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BACKGROUND CONTEXT The transpsoas lateral lumbar interbody fusion (LLIF) technique is an effective alternative to traditional anterior and posterior approaches to the lumbar spine; however, nerve injuries are the most reported postoperative complication. Commonly used strategies to avoid nerve injury (eg, limiting retraction duration) have not been effective in detecting or preventing femoral nerve injuries. PURPOSE To evaluate the efficacy of emerging intraoperative femoral nerve monitoring techniques and the importance of employing prompt surgical countermeasures when degraded femoral nerve function is detected. STUDY DESIGN/SETTING We present the results from a retrospective analysis of a multi-center study conducted over the course of 3 years. PATIENT SAMPLE One hundred and seventy-two lateral lumbar interbody fusion procedures were reviewed. OUTCOME MEASURES Intraoperative femoral nerve monitoring data was correlated to immediate postoperative neurologic examinations. METHODS Femoral nerve evoked potentials (FNEP) including saphenous nerve somatosensory evoked potentials (snSSEP) and motor evoked potentials with quadriceps recordings were used to detect evidence of degraded femoral nerve function during the time of surgical retraction. RESULTS In 89% (n=153) of the surgeries, there were no surgeon alerts as the FNEP response amplitudes remained relatively unchanged throughout the surgery (negative group). The positive group included 11% of the cases (n=19) where the surgeon was alerted to a deterioration of the FNEP amplitudes during surgical retraction. Prompt surgical countermeasures to an FNEP alert included loosening, adjusting, or removing surgical retraction, and/or requesting an increase in blood pressure from the anesthesiologist. All the cases where prompt surgical countermeasures were employed resulted in recovery of the degraded FNEP amplitudes and no postoperative femoral nerve injuries. In two cases, the surgeons were given verbal alerts of degraded FNEPs but did not employ prompt surgical countermeasures. In both cases, the degraded FNEP amplitudes did not recover by the time of surgical closure, and both patients exhibited postoperative signs of sensorimotor femoral nerve injury including anterior thigh numbness and weakened knee extension. CONCLUSIONS Multimodal femoral nerve monitoring can provide surgeons with a timely alert to hyperacute femoral nerve conduction failure, enabling prompt surgical countermeasures to be employed that can mitigate or avoid femoral nerve injury. Our data also suggests that the common strategy of limiting retraction duration may not be effective in preventing iatrogenic femoral nerve injuries.

Organizational ethics programs often are created to address tensions in organizational values that have been identified through repeated clinical ethics consultation requests. Clinical ethicists possess some core competencies that are suitable for the leadership of high-quality organizational ethics programs, but they may need to develop new skills to build these programs, such as familiarity with healthcare delivery science, healthcare financing, and quality improvement methodology. To this end, we suggest that clinical ethicists build organizational ethics programs incrementally and via quality improvement projects undertaken in collaboration with senior clinical leaders. Organizational ethics programs often differ from clinical ethics programs in their membership and processes, and likely will require ethicists to forge new partnerships with a wide array of organizational leaders. With attention to the ways that organizational ethics programs differ from clinical ethics programs, and investment in quality improvement methodology and formal institutional needs assessments, clinical ethics leaders can position an organizational ethics program to advocate effectively for visible and compelling alignment of leadership decision making with the values of the organization.

Substantial medical evidence shows that about half of ovarian cancers originate in the fallopian tube. Some medical organizations and clinical articles have suggested opportunistic salpingectomy to reduce the risk of ovarian cancer in patients at average risk of developing it. This entails removing the fallopian tubes at the same time as another procedure that would occur anyway. The authors argue that the principles of totality and double effect can justify such salpingectomies, even though there is a low incidence of ovarian cancer. Since screening tools for ovarian cancer are ineffective and treatment options are poor, the good effect of reducing the risk of death from this type of ovarian cancer can be proportionate to the bad effects of the minor increase in surgical risk over the other procedure, the unintended side effect of infertility, and the removal of normally functioning tissue. The authors conclude that it is within the purview of a patient and physician to determine whether the benefits are proportionate to the risks in a particular case.

