course. In 18% of patients abnormalities were seen on the initial CT scan and 5% required surgery. Among the 62 patients with a Glasgow Coma Scale score of 13, 40% had abnormalities on the CT scan and 10% required surgery. None of the 542 patients with normal CT scans on admission showed subsequent deterioration and none needed surgery. These figures suggest that history and physical examination alone are not adequate to assess head injury or severity of risk and that the addition of a CT scan greatly improves patient assessment. Abnormalities on CT scans are so common in patients with a Glasgow Coma Scale score of 13 that head injuries in these patients should be classified as "moderate" rather than "mild" in severity and risk. Patients with normal CT scans should be considered for observation at home, allowing hospital personnel to devote full attention to the more seriously injured patients.

Brain Injuries↗