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Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_X | Pages 90 - 90
1 Apr 2012
Farmer C McCarthy C
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To identify the validity of the Straight leg raise and crossed straight leg raise in the diagnosis of Lumbar disc prolapse. Systematic review of the literature. The Medline database was used (1966-09) using the search terms Lumbar disc prolapse /disc herniation/straight leg raise /crossed straight leg raise. 80 papers were identified from the search after duplicates had been removed. Of these, 6 abstracts were read and the full papers of 5 reviewed. Four papers scored highly on the STARD criteria and were used in the final review. Two systematic reviews (Vroomen et al, 1999; Deville et al, 2000) and two diagnostic studies (Majessi et al,2000; Vroomen et al, 2002). The review by Vroomen in 1999 identified 37 papers. Trials were included that used CT myelography, MRI or surgical findings as the gold standard. Deville identified 15 studies with the gold standard being findings at surgery. The diagnostic trial by Majessi et al (2008) and Vroomen et al (2002) both used MRI as the gold standard. The Diagnostic odds ratio for SLR ranged from 2.3-8.8 and for CSLR from 4.4 to 11.2. The most valid clinical test in the diagnosis of Lumbar disc prolapse is. the crossed straight leg raise. The straight leg raise has not been shown to have high validity


Aim: The aim is to assess the accuracy of post-contrast imaging in identifying recurrent disc prolapse (RDP).

Material and methods: 246 revision discectomies performed between January 1994 and June 2004 were considered. Of these, for 192 LIRDs, post-contrast scans (95 CTs and 97 MRIs) within 6 months of operation, and adequate operation records were available. Original scan reports and scan interpretation of an independent observer were taken into account.

Results: Of 95 post-contrast CTs, 88 showed RDP (29 large-contained, 12 large-sequestrated, 39 moderate-contained, and 8 small-contained), 2 hypertrophic epidural scar (HES), and 5 lateral recess stenosis but no RDP or HES. From operation records, 30 of these 88 were found to have HES, but no RDP. Also, operation records confirmed presence of RDP in 21 of 29 large-contained (72.4%), 10 of 12 large-sequestrated (83.3%), 16 of 39 moderate-contained (41%) and 2 of 8 small-contained (25%). Of the 5 which did not show RDP, 2 (40%) were found to have RDP (1 moderate-contained and 1 large-contained) during operation.

Of 97 post-contrast MRIs, 85 showed RDP (18 large-contained, 22 large-sequestrated, 26 moderate-contained,4 moderate-sequestrated,13 small-contained, and 2 small-sequestrated), 5 HES, and 7 lateral recess stenosis but no RDP or HES. From operation records, 31 of these 85 were found to have HES, but no RDP. Also, operation records confirmed presence of RDP in 10 of 18 large-contained (55.6%), 19 of 22 large-sequestrated (86.4%), 8 of 26 moderate-contained (30.8%), 4 of 4 moderate-sequestrated (100%), 6 of 13 small-contained (46.2%) and 1 of 2 small-sequestrated (50%). Of the 7 which did not show RDP, 1 (14.3%) was found to have moderate-contained RDP during operation.

Conclusion: Accuracy of post-contrast scans is proportional to the size of RDP. MRI has high accuracy for sequestrated RDP.