The Catholic moral tradition asserts an intrinsic moral value of all human life that is endowed by its creator and inheres from the earliest stage of its development to the end of its biological existence. This understanding of human dignity has significant practical implications when one contrasts it with a secular approach to decision-making regarding fetuses with anomalies incompatible with life, such as anencephaly. Within the secular framework the primary focus is on weighing the burdens and benefits exclusively to the mother. In this chapter, we argue that the Catholic tradition actually provides a framework that takes full account of both the inherent dignity of the child and the maternal burdens and benefits. After reviewing the clinical circumstances of anencephaly, we review the contemporary theological debates in light of Catholic moral teaching. Next, we propose a re-conceptualized understanding of viability relative to the role of “proportionate reasoning” within the framework of moral objectivity articulated within the tradition. Based on these considerations, we argue that previous attempts to address the issue within the tradition, whether by identifying a temporal threshold at which labor and delivery may be induced or denying the permissibility of early induction, are ultimately insufficient. These approaches fail due to an inadequate understanding of both the concept of viability and of the valid role subjective judgments can play relative to proportionate reasoning as understood within the tradition.

Catholic healthcare institutions live amidst tension between three intersecting primary values, namely, a commitment of service to the poor and vulnerable, promoting the common good for all, and financially sustainability. Within this tension, the question sometimes arises as to whether it is ever justifiable, i.e., consistent with Catholic identity, to place limits on charity care. In this article we will argue that the health reform measures of the Affordable Care Act do not eliminate this tension but actually increase the urgency of addressing it. Moreover, we will conclude that the question of limiting charity care in a manner that is consistent with the obligations of Catholic identity around serving the poor and vulnerable, promoting the common good, and remaining financially sustainable is not a question of if, but of how such limits are established. Such limits, however, cannot be established in light of one overriding moral consideration or principle, but must be established in light of a multitude of principles guiding us to a holistic understanding of the interrelatedness of the moral dimensions of Catholic identity.

Whiplash is neck pain experienced as a result of a motor vehicle collision or similar trauma. Following a motor vehicle collision, 15% to 40% of patients with acute neck pain develop chronic neck pain. The cervical facet joint is the most common source of chronic neck pain after whiplash injury, followed by disk pain. Some patients experience pain from both structures. Initial management recommendations need not be directed toward an exact structural cause, but treatment includes advising the patient to remain active, prescribing medications when necessary, and providing advice regarding the generally favorable outcome. When neck pain persists, the physician should recommend medial branch blocks of the dorsal rami of the spinal nerves that supply the putative painful facet joint or joints; this is done to determine whether the facet joints are the cause of pain. When significant relief occurs on two occasions, radiofrequency neurotomy typically provides substantial relief for approximately 8 to 12 months and can be repeated indefinitely as needed. Occasionally, long-term treatment with medication may be indicated. Anterior cervical diskectomy and fusion is necessary on rare occasions.

Study Design. A literature review was conducted. Objective. To review the indications and efficacy of spinal cord stimulation, particularly in reference to chronic pain of spinal origin. of Background Data. The first spinal cord stimulation was implanted by Shealy in 1967 via a subarachnoid route. Early systems were plagued with a high rate of complications and technical problems. With the evolving technology, especially the advent of multichannel programmable systems and more precise epidural placement, the ability of spinal cord stimulation to treat various pain syndromes improved. This article reviews the literature on spinal cord stimulation from 1967 to the present. Methods. The literature is reviewed, with a particular focus on recent studies investigating the efficacy of spinal cord stimulation for low back pain. Results. Most studies are limited by the same flaws, namely, retrospective study design. At this writing, the few published randomized prospective studies have suggested that spinal cord stimulation may be superior to repeat surgery.Complication rates have declined to approximately 8%, and reoperation is necessary in approximately 4% of patients. When current percutaneous techniques are used, a lead migration rate lower than 3% may be achieved. For certain topographies, laminotomy leads may be superior, particularly with regard to low back pain. Conclusions. The ultimate efficacy of spinal cord stimulation remains to be determined, primarily because of limitations associated with the published literature. However, on the basis of the current evidence, it may represent a valuable treatment option, particularly for patients with chronic pain of predominately neuropathic origin and topographical distribution involving the extremities. The potential treatment of other pain topographies and etiologies by spinal cord stimulation continues to be studied.

(2003). The Ethics of Neonatal Male Circumcision: A Catholic Perspective. The American Journal of Bioethics: Vol. 3, No. 2, pp. 62-64.

Ethics committees are use [sic] to questions concerning the withdrawal of life-support. Such questions become increasingly complex when that life-support is implantable, like a pacemaker. This essay seeks to address the question of under what, if any, circumstances it would be permissible to discontinue the use of such implantable devices.

The Address to Participants in the International Congress on "Life-Sustaining Treatments and the Vegetative State: Scientific Advances and Ethical Dilemmas," promulgated in March of this year by Pope John Paul II, has become a source of considerable controversy, partly due to the theological and clinical complexity of this issue, and partly because of how it has been portrayed in the popular media. (1) In light of this controversy, many Catholics, as well as Catholic health systems, are re-examining the half-millennium-old tradition of Catholic moral teaching regarding the obligation to use particular means of sustaining human life. (2) In this essay, we seek to foster that effort. In light of that tradition, and particularly the discussion of the principles of proportionate and disproportionate means, we will propose a way of interpreting the recent papal address that has not received significant attention. The Duty to Sustain Life Perhaps the most fundamental tenet of the Roman Catholic moral tradition is that life is a precious gift from God. (3) This conviction is the basis for a duty to protect and preserve our lives, but that duty does not imply an obligation to use every and all means available to sustain our lives at all costs. (4) Catholic moral teaching holds that the ultimate end of human life lies with God and that life on earth is itself only a penultimate good. As Pope Pius XII notes, "Life, health, all temporal activities are in fact subordinated to spiritual ends." (5) Reaffirming this insight, Pope John Paul II wrote in Evangelium Vitae that "it is precisely [our] supernatural calling which highlights the relative character of each individual's earthly life. After all, life on earth is not an 'ultimate' but a 'penultimate' reality." (6) Thomas Shannon and James Waiters have recently pointed out that the resulting duty to sustain life has traditionally been understood in the Roman Catholic moral tradition as teleological. (7) In the context of the Catholic moral tradition, "teleological" is not synonymous with consequentialist. Rather, as we understand it, the teleological framework found within the Catholic tradition recognizes the moral relevance both of rules of right conduct and of consequences. (8) In other words, the Catholic moral tradition has always recognized some negative obligations of a fundamentally deontological nature, including of course the obligation never to directly intend the destruction of innocent human life. It is our view, however, that these deontological obligations do not preclude the use of the principles of proportionate and disproportionate means as teleological guides for discerning whether discontinuing a particular life-sustaining treatment would constitute the directly intended destruction of innocent human life. As defined by the Ethical and Religious Directives for Catholic Health Care Services (ERDs), a proportionate means is one that individuals are obligated to use to preserve life insofar as, in the judgment of the patient, the means in question offer a reasonable hope of benefit and do not entail excessive burdens. (9) One is not obligated to use any means of sustaining life that, in one's own judgment, either do not offer a reasonable hope of benefit or entail excessive--that is, disproportionate--burdens. The Catechism of the Catholic Church affirms this when it says, "Discontinuing medical procedures that are burdensome, dangerous, extraordinary, or disproportionate to the expected outcome can be legitimate; it is the refusal of 'over-zealous' treatment. Here one does not will to cause death; one's inability to impede it is merely accepted." (10) It is important to note here that neither the ERDs nor the Catechism specify which procedures, diagnostics, or therapies constitute proportionate or disproportionate means. In fact, the ERDs explicitly emphasize that those determinations are to be made "in the judgment of the patient. …

Over the past several years, the bioethics community has seen considerable attention being given in the bioethics literature and in various initiatives to the matter of standards and quality in hea...

Study Design. A literature review was conducted. Objective. To provide an evidence-based approach for patients with neurogenic symptoms after lumbar surgery. of Background Data. Patients may present with chronic pain of spinal origin after iumbar surgery Fallure to decompress the involved neural structures adequately or progression of the underlying degenerative condition may lead to neurologic symptoms. Methods. A literature search of paer-reviewed publications that investigate etiologles and treatments for neurogenic pain in patients whe have undergone previous spinal surgery was conducted. Results. In the absence of profound or progressive neurologic deficits, most pationts with chronic back and leg pain who have undergone previous spinal surgerv should be treated nonoperatively. Additional decompressive surgical intervention may be justified in patients with well-defined, discrete pathology amenable to surgical correction who have been refractory to conservative care. The surgery typically will include meticulous decompression of the affected neural structures and may include arthrodesis to address any deformity or instability. Conclusions. In a patient presenting with neurogenic symptoms after lumbar surgery, a meticulous workup is required to elucidate the source of these symptoms. Surgical indications are similar to mess for primary lumba spinal surgery and include a well-defined anatomic source of neural compression that is amenable to a surgical solution.