Cervical spine surgery for tandem spinal stenosis: The impact on low back pain

Objective Tandem spinal stenosis (TSS) can present similarly to cervical myelopathy, but often has a worse prognosis. Few studies have investigated outcomes and compared treatment approaches for patients with TSS. We sought to determine the impact of cervical spine surgery on cervical and lumbar spine symptoms in patients with symptomatic tandem spinal stenosis. Patients Methods 84 patients with TSS were identified over 5 years. 48 underwent cervical spine surgery alone, 20 underwent both cervical and lumbar spine surgery, and 16 received conservative treatment alone (conservative cohort). Quality of life (QOL) measures included the Visual Analogue Scale (VAS) for arm, neck, and back pain, and EuroQOL-5 Dimensions (EQ-5D). QOL data were acquired at baseline (pre-operative) and 1 year postoperatively via an institutional prospectively collected database. Results Both surgical cohorts showed significant (p < 0.01) pre- to postoperative improvement for VAS neck and arm scores at 1-year post-op and significantly (p < 0.01) greater improvements than the conservative cohort. In addition, the cohort undergoing cervical spine surgery alone experienced significant improvement in the EQ-5D score whereas those undergoing both cervical and lumbar spine surgery did not. Conclusions Cervical spine surgery with or without follow-up lumbar spine surgery significantly improves neck pain in patients with TSS. In contrast, cervical spine surgery in these patients does not improve lumbar symptoms. Lumbar surgery also did not improve low back pain or quality of life. Future prospective studies are necessary to examine the impact of lumbar decompression alone on cervical spine symptoms in patients with TSS

Superior Segment Facet Joint Violation During Instrumented Lumbar Fusion is Associated With Higher Reoperation Rates and Diminished Improvement in Quality of Life

Study Design: A retrospective cohort study at a single tertiary care center. Objective: To determine the impact of superior segment facet joint violation (FJV) during lumbar fusion on reoperation rates and quality of life (QOL). Summary of Background Data: Although lumbar fusion is an efficacious and durable treatment for numerous spinal pathologies, adjacent segment degeneration remains a serious complication. FJV has been suggested to alter load-bearing capability and potentially contribute to adjacent segment degeneration. Materials and Methods: Patients who underwent instrumented lumbar fusion surgery between 2009 and 2013 with postoperative computed tomography imaging were included. Patients were placed in the FJV group if either of the superior segment facet joints were compromised by the pedicle screw or rod. Patients with preserved facet joints were placed in the control group. Demographic, perioperative, QOL, and reoperation data were collected. QOL scores including the Pain Disability Questionnaire, Patient Health Questionnaire-9, and EuroQOL 5 Dimensions (EQ-5D) were acquired. Results: Of 240 patients included, 112 patients were found to have FJV and the remaining 128 patients were placed in the control group. One year following lumbar fusion, QOL outcomes and reoperation rates were similar between the FJV and control groups. At 2-year follow-up, patients in the FJV group were less likely to make a significant improvement in EQ-5D (P=0.041). Also, the reoperation rate in the FJV group was significantly higher than in the control group at 2 years (15.2% vs. 6.3%, respectively; P=0.024) and 3 years (19.6% vs. 9.4%, P=0.023). Multivariable logistic regression showed FJV to be an independent predictor of both (1) failing to make a significant improvement in EQ-5D (P=0.046) and (2) undergoing reoperation at both 2 and 3 years postoperatively (P=0.024 and 0.020, respectively). Conclusions: FJV was independently associated with a higher reoperation rate and diminished improvement in QOL

Intracranial Vasospasm After Evacuation of Acute Spontaneous Subdural Hematoma

Cerebral vasospasm is a well-known entity following aneurysmal subarachnoid hemorrhage. While it has been described in trauma, it has been much less studied. There have been no previous reports of cerebral vasospasm following spontaneous subdural hematoma or after subdural hematoma evacuation. In this case report, we present a 38-year-old otherwise healthy female who suffered an acute spontaneous subdural hematoma. After surgical evacuation of her hematoma, she developed neurologic decline. Computer tomography angiography demonstrated intracranial vasospasm. She was treated with blood pressure augmentation and nimodipine. She went on to make a full neurologic recovery.To our knowledge, this is the first reported case of cerebral vasospasm after acute spontaneous subdural hematoma or after subdural hematoma evacuation, and the patient recovered without sequelae. The promising outcome of this case may provide a framework for future similar cases. Neurosurgeons and intensivists should keep cerebral vasospasm in their differentials for patients who have neurologic decline after craniotomy for acute subdural hematoma and have an otherwise negative scan for new acute abnormality

Variability in Surgical Treatment of Spondylolisthesis Among Spine Surgeons

Background There are a multitude of treatments for low-grade lumbar spondylolisthesis. There are no clear guidelines for the optimal approach. Objective To identify the surgical treatment patterns for spondylolisthesis among United States spine surgeons. Methods 445 spine surgeons in the United States completed a survey of clinical/radiographic case scenarios on patients with lumbar spondylolisthesis with neurogenic claudication with (S+BP) or without (S−BP) associated mechanical back pain. Treatment options included decompression, laminectomy with posterolateral fusion, posterior lumbar interbody fusion, or none of the above. The primary outcome measure was the probability of 2 randomly chosen surgeons disagreeing on the treatment method. Results There was 64% disagreement (36% agreement) among surgeons for treatment of spondylolisthesis with mechanical back pain (S+BP) and 71% disagreement (29% agreement) for spondylolisthesis without mechanical back pain (S−BP). For S+BP, disagreement was 52% for those practicing 5 to 10 years versus 70% among those practicing more than 20 years. Orthopedic surgeons had greater disagreement than did neurosurgeons (76% vs. 56%) for S+BP. Greater clinical equipoise was seen for S−BP than for S+BP regardless of surgeon characteristics. For spondylolisthesis without mechanical back pain, neurosurgeons were significantly more likely to select decompression-only than were orthopedic surgeons, who more commonly selected fusion. Conclusions Clinical equipoise exists for the treatment of spondylolisthesis. Differences are greater when the patient presents without associated back pain. Surgeon case volume, practice duration, and specialty training influence operative decisions for a given pathologic condition. Recognizing this practice variation will hopefully lead to better evidence and practice guidelines for the optimal and most cost-effective treatment paradigms

Quality of life changes after lumbar decompression in patients with tandem spinal stenosis

Objective Tandem spinal stenosis (TSS) is a degenerative spinal condition characterized by spinal canal narrowing at 2 or more distinct spinal levels. It is an aging-related condition that is likely to increase as the population ages, but which remains poorly described in the literature. Here we sought to determine the impact of primary lumbar decompression on quality-of-life (QOL) outcomes in patients with symptomatic TSS. Patients and methods We retrospectively reviewed 803 patients with clinical and radiographic evidence of TSS treated between 2008 and 2014 with a minimum 2-year follow-up. The records of patients with clinical and radiographic evidence of concurrent cervical and lumbar stenosis were reviewed. Prospectively gathered QOL data, including the Pain Disability Questionnaire (PDQ), Patient Health Questionnaire-9 (PHQ-9), EuroQOL-5 Dimensions (EQ-5D), and Visual Analogue Scale (VAS) for low back pain, were assessed at the 6-month, 1-year, and 2-year follow-ups. Results Of 803 identified patients (mean age 66.2 years; 46.9% male), 19.6% underwent lumbar decompression only, 14.1% underwent cervical + lumbar decompression, and 66.4% underwent conservative management only. Baseline VAS scores were similar across all groups, but patients undergoing conservative management had better baseline QOL scores on all other measures. Both surgical cohorts experienced significant improvements in the VAS, PDQ, and EQ-5D at all time points; patients in the cervical + lumbar cohort also had significant improvement in the PHQ-9. Conservatively managed patients showed no significant improvement in QOL scores at any follow-up interval. Conclusion Lumbar decompression with or without cervical decompression improves low back pain and QOL outcomes in patients with TSS. The decision to prioritize lumbar decompression is therefore unlikely to adversely affect long-term quality-of-life improvements

Aplicación práctica de la normativa sobre extinción de contratos laborales a partir de la reforma de la Ley 3/2012, de 6 de julio, de medidas urgentes para la reforma del mercado laboral

[ES] El trabajo consistirá en la aplicación a supuestos concretos de la normativa sobre despidos aplicable en España. En particular se trata de comparar a partir de supuestos prácticos la normativa sobre esta materia antes y después de la reforma laboral de 2012.Alentado Escriva, A. (2015). Aplicación práctica de la normativa sobre extinción de contratos laborales a partir de la reforma de la Ley 3/2012, de 6 de julio, de medidas urgentes para la reforma del mercado laboral. http://hdl.handle.net/10251/53232.TFG

Aplicación de la metodología Servqual para el análisis de la satisfacción del cliente de la empresa Instalaciones Eléctricas y Telecomunicaciones Antonio Cascant Calatayud

Se realiza un estudio que mida lacalidad del servicio ofrecido por la empresa ¿Instalaciones Eléctricas y Telecomunicaciones Antonio Cascant Calatayud¿. Dicho estudio estará basado en la realización de un cuestionario Servqual. Además, con la realización de este proyecto se pretende definir una línea de objetivos a cumplir a largo plazo.Alentado Gómez, C. (2011). Aplicación de la metodología Servqual para el análisis de la satisfacción del cliente de la empresa Instalaciones Eléctricas y Telecomunicaciones Antonio Cascant Calatayud. http://hdl.handle.net/10251/11817.Archivo delegad

Belousov-Zhabotinsky Oscillations: Chaotic Chemistry

To monitor the oscillations in potential of the BZ reaction, and determine the existence of transient chaotic regimes, instability, and bifurcation in the dynamic behavior of the system

Soldabilidade do aço 12Cr1MoV

Dissertação apresentada na Faculdade de Ciências e Tecnologia da Universidade Nova de Lisboa para obtenção do grau de Mestre em Engenharia da Soldadur