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January 30, 2017 — January 31, 2017
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Comparing clinical outcomes of repeat discectomy versus fusion for recurrent disc herniation utilizing the N(2)QOD
The strict definition of recurrent lumbar disc herniation is the presence of herniated disc material at the same level, ipsi- or contralateral, in a patient who has experienced a pain-free interval of at least 6 months since surgery. The clinically more appropriate definition, however, is disc herniation at the previously operative site and side. The pain-free interval should not be restricted to the minimum of 6 months. It has been suggested that the mean interval for recurrent pain associated with recurrent herniated discs is 18 months, longer than that for de novo herniated discs or symptomatic epidural fibrosis.
It has been suggested that the mean interval for recurrent pain associated with recurrent herniated discs is 18 months, longer than that for de novo herniated discs or symptomatic epidural fibrosis 1).
It has been suggested that the mean interval for recurrent pain associated with recurrent herniated discs is 18 months, longer than that for de novo herniated discs or symptomatic epidural fibrosis 1).
Epidemiology
Although the recurrence of lumbar disc herniation (LDH) requiring reoperation remains a controversial question in spinal surgery, the incidence is reported to linger around 5-15% according to several previous studies 2) 3) 4) 5) 6) 7).
Risk factor
Reported risk factors include age, gender and smoking, while its surgical treatment is associated to a higher rate of complications and costs.
A subligamentous disc herniation and patient’s age inferior to 35 years at the time of the first surgery are risk factors for requiring surgical treatment of a first RLDH among workers’ compensation patients 8).
Young adults (< 40 years) with uncorrected scoliosis are at higher risk of recurrent lumbar disc herniation (LDH) after lumbar microdiscectomy 9).
Patients in the Fragment-Fissure group, who had disc fragments and a small anular defect, had the best overall outcomes and the lowest rates of reherniation (1%) and reoperation (1%). Patients in the Fragment-Contained group had a 10% rate of reherniation and a 5% rate of reoperation. Patients in the Fragment-Defect group, who had extruded fragments and massive posterior anular loss, had a 27% rate of reherniation and a 21% rate of reoperation. Patients in the No Fragment-Contained group did poorly: 38% had recurrent or persistent sciatica, and the standard outcomes scores were less improved compared with those in the other groups (p < 0.001).
Intraoperative findings, as described, were more clearly associated with outcomes than were demographic, socioeconomic, or clinical variables. The degree of anular competence after discectomy and the type of herniation appear to have value for the prediction of the recurrence of sciatica, reoperation, and clinical outcome following lumbar discectomy 10).
A subligamentous disc herniation and patient’s age inferior to 35 years at the time of the first surgery are risk factors for requiring surgical treatment of a first RLDH among workers’ compensation patients 8).
Young adults (< 40 years) with uncorrected scoliosis are at higher risk of recurrent lumbar disc herniation (LDH) after lumbar microdiscectomy 9).
Patients in the Fragment-Fissure group, who had disc fragments and a small anular defect, had the best overall outcomes and the lowest rates of reherniation (1%) and reoperation (1%). Patients in the Fragment-Contