Search

AIM Combined analgesic regimens produce sufficient analgesia by additive or synergistic effects, and reduce the total dose of analgesics and minimise adverse effects. We investigated the metamizole, paracetamol and morphine combination with respect to postoperative pain treatment in lumbar disc surgery. MATERIAL AND METHODS After Ethics Committee approval and informed consent, 63 patients were allocated to three treatment groups; as Group paracetamol: paracetamol (1 g), Group paracetamol-metamizole: paracetamol (1 g) and metamizole (1 g), and Group placebo: no analgesic. All the patients received intravenous (i.v.) morphine with a patient-controlled analgesia device (PCA) as the rescue analgesic. Pain was assessed by the numerical pain rating scale (NRS, 0-3). Total morphine consumption at 24 hours, patient satisfaction and side effects were investigated. RESULTS NRS of Group paracetamol-metamizole was low at 15th min, 30th min and 1st hour, and the difference reached statistical significance at 30th min (p=0.033). Patient satisfaction at the same measurement times was high in this group. Total morphine consumption and side effects were not statistically different between the three groups. CONCLUSION Addition of metamizole to paracetamol along with iv morphine PCA offers an advantage over single iv morphine PCA and paracetamol, with respect to early postoperative pain treatment and patient satisfaction.

Although lumbar disc surgery (discectomy) definitely improves the overall situation of the patient in most cases, it does create problems of a hitherto absent kund in about 6% of the patients. Expertising of uncomplicated cases should not be too difficult. However, modulated by individual disposition, a syndrome may develop known as "failed back surgery syndrome" caused by intersegmental loosening, crumbling or fusing and scarification. The pain it causes is decisive for its assessment, not so much any motor or other neurological deficits. In mild cases the loss in capacity for gainful employment may be assessed at between 20% to at the most 30%, but the severely handicapped are unable to cope with their daily life without assistance, their incapacitation amounting to as much as 100%. If the patient concerned is on a job that places stress on this spine, he may be unfit for work even if the affliction is relatively mild.

In this propsective cohort study of 122 patients with sciatica and herniated lumbar disc, aiming to assess long-term results and predictors of outcome of surgery, 70% of the patients were shown to have a satisfactory outcome seven years postoperatively. Preoperative hypofibrinolysis and psychological distress were associated with increased amount of peridural scar tissue formation, as assessed seven years after surgery by magnetic resonance imaging (MRI). The extent of the surgical intervention had minor impact on the clinical outcome. The MRI investigation indicated, however, that scar tissue was related to the extent of the surgical intervention and the clinical outcome of surgery, with less scar in patients with good outcome and in those having undergone smaller operations. Women were shown to have poorer outcome than men. Preoperative smoking habits and overweight were not associated with the clinical outcome. However, these variables were strongly associated with impaired fibrinolytic activity. Indir...

The saying goes: “if you have a hammer, everything looks like a nail”. This holds true for the communication by Oertel et al. [1], despite the honesty they display in it for which they are to be commended. I am grateful for the opportunity to write an editoral, because it may help to clarify some issues: Although there is no proof at all that minimally invasive access translates into a clinically meaningful advantage[2], the perpetual quest for it is understandable and certainly justified. It is my firm conviction that papers dealing with this topic are necessary, because progress in science as well as advances in surgery will always come in very small steps these days. Thus, refuting new techniques or modifications completely for the above reason is not my concept at all. However, two prerequisites need to be met when a new technique is promoted

Herein, a case of ureteric injury was inflected during lumbo-sacral laminectomy is reported to be added to the previously published 15 cases. Ureteric injury is a rare complication that may be encountered during lumbar disc surgery. We traced 15 cases that were published in literatures allover the past years with different management techniques. To the best of our knowledge, we report the first case that was treated by ileal ureteric replacement. Special attention should be paid regarding ureteric injury during surgery. Despite rare incidence of such injury with laminectomy, there were some reportable complications. So, surgeons should be aware of prediction, early diagnosis, and possible management alternatives for such injuries to safe patients from unsuspected handicapping.

We evaluated 190 patients with disc space explorations for the treatment of back pain and radiculopathy. In detailed evaluation of 144 patients with CT-diagnosed herniated nucleus pulposus(HNP), these HNPs were classified by location, extrusion. If the maximum anteroposterior diameter was less than one-third of the anticipated normal sagittal diameter of the dural sac, we classified it as Grade I , and if more than two-third, we classified it as Grade III, and intermediate size of HNP was clssified as Grade II. Seventy-five cases were located in L4/5 and 57 cases in L5/S1. And central extrusion was noted in 38.3%, central-lateral in 47.7%, lateral in 7.2%, and extreme lateral in 6.5%. The operative rate was as follows ; 7.3% (4/55) in G.I, 61.9% (39/63) in G.II, 96% (24/25) in G.III, and 40% (4/10) in G .X. Computed tomography (CT) is an accurate method of diagnosing HNP in patients with back pain and radiculopathy. And if CT reveals G.M finding, emergent surgical therapy will be indicated in that case, and the conservative therapy will be indicated in G.I HNP.

Spondylodiscitis is a well-known as well unavoidable complication of lumbar disc surgery. For diagnosis typical clinical symptoms and diagnostic procedures such as x-ray and scintigram are important but MRI proved to be the most sensitive and reliable. However, meaningful results can only be obtained with MRI if the measurement parameters are carefully considered, where by the field strength of the magnet plays a subordinate role. Therapy of spondylodiscitis using a light cast corset is described and it's advantages over other methods are shown.

Age- and sex-specific incidence rates of operation for suspected lumbar disc prolapse were determined for residents of Olmsted County, Minnesota, for the 30-year period 1950 through 1979. The incidence rate (adjusted to the age and sex distribution of the United States white population in 1980) was 52.3 per 100,000 person-years for all such operations and 46.3 per 100,000 person-years for initial operations. These rates remained fairly constant over the study period. A distinction was made between surgically proven and unproven cases of lumbar disc prolapse. Patients with a surgically proven lumbar disc prolapse had about 10 times the risk of another operation for disc prolapse within 10 years after the first operation compared with the general population.

Purposes: 1. To determine whether lumbar disc surgery (LS) provides a sufficiently detectable rise in serum creatine kinase (CK) concentration to serve as a model to study biochemical measurement of muscle injury, and 2. To use the model to examine the consistency of the time course of CK concentration changes. Method: The study used a repeated measures design. Six women and six men scheduled for LS were recruited. Blood samples were taken in the pre-operative waiting areas, immediately after surgery, at 6 hour intervals until discharge, and at 2, 4, and 6 to 7 days following surgery. Total serum CK was quantified using the Roche Modular to detect enzyme concentration. Results: Following LS, mean Total CK increased from a baseline 50 U/L (SD = 53) to a peak 114 U/L (SD = 32) in women (P < 0.001) and from 183 U/L (SD = 69) to a peak 454 U/L (SD = 173) in men (P < 0.05). Baseline to peak changes in CK exceeded subjects’ own baseline fluctuations in all 6 women and all 6 men, and amounted to a mean 6 fold (SD = 4) increase in women and 16 fold (SD = 31) increase in men. While CK concentrations returned to baseline over the observation period in all subjects, time to peak ranged between 9 to 47 hours. Conclusions: The LS model produced a consistently detectable CK response in both genders. Time to peak is variable indicating a need for multiple serial measures to capture this biochemical injury response.

Low-back pain (LBP) is a frequent complaint and a leading cause of disability in the general population. Epidemiological studies have identified many individual, psychosocial, and occupational risk factors for its onset, but the primary causative mechanisms of LBP remain largely undetermined. Psychological factors have an important role in the transition from acute to chronic pain and related disability (Manek and MacGregor 2005). Recent advances show that there is also a significant genetic effect on severe LBP, a condition which is responsible for a substantial loss in productivity. The total costs of LBP in the US exceed $100 billion per year (Katz 2006). Two-thirds of these costs are indirect, due to lost wages and reduced productivity. Each year, the less than 5% of the patients who have an episode of LBP account for 75% of the total costs (Jinkins 1997). Most episodes of LBP have a mechanical origin and are self-limiting, resolving within a few days or weeks (Borenstein 1996).

Previous studies have shown that Propionibacterium acnes may be responsible for low-grade infection of the intervertebral discs of patients with severe sciatica. The aim of this study was to prospectively investigate the presence of bacteria in disc fragment samples obtained during surgery for lumbar disc herniation. P. acnes was cultured from disc fragments in two (3.7%) of 54 patients studied. In addition, control cultures taken from ligamentum flavum and muscle from these two patients were also positive for P. acnes. Similar control cultures were positive for P. acnes from a further ten (18.5%) patients. Four air samples taken during surgery all contained P. acnes; the organism was also found from three of 54 laminar flow control cultures. Sample contamination appears the most likely cause for the presence of P. acnes in the lumbar disc fragment cultures.

In this prospective, observer-masked clinical study, we evaluated if insertion of a drain had a significant role in decreasing the existence and the size of postoperative epidural hematoma, which is believed to be a factor causing epidural fibrosis in patients undergoing lumbar discectomy.Fifty patients undergoing lumbar disc surgery were randomly assigned to two groups: with or without insertion of a drain in the epidural space. A drain was inserted in 22 patients, whereas 28 were left without a drain. All patients were evaluated, by means of magnetic resonance imaging (MRI) on the first postoperative day, specifically looking for the existence and the size of epidural hematoma. The size of epidural hematoma was graded as none, minimal, moderate, or prominent. The patients were clinically examined preoperatively and at the follow-up of 6 months by Oswestry Disability Index and recurrence of pain. A follow-up MRI was repeated at 6 months, and the subsequent development of epidural fibrosis was evaluated.Epidural hematoma was detected in 36% of patients with a drain and in 89% of patients without a drain (P=0.000). There were significant less number of minimum, moderate, and prominent sized hematomas in the group with a drain (P=0.000). On the 6-month follow-up, epidural fibrosis was found in 58.3% of patients without a drain and in 31.6% of patients with a drain (P=0.08). Late clinical outcome (improvement in Oswestry Index and no recurrent pain) was better in the group with drain, but not statistically significant (P=0.4).Occurrence of hematoma in the epidural space is common after lumbar disc surgery even if meticulous hemostasis has been achieved. Insertion of a drain decreases both the incidence and the size of hematoma on the first postoperative day as detected by MRI. This may have practical implications for the prevention of significant postoperative fibrosis and obtaining better surgical outcome.

Die hohe Anzahl an Arbeiten zu dem Thema der thromboembolischen Komplikationen nach operativen Eingriffen und die damit verbundene hohe Anzahl an Empfehlungen sorgt mehr für Verwirrung als für ein einheitliches Regime in der Thromboseprophylaxe. In dieser Arbeit werden anhand der primären und sekundären Risikofaktoren der Patienten und aktuell publizierten Studien zur Entstehung der postoperativen Thrombose Risikoprofile erstellt, die eine patientenadapierte Prophylaxe zulassen sollen. Es wurden retrospektiv des Zeitraum 1992-2001 die Patientendaten der neurochirurgischen Klinik und Poliklinik des Klinikums rechts der Isar evaluiert und miteinander verglichen. Die Untersuchung konzentrierte sich auf Patienten der lumbalen Bandscheibenchirurgie. Anhand der vorhandenen Patientenakten wurden Alter, Geschlecht, Gewicht, Größe, Labordaten, Dauermedikationen, primäre und sekundäre Risikofaktoren, Vorerkrankungen sowie Operations- und Narkosedauer miteinander verglichen. Der statistische Vergleich der Patienten erfolgte anhand einer Kontrollgruppe, die 200 Patienten (143 Frauen und 57 Männer) umfasste und in ebendiesem Zeitraum in dieser Klinik operiert wurden. Die Einteilung der Patienten erfolgt nach Geschlecht und Kontroll- und Studiengruppe. Die statistische Berechnung zeigte signifikante Unterschiede zwischen der Studien- und Kontrollgruppe bei der Narkosedauer (p

A subgroup analysis of patient outcomes from a double-blind randomized controlled study comparing corticosteroid versus saline in microscopic lumbar disc surgery.To study if the use of corticosteroids combined with surgery alleviates the damage to the nerve fibers in lumbar disc herniation.The use of quantitative sensory testing can detect damage to the myelinated A-delta fibers (cold sense) and the unmyelinated C-fibers (warmth sense). Corticosteroids combined with surgery in lumbar disc surgery enhance the outcome after surgery in terms of less pain and more rapid rehabilitation.Analyzing quantitative sensory testing before surgery and after 2 weeks and 2 years.In the corticosteroid group, we saw a statistically significant normalization for the warmth disturbance comparing with control group, which not was detected concerning the cold disturbance.The use of corticosteroids combined with surgery seems to protect some of the damage to the C-fibers in lumbar disc herniation.

Background. Postoperative epidural fibrosis is a major causative factor of low-back pain even if microsurgical techniques are adopted to reduce this phenomenon. To prevent the recurrent radicular pain caused by this problem, we utilized adipose tissue drawn from the same patient; at the end of surgical procedure, the fat was placed around the spinal root or the dural sac. This procedure was evaluated by a prospective, randomised study.

This study compared health related quality of life (HRQOL) among lumber disc surgery patients to general population, and assessed the relationships between HRQOL and other outcome measures 2 and 14 months after surgery.The 15D instrument was use to measure HRQOL in 145 lumber disk surgery patients. Subjective outcome was also assessed by the Oswestry index, Short Depression Inventory (SDI) and pain, and objective outcome by trunk muscle strength and mobility of the spine.The mean (SD) 15D score among the patients 2 months after surgery was 0.880 (0.104) compared to 0.941 (0.076) among general population (p = 0.016). The 15D, Oswestry and SDI scores remained unchanged during the follow-up, while the improvements in the spine mobility and trunk muscle strength were significant. Back pain decreased by 68% and leg pain by 74% from preoperative level to 2 months check-up. Leg pain further decreased during the following 12 months, while back pain remained unchanged. HRQOL was associated with age, pain, Oswestry and SDI indices, but not with physical function.HRQOL measured by 15D was lower in lumber disc surgery patients compared to general population. 15D was associated with the subjective outcome measures of pain, Oswestry and SDI indices, but not with the objective measures of physical function. Thus, a combination of "disease specific" and "generic" measures is recommended to be used to obtain more accurate information about the overall welfare of individual.

To illustrate multifaceted clinical components often present with lumbar disc herniation that require concomitant resolution before optimal conservative case management can be achieved.A 33-year-old male with insidious low back pain and a gradual onset of lower extremity symptoms had a declining physical activity lifestyle, diminished fitness level, and weight gain over a 4-year period. Symptoms progressively worsened over a two-year period. Magnetic resonance imaging revealed a disc herniation with neurological compromise and surgical intervention was medically recommended.Management consisted of patient education, acute inflammation control, closed disc reduction, remedial therapeutic (passive joint movement) care directed at preservation and improvement of joint and soft tissue mobility, low tech physical capacity evaluation and individualized rehabilitation training for home based care exercise. Patient compliance was ultimately achieved with a positive long-term outcome.This case illustrates common clinical components of care associated with disc herniation case management, the potential of conservative care, and the benefits of combining manual therapy and rehabilitative exercise.

Intraradicular lumbar disc herniation is very rare. The exact mechanism of the dural tear by a herniated disc is not known. Diagnosis of intraradicular lumbar disc herniation is difficult, so that it is rarely suspected preoperatively. This pathological entity may be a factor in the failure of lumbar disc surgery. We present the seventeenth and eighteenth cases of intraradicular lumbar disc herniation. We emphasise its importance and review the literature on intraradicular disc herniation.

A total of 73 patients underwent microdiscectomy for lumbar disc herniation between September 2001 and May 2002 at the Department of Neurosurgery of the Second University of Naples. Preoperatively and 3 and 6 months after surgery, patients were assessed on the Zung Self-rating Depression Scale (SDS) and on a visual analogue scale (VAS) for the subjective perception of pain. At 3 and 12 months, we found that patients with lower SDS scores (n=41) had a better outcome regarding pain than patients with relevant depressive symptoms (n=32). In agreement with the literature, our results confirm the negative role of depression in outcome after lumbar disc surgery. We emphasize the consideration of psychological factors in the management of lumbar disc herniation.