Orthopaedic Proceedings
Vol. 86-B, Issue SUPP_II | Pages 116 - 116
1 Feb 2004
Weatherley CR Emran IM
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Objectives: To establish the side incidence of acute lumbar disc prolapse and to determine whether there is a correlation between the side of the prolapse and hand dominance. Design: A retrospective study of consecutive cases of acute lumbar disc prolapse in which the diagnosis was confirmed at operation and the patients contacted about hand dominance. Summary of background data: The side incidence of operatively confirmed disc herniation does not appear to have been reported. Lifting and turning with the trunk in the flexed position is the commonest cause of an acute disc prolapse. Flexion and rotation of the lumbar spine, under load, may also give rise to unilateral fractures in the lumbar spine in fast bowlers in cricket and in eighty percent of these cases the fracture occurs on the opposite side to the bowling arm (ref . 1. ) Given that the majority of the population (eighty nine percent) are right handed it was speculated that the incidence of lumbar disc prolapse might not be equal and might be greater on the side opposite the dominant hand. Methods: From a review of case notes one hundred and twenty six patients were identified in which a sequestrated disc fragment was confirmed at operation. The side of the prolapse was noted. These patients were contacted to determine their hand dominance. Results: Fifty nine patients (47%) had a disc prolapse on the right side and sixty seven (55%) had a disc prolapse on the left side. There was no statistically significant difference in the numbers. Ninety two of the one hundred and twenty six patients contacted about their hand dominance responded: eighty three patients (90.2%) were right handed, eight (8.7%) were left handed and one patient (1.1%) was ambidextrous. Of the eighty three right handed patients, forty (48.2%) had a left sided disc prolapse and forty three (51.8%) had a right sided disc prolapse. Conclusion: This study revealed no difference in the side incidence of lumbar disc prolapse. There was no correlation either with the side of the prolapse and hand dominance. The findings are considered to support the view that a disc prolapse, and the side on which it occurs, is not a consequence of a single unilateral action but an end product of pre-existing disc degeneration in a midline structure


Bone & Joint 360
Vol. 3, Issue 6 | Pages 21 - 23
1 Dec 2014

The December 2014 Spine Roundup. 360 . looks at: surgeon outcomes;. complications and scoliosis surgery; is sequestrectomy enough in lumbar disc prolapse?; predicting outcomes in lumbar disc herniation; sympathectomy has a direct effect on the dorsal root ganglion; and distal extensions of fusion in adolescent idiopathic scoliosis


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_6 | Pages 27 - 27
1 Feb 2016
Hourigan P Challinor H Whitehouse S Clarke A
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Purpose:. To evaluate if adding clonidine to a standard nerve root block containing local anaesthetic and steroid improved the outcome of patients with severe lumbar nerve root pain secondary to MRI proven lumbar disc prolapse. Methods:. We undertook a single blind, prospective, randomised controlled trial evaluating 100 consecutive patients with nerve root pain secondary to lumbar disc prolapse undergoing trans-foraminal epidural steroid injection either with or without the addition of clonidine. 50 patients were allocated to each arm of the study. The primary outcome measure was the avoidance of a second procedure- repeat injection or micro-discectomy surgery. Secondary outcome measures were also studied: pain scores for leg and back pain using a visual analogue scale (VAS), the Roland Morris Disability Questionnaire (RMDQ) and the Measure Your Own Medical Outcome Profile (MYMOP). Follow up was carried out at 6 weeks, 6 months and 1 year. Results:. No serious complications occurred. Of the 50 patients who received the addition of clonidine, 56% were classified as successful injections, with no further intervention required, as opposed to 40% who received the standard injection. This difference did not reach statistical significance (p=0.109, chi-squared test). All secondary measures showed no statistically significant differences between the groups except curiously, the standard group who had been classified as successful had better leg pain relief than the clonidine group (p=0.026) at 1 year. Conclusions:. This pilot study has shown a 16% treatment effect with adding clonidine to lumbar nerve root blocks and that it is a safe injectate for this purpose


Bone & Joint 360
Vol. 2, Issue 3 | Pages 29 - 31
1 Jun 2013

The June 2013 Spine Roundup. 360 . looks at: the benefit of MRI in the follow-up of lumbar disc prolapse; gunshot injury to the spinal cord; the link between depression and back pain; floating dural sack sign; short segment fixation at ten years; whether early return to play is safer than previously thought; infection in diabetic spinal patients; and dynesis


Orthopaedic Proceedings
Vol. 88-B, Issue SUPP_II | Pages 218 - 218
1 May 2006
Coltman T Chapman-Sheath P Riddell A McNally E Wilson-MacDonald J
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Study design: A prospective comparison of MRI findings with surgical findings in patients presenting to our spinal triage service with a prospective diagnosis of a lumbar disc herniation. Objective: To investigate consistency between radiologists interpretation of MRI scans, and comparison between MRI and surgical findings, in an attempt to identify those patients suitable for percutaneous treatment. Background: MRI has assumed a preeminent position in the diagnosis of lumbar disc prolapse. Methods: 87 consecutive patients presenting with signs and symptoms suggestive of a lumbar disc prolapse that underwent an MRI and based on that a discectomy. Results: Reliability tests show only fair agreement (k=0.36) between the radiologists and at best only moderate agreement (k=0.41) between the radiologists and surgical findings. Conclusions: MRI is an excellent tool for diagnosis of a disc prolapse but does not appear to help in classifying discs suitable for percutaneous treatment


Orthopaedic Proceedings
Vol. 88-B, Issue SUPP_II | Pages 265 - 265
1 May 2006
Coltman T Chapman-Sheath P Riddell A McNally Wilson-MacDonald J
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Study design: A prospective comparison of MRI findings with surgical findings in patients presenting to our spinal triage service with a prospective diagnosis of a lumbar disc herniation. Objective: To investigate consistency between Radiologists’ interpretation of MRI scans, and comparison between MRI and surgical findings, in an attempt to identify those patients suitable for percutaneous treatment. Background: MRI has assumed a pre-eminent position in the diagnosis of lumbar disc prolapse. Methods: 87 consecutive patients presenting with signs and symptoms suggestive of a lumbar disc prolapse that underwent an MRI and based on that a discectomy. Results Reliability tests show only fair agreement (k=0.36) between the Radiologists and at best only moderate agreement (=0.41) between the Radiologists and surgical findings. Conclusion: MRI is an excellent tool for diagnosis of a disc prolapse. MRI is poor at defining the character of a disc prolapse, and does not appear to help in classifying discs suitable for percutaneous treatment


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_X | Pages 82 - 82
1 Apr 2012
Barrett C Cowie C Mitchell P
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Several human conditions have a tendency to affect one side of the body over the other. Do lumbar disc prolapses have such a tendency? We sought to answer this question by an analysis of operated cases. Primary lumbar microdiscectomy cases were identified using the coding system. 1286 cases were identified and in 764 the laterality was not recorded. Electronic records were then examined to establish, where possible, the side of the procedure from the clinic letter or discharge summary. 22 cases were eliminated due to miscoding (laminectomy, instrumentation, revision) and in 24 the side of the operation could not be established. In the remaining 1240 cases (96.4%) the laterality was determined. Patients who underwent primary lumbar microdiscectomy in a single neurosurgical unit over a 5-year period (2002-2007). Procedures were bilateral, left or right. 126 cases were bilateral. There were 1114 defined lateral cases. 618 (55.5%) were on the left compared to 496 (44.5%) on the right. The ratio of left to right is close to 5:4. The null hypothesis was that the number of left and right sided operations would be equal. The findings of this study were statistically highly significant (p value < 0.001, binomial test) and the null hypothesis could be rejected. There is a small but definite preponderance of left sided over right sided cases at a ratio of 5:4. This finding may have implications regarding our understanding of both the epidemiology and biomechanics of lumbar disc prolapse


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_4 | Pages 19 - 19
1 Jan 2013
Gaastra B Scoffings D Guilfoyle M Scholz J Laing R Mannion R
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Study Purpose. To examine the presence of radicular pain and its relationship to the degree of lumbar nerve root compression in patients with a degenerative lumbar spine condition about to undergo surgery for either lumbar disc prolapse or lumbar canal stenosis. Background. The pathophysiology underlying radicular pain is not completely understood but it is thought that nerve root compression is a key factor and from a surgical perspective, decompressing the nerve root is considered to be the key therapeutic step. However, despite often severe root compression in patients with lumbar stenosis, radicular pain is not a typical feature. Methods. Thirty-nine pre-surgical patients with either lumbar disc prolapse or lumbar canal stenosis were studied using the Standardised Evaluation of Pain (StEP), a clinical assessment tool known to predict with a high degree of sensitivity and specificity the presence or absence of lumbar radicular pain. A nerve root compression score was given from lumbar MRI for each patient by a neuroradiologist blinded to the patients history. Results. The StEP assessment tool was able to distinguish the presence or absence of radicular pain with high sensitivity and specificity. This correlated well with the pre-operative diagnosis of disc prolapse or canal stenosis. The relationship between radicular pain and nerve root compression was less clear and will be discussed. Conclusion. This study confirms StEP as a useful bedside tool for identifying the presence of radicular pain in patients with a degenerative lumbar spine condition. Nerve root compression per se does not necessarily produce radicular pain. Conflicts of Interest. None. Source of Funding. None. This study has not been published or presented at a previous meeting