Study Design. An economic evaluation was conducted alongside a randomized controlled trial. Summary of Background Data. Little is known about the effectiveness of cognitive-behavioral treatment options for patients following lumbar disc surgery. If the knowledge available was supported by an economic evaluation, the information could then be used to make recommendations for the implementation of cognitive-behavioral treatment in the routine of rehabilitation following lumbar disc surgery. Objective. To examine the cost-effectiveness of a behavioral-graded activity program, which is an operant treatment, compared to usual care as delivered by a physical therapist for patients following first-time lumbar disc surgery. Methods. For the economic evaluation, a societal viewpoint was applied. The primary outcome measures (measured at the 12-month follow-up) were global perceived effect and functional status. To evaluate the economic consequences of the treatments, direct health care and non-health care costs were considered, as well as indirect costs. Results. The clinical outcomes showed no relevant cifferences between behavioral-graded activity (n = 52) and UC (n = 53). Treatment costs were almost identical in the two intervention groups. The difference in direct health care costs was, although not statistically significant, 264 EURO [95% CI: -3-525] higher in behavioral-graded activity than in usual care per patient-year. It was mainly the excess cost of visiting the physiotherapist in the behavioral-graded activity group that accounted for this difference. The difference in direct non-health care costs, although not statistically significant, was 388 EURO [95% CI: -217; 992] lower in the usual care group due to unpaid help by friends or family. Consequently, although again not statistically significant, the total direct costs in behavioral-graded activity are 639 EURO [95% CI: -91; 1368] higher than in usual care. For the indirect costs, there was a statistically significant difference, behavioral-graded activity being more expensive. The sensitivity analysis showed that these results are fairly robust. Conclusions. This study concludes that there are no differences between the two treatment conditions on any of the clinical outcome measures but that behavioral-graded activity is associated with higher costs. Consequently, there is no reason for the implementation of behavioral-graded activity as the standard treatment for patients following lumbar disc surgery.

Objective: Measurement properties of questionnaires should be based on samples of populations on whom these measurements will be used. The purpose of this study is to establish an evidence based recommendation regarding the use of functional status questionnaires in patients following a lumbar disc surgery by a direct comparison of the reproducibility and responsiveness. Study Design and Setting: The measurement properties of six functional status questionnaires were assessed: 1) Roland-Morris Disability Questionnaire (RDQ-24), 2) Modified Roland-Morris Disability Questionnaire (MRDQ), 3) short Roland-Morris Disability Questionnaire (RM-18), 4) Physical Functioning scale, 5) Role Limitations-Physical scale of the SF-36, and 6) The Main Complaint (MC). Subjects (n 97) that still suffered residual complaints 6 weeks following a lumbar disc surgery completed the questionnaires before and 3 months after treatment. In a direct comparison the A) The test-retest reproducibility (Intraclass Correlation Coefficients [ICC] and the Standard Error of Measurement [SEM]) and B) 3 parameters of responsiveness (Minimal Detectable Change [MDC], Standardised Response Mean [SRM], and the Area Under the receiver operator characteristic Curve [AUC]) were assessed. Results: This study suggests the superiority of the 3 versions of the RDQ compared to the 3 other questionnaires. Comparing the 3 versions of the RDQ reveals no substantial differences thereby indicating that the 2 modified version of the RDQ hold no better measurement properties in this specific population. Conclusion: The use of the RDQ-24 for this specific post-surgery population is suggested. The optimal cut-off point of the RDQ-24 that minimizes the overall classification error was found to be 3.5 with a sensitivity of 94.6% and a specificity of 88.2%. 2004 Elsevier

WOS: 000235227000011 PubMed: 16412838 Intra-operative injuries of pelvic vessels are quite infrequent but serious complications of lumbar disc surgery. Injury may cause laceration of the vessel with acute life threatening retropentoneal haemorrhage, formation of pseudoaneurysms or arteriovenous fistulae in the late phase. It is important for surgeons to be aware of these potentially fatal complications. Authors reported a case of major vascular injury recognised intra-operatively during posterior lumbar discectomy and repaired immediately. (c) 2004 Elsevier B.V. All rights reserved.

In this retrospective study, 85 patients previously operated on for lumbar disc herniation who had undergone reoperation due to persistent pain or recurrence of the symptoms were investigated. The surgical findings were: recurrent herniation (20%), epidural fibrosis alone (36.4%), small recurrent herniation with epidural fibrosis (28.2%), herniation at another level (10.6%), spinal stenosis (2.4%), lumbar pseudomeningocele (1.2%) and adhesive arachnoiditis (1.2%). The overall success rate of re-operation was 60%. The best results were obtained in recurrent disc herniation (47.1% excellent and 35.3% good results) and in herniation at another level (77.8% excellent and 22.2% good). Re-operation in epidural fibrosis had less-satisfactory results (29.1% excellent and 12.9% good).

A case report of spontaneous resolution of a lumbar postdiscectomy pseudomeningocoele.To suggest the role of nonoperative treatment even in symptomatic pseudomeningocoeles.Withybush General Hospital, Haverfordwest, Pembrokeshire, South Wales, UK.A 65-year-old lady underwent L4/L5 discectomy for lumbar disc prolapse in 1998. As the patient did not have relief of symptoms, an MRI was taken at 1 month following the operation, which showed a residual disc at L4/L5 and a pseudomeningocoele communicating with the subarachnoid space. The patient could not undergo further treatment because of the untimely demise of the surgeon. Over the next 3 months, the symptoms began to improve and the patient was totally asymptomatic and remained so for 3 years. In 2001, she was seen for a recurring leg pain and back pain and an MRI was done, which showed complete disappearance of the pseudomeningocoele but with recurrent disc lesion.Although the current medical literature favours re-exploration and repair of the dural defect in symptomatic pseudomeningocoele, the authors are of the opinion that conservative treatment may have a role in the treatment of the above condition as illustrated by the above example.

Numerous materials have been used to prevent epidural scar tissue after lumbar disc surgery. Free fat grafts are common both experimentally and clinically, but there is some doubt about their protection against fibrosis, and some complications have been reported. In this prospective study, the usefulness of free fat grafts during lumbar disc surgery was evaluated. Ninety-nine patients who had undergone operation due to lumbar disc herniation were divided in two groups: those with implantation of free fat grafts (group A) and those without (group B). Outcome was evaluated at a mean of 2.6 years postoperatively according to the following criteria: visual analog scale for back and leg pain, Hannover Questionnaire on activities of daily living, reflex findings, sensory and motor deficits, consumption of analgesics, walking distance, straight leg raising test, and clinical examination. The outcome variables showed no significant differences between the two groups (P>0.05). This study suggests that the use of free fat grafts during lumbar disc surgery was clinically ineffective.

Study design A systematic review of randomized controlled trials. Background Although several rehabilitation programs, physical fitness programs, or protocols regarding instruction for patients to return to work after lumbar disc surgery have been suggested, little is known about the efficacy of these treatments, and there are still persistent fears of causing reinjury, reherniation, or instability. Objectives The objective of this systematic review was to evaluate the effectiveness of active treatments that are used in the rehabilitation after first-time lumbar disc surgery. Methods The authors searched the MEDLINE, Embase, and Psyclit databases up to April 2000 and the Cochrane Controlled Trials Register 2001, issue 3. Both randomized and nonrandomized controlled trials on any type of active rehabilitation program after first-time disc surgery were included. Two independent reviewers performed the inclusion of studies, and two other reviewers independently performed the methodologic quality assessment. A rating system that consists of four levels of scientific evidence summarizes the results. Results Thirteen studies were included, six of which were of high quality. There is no strong evidence for the effectiveness for any treatment starting immediately postsurgery, mainly because of the lack of good quality studies. For treatments that start 4 to 6 weeks postsurgery, there is strong evidence (level 1) that intensive exercise programs are more effective on functional status and faster return to work (short-term follow-up) as compared to mild exercise programs, and there is strong evidence (level 1) that on long-term follow-up there is no difference between intensive exercise programs and mild exercise programs with regard to overall improvement. For all other primary outcome measures for the comparison between intensive and mild exercise programs, there is conflicting evidence (level 3) with regard to long-term follow-up. Furthermore, there is no strong evidence for the effectiveness of supervised training as compared to home exercises. There is also no strong evidence for the effectiveness of multidisciplinary rehabilitation as compared to usual care. There is limited evidence (level 3) that treatments in working populations that aim at return to work are more effective than usual care with regard to return to work. Also, there is limited evidence (level 3) that low-tech and high-tech exercises, started more than 12 months postsurgery, are more effective in improving low-back functional status as compared to physical agents, joint manipulations, or no treatment. Finally, there is no strong evidence for the effectiveness of any specific intervention when added to an exercise program, regardless of whether exercise programs start immediately postsurgery or later. None of the investigated treatments seem harmful with regard to reherniation or reoperation. Conclusions There is no evidence that patients need to have their activities restricted after first-time lumbar disc surgery. There is strong evidence for intensive exercise programs (at least if started about 4-6 weeks postoperative) and no evidence they increase the reoperation rate. It is unclear what the exact content of postsurgery rehabilitation should be. Moreover, there are no studies that investigated whether active rehabilitation programs should start immediately postsurgery or possibly 4 to 6 weeks later.