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_X | Pages 38 - 38
1 Apr 2012
Spiteri V Newey M
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The use of nerve root blocks is common in the management of radicular pain due to lumbar disc prolapse. However, most papers reporting their use do not necessarily specify the position or level at which the needle is positioned with respect to the level of pathology. We therefore set out to investigate this. We performed a survey of medical practitioners across the UK with an interest or involvement in the management of radicular pain secondary to lumbar disc prolapse The survey depicted the clinical scenario of a patient with radicular pain from an L4/5 disc prolapse and a number of questions were asked in relation to the use of nerve root blocks. Questionnaires were sent to 319 practitioners. We received 153 responses of which, 120 (37.6%) were sufficiently complete to be analysed. Of those who responded, 83% used a combination of local anaesthetic and steroids together with or without contrast. There were variations across the respondents in terms of the level injected with 22.5% injecting at the level of the L4/5 foramen, while 45% injected at the level of the L5/1 foramen. Differences were also noted when respondents were subgrouped according to their speciality. Of those who worked in pain management, 34.1% injected at the L4/5 foramen while 31.8% injected at the L5/1 foramen. For spine surgeons the respective figures were 20.5% and 43.2% and for radiologists 9.4% and 65.6%. In the treatment of radicular leg pain, there are apparent variations in the use and positioning of root blocks for a given level of disc pathology. This suggests that caution is necessary when considering the validity of published studies on the use of root blocks relative to an individual clinician's practice


Orthopaedic Proceedings
Vol. 87-B, Issue SUPP_III | Pages 243 - 243
1 Sep 2005
Cribb G Jaffray D
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Study Design: Review of patients with massive disc prolapse, with a minimum of 50% canal occlusion, treated non-operatively. Objectives: To demonstrate the behaviour of massive disc prolapse treated non-operatively. Subjects: Patients with massive disc prolapse whose symptoms had started to resolve or who had refused surgery. Outcome Measures: Spontaneous reduction of disc herniation on MRI scans. Results: There were 10 patients who have had massive lumbar disc prolapse treated non-operatively. All had MRI scans which showed a lumbar disc prolapse occluding greater than 50% of the canal diameter on the axial cuts. The average occlusion of the canal was 62%. Repeat MRI scans showed reduction of the disc prolapse in all cases, with an average of 83% (range 68–100) reduction in the canal occlusion. The scans were performed between 6 and 68 months apart. 9/10 patients had resolution of leg pain. One patient had persistent leg pain despite complete resolution of the disc prolapse. He went on to have an exploration of the right S1 nerve root. No disc prolapse was identified and the S1 root was free and healthy. This however resolved the majority of his leg pain. Conclusion: We have demonstrated that the natural history, in these cases of massive prolapse was to resolve both clinically and radiologically in the majority of cases


Orthopaedic Proceedings
Vol. 101-B, Issue SUPP_10 | Pages 43 - 43
1 Oct 2019
Chitgopkar S
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Background. Acute lumbar radiculopathy is a very painful condition sometimes requiring admission for strong analgesia. Purpose. To evaluate the efficacy of distal nerve root blocks as an outpatient procedure for immediate pain relief. Methods. Local anaesthetic was injected in the distal nerve root areas of the leg and foot in the clinic in patients with lumbar radiculopathy who consented to the procedure. Results. There were 29 patients, 18 females and 11 males, aged 25 to 76 years. 13 patients had acute lumbar disc prolapse, 11 had lumbar canal stenosis, 2 had annular tears and one a facet joint cyst. The VAS pain scores ranged from 3 to 11 (patient's description), with an average VAS score of 7.5. The improvement in VAS scores was between 2 and 9 with average improvement of 6. 19 patients had associated back pain which improved in 14. Walking improved in all 29 patients. Pain relief was immediate in all patients. This lasted from 30 min to 11 days with one patient having no recurrence. 27 patients had at least 24 hours pain relief. All patients could be sent home immediately after the procedure. 12 patients had recent onset of foot weakness which improved one MRC grade immediately after the injection. The analgesic effect was most significant in acute disc prolapse. There were no complications. Conclusion. This technique is simple and would be valuable in the acute setting to provide immediate pain relief allowing immediate discharge from accident and emergency. Conflicts of interest: None. Sources of funding: None


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_X | Pages 85 - 85
1 Apr 2012
Molyneux S Spens H Gibson J
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To compare outcomes and costs of transforaminal endoscopic surgical discectomy (TES) with those of microdiscectomy (Micro). 48 patients with a primary lumbar disc prolapse were randomly allocated by computer to surgery. Assessments were made of leg and back pain (VAS), Oswestry Disability index (ODI), and SF-36 as primary outcomes. Cost data was collated. 25 TES and 23 Micro patients are reported with similar age, sex, smoking status and affected disc levels (14 v.17 L5/S1). Three months following surgery leg pain scores had decreased by 55 and 65% in the two groups. Patient satisfaction ratings were equal. ODI had decreased 15 points in both groups by 1yr and this improvement was maintained to 2 years (final scores: 7±3 TES v.14±13 Micro - means ±SD; p<0.05). Similar changes were noted in SF36-P. Mean bed stay was lower in the TES group (16 v. 40 hours). Other post-operative costs were similar. There were no immediate complications. One revision was required at 12 months (TES) and one at 18 months (Micro). Two patients presented with a disc prolapse at a different level and side (both TES). Results at up to two years follow-up are similar following the two interventions. Recovery was more rapid in those patients undergoing endoscopic surgery


Orthopaedic Proceedings
Vol. 87-B, Issue SUPP_I | Pages 22 - 23
1 Mar 2005
Heiss-Dunlop W Hadlow A
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The purpose of this study was to highlight uncommon and confusing clinical problem of unilateral prolapsed intervertebral disc (PIVD) producing contralateral symptoms based on case reports and literature review. Four cases of patients with disc prolapse contralateral to the symptomatic limb are presented. Two patients had cervical disc herniations, and one patient had a lumbar disc prolapse. All three patients had resolution of their contralateral radicular pain following discectomy. Few reports have been published of patients with unilateral sciatica following contralateral lumbar disc herniation. The authors described the unique features of their patients’ anatomy and related this to their respective pathology. Coexistence of lumbar spondylosis and lateral recess stenosis, as well as the unique features of the attachments of the dural sac and nerve root sleeves to the surrounding osseous structures serve to provide an explanation for contralateral symptoms. The cervical spine is quite different from the lumbar spine. Here the spinal cord rather than the more flexible cauda equina fills most of the spinal canal. A number of reports can be found describing Brown-Sequard syndrome as a consequence of cervical disc herniation. The two cases presented are in our opinion also the consequence of direct pressure on the spinal cord. We suggest that pressure on the ascending spinothalamic tracts leads to contralateral pain without other neurological symptoms


Orthopaedic Proceedings
Vol. 86-B, Issue SUPP_I | Pages 87 - 87
1 Jan 2004
Nowitzke A
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Introduction: Repetitive undertaking of a physical tasks results in an innate memory for that task. Development of this memory is an important component of surgical training and the ease and safety with which these changes are incorporated into a smoothly flowing procedure is represented by the so-called “learning curve”. Changes in equipment and technology may radically alter the paradigm used by surgeons for completing the task of an operation. An example of this is the integration of endoscopy. The hand-eye orientation, field of view, angle of approach, binocularity of vision and skew of the visual field are all altered in lumbar micro-endoscopic discectomy (MED), when compared to open microdiscectomy. Methods: This is a prospective observational study of the initial twenty-five cases of lumbar MED in the hands of a single surgeon. The twenty-five cases of open micro-discectomy immediately predating the current series are used as a cohort for comparison. Results: A definite alteration in the ability of the surgeon to undertake a new method of discectomy occurred. Three of the first seven cases of MED were converted to an open discectomy. None of the ensuing 18 cases was converted. The major learning outcomes to account for the change were familiarity with the radiological and videoscopic anatomy, and recognition of the importance of angles of approach. The average time for surgery in the first ten cases was significantly longer than the second fifteen. The time for surgery in the latter group was not significantly altered from the open cohort group. The facets of surgery responsible for the increased time in the first group were techniques of exposing the nerve root, comfort of the extent of decompression of the nerve root and excision of the disc and comfort with the orientation and cleaning of the camera. The quality of illumination and visualisation of the operative field improved over the study although the significance of this could not be quantified. Subjectively, surgeon “comfort” with the procedure developed relatively early in the “learning curve”. There was no significant difference in clinical outcome and complications between the two groups. Discussion: Minimal access techniques have been widely integrated into other fields of surgical endeavour. Open microdiscectomy is well accepted as a treatment for acute lumbar disc prolapse. The decision whether or not to change a surgeon’s operative technique should be based on the final anticipated clinical benefit of such a change compared to the cost and risk of changing. This study shows that there is a learning curve associated with lumbar MED, but that it can be integrated relatively easily into a surgical armamentarium


Orthopaedic Proceedings
Vol. 85-B, Issue SUPP_III | Pages 282 - 283
1 Mar 2003
Nowitzke A
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INTRODUCTION: Repetitive undertaking of a physical task results in an innate memory for that task. Development of this memory is an important component of surgical training and the ease and safety with which these changes are incorporated into a smoothly flowing procedure is represented by the so-called “learning curve”. Changes in equipment and technology may radically alter the paradigm used by surgeons for completing the task of an operation. An example of this is the integration of endoscopy. The hand-eye orientation, field of view, angle of approach, binocularity of vision and skew of the visual field are all altered in lumbar microendoscopic discectomy (MED), when compared to open microdiscectomy. METHODS: This is a prospective observational study of the initial twenty-five cases of lumbar MED in the hands of a single surgeon. The twenty-five cases of open microdiscectomy immediately predating the current series are used as a cohort for comparison. RESULTS: A definite alteration in the ability of the surgeon to undertake a new method of discectomy occurred. Three of the first seven cases of MED were converted to an open discectomy. None of the ensuing 18 cases was converted. The major learning outcomes to account for the change were familiarity with the radiological and videoscopic anatomy, and recognition of the importance of angles of approach. The average time for surgery in the first ten cases was significantly longer than the second fifteen. The time for surgery in the latter group was not significantly altered from the open cohort group. The facets of surgery responsible for the increased time in the first group were techniques of exposing the nerve root, comfort of the extent of decompression of the nerve root and excision of the disc and comfort with the orientation and cleaning of the camera. The quality of illumination and visualisation of the operative field improved over the study although the significance of this could not be quantified. Subjectively, surgeon “comfort” with the procedure developed relatively early in the “learning curve”. There was no significant difference in clinical outcome and complications between the two groups. DISCUSSION: Minimal access techniques have been widely integrated into other fields of surgical endeavour. Open microdiscectomy is well accepted as a treatment for acute lumbar disc prolapse. The decision whether or not to change a surgeon’s operative technique should be based on the final anticipated clinical benefit of such a change compared to the cost and risk of changing. This study shows that there is a learning curve associated with lumbar MED, but that it can be integrated relatively easily into a surgical armamentarium


Bone & Joint 360
Vol. 7, Issue 6 | Pages 29 - 31
1 Dec 2018


Bone & Joint 360
Vol. 8, Issue 6 | Pages 18 - 19
1 Dec 2019


Bone & Joint 360
Vol. 3, Issue 1 | Pages 27 - 29
1 Feb 2014

The February 2014 Spine Roundup360 looks at: single posterior approach for severe kyphosis; risk factors for recurrent disc herniation; dysphagia and cervical disc replacement or fusion; hang on to your topical antibiotics; cost-effective lumbar disc replacement; anxiolytics no role to play in acute lumbar back pain; and surgery best for lumbar disc herniation.