General and regional anesthesia (spinal and epidural) can be performed successfully for lumbar disc surgery. The aim of this study was to assess the superiority of general anesthesia or epidural anesthesia techniques in lumbar laminectomy and discectomy. Sixty patients undergoing lumbar partial hemilaminectomy and discectomy were randomly divided into two groups receiving standardized general anesthesia (GA) or epidural anesthesia (EA). Demographically, both groups were similar. Surgical onset time (36.72 +/- 5.47 vs. 25.40 +/- 7.83 minutes) was longer in the EA group, but total anesthesia time (154.32 +/- 35.73 vs. 162.40 +/- 26.79 minutes) did not differ between the two groups. Surgical time (118.80 +/- 35.42 vs. 139.60 +/- 26.80 minutes) was longer in the GA group. The heart rate and mean arterial pressure values of the EA group measured 15, 20, and 25 minutes after local anesthetic administration to the epidural catheter were found to be lower than in the GA group measured after induction of general anesthesia. The frequency of bradycardia (EA vs. GA, 3 vs. 2), tachycardia (3 vs. 7), and hypotension (6 vs. 4) during anesthesia did not differ between the groups, but the occurrence of hypertension (1 vs. 7) was higher in the GA group. Blood loss was less in the EA group than in the GA group (180.40 +/- 70.38 vs. 288.60 +/- 112.51 mL). Postanesthesia care unit (PACU) heart rate and mean arterial pressure were higher in the GA group. Peak pain scores in PACU and postoperative 24 hours were higher in the GA group when compared with the EA group. Nausea was more common in the GA group both in PACU and 24 hours after surgery. There was no difference between the hospitalization duration of the groups. In conclusion, this study suggests that EA is an important alternative to GA during lumbar disc surgery.

Vascular complications during posterior lumbar disc surgery are rare and its presentation with varicose veins is even rarer. A 23 year-old male patient presented with large varicose veins in right lower limb. He underwent a posterior lumbar spine discectomy surgery. He noticed mild swelling of the distal third right lower limb 3 months after index surgery and reported 6 months later when he developed varicose veins. Duplex Doppler confirmed varicose veins of the long saphenous vein and its tributaries with a patent deep venous system. A digital subtraction angiogram demonstrated a large right common iliac artery (CIA) false aneurysm with an arteriovenous fistula between right common iliac vessels. He had a right CIA covered stent insertion with good results. Varicose veins were later managed with sapheno-femoral junction ligation and a below knee long saphenous vein stripping. At six month follow-up the lower limb swelling had completely recovered and duplex ultrasound did not show any recurrence of varicose veins.

Background: A 54-year-old patient presented with dyspnea, palpitation, a swollen, dysfunctional edematous left leg and discomfort. Medical history revealed chronic, a-specific leftsided thoracic pain, corticosteroid use because of Morbus Sjogren and a recent surgical lumbar hernia repair. Retrospectively, follow-up conventional imaging showed a progressive right-sided cardiac enlargement, left pleural effusion and a prominent superior mediastinum.

We thank Dr. M. del-Rio-Vellosillo et al. [1] for addressing our article [2]. We wish to respond to their questions. In our study, intravascular (iv) solutions and injection rates were the same in both groups. We did not administer special iv pre-loading. Intrathecal injections were carried out for 20 s without barbotage or aspiration. The methods used by our group and by del-Rio-Vellosillo et al. were different as it relates to the dose of local anesthetic and patient position. The most important methodological difference affecting the level of anesthesia and the block duration times between the two studies is the dose of local anesthetic. In our study, 15 mg of bupivacaine or levobupivacaine was administered and, in their study, 12.5 mg was administered. In our study, spinal anesthesia was administered with the patient in the left lateral decubitus position with a 25-gauge Quincke needle at the L3–L4 interspace. In their study, local anesthetics were administered intrathecally with a 29-gauge Quincke needle at the L3–L4 interspace while the patient was in a seated position. It is important to note that the patient population was different in the two studies. Del-Rio-Vellosillo et al. studied young patients who underwent arthroscopic knee operations, while our study included patients suffering from back and leg pain with lumbar disc herniation. Due to the differences in the patient groups, patient positions, doses of local anesthetic, and spinal needle size, it is not appropriate to compare the results of the two studies. Instead, the results should be evaluated separately. We believe that the dose of local anesthetic and the position of the patient are the two major factors in understanding why there are differences in the results of the two studies [3].

Nerve root retraction is a component of lumbar disc surgery. The authors describe a transdural approach for lumbar microdiscectomy through the nerve root, instead of retracting the root. This technique can be safely used in rare cases where root manipulation is considered to be difficult and dangerous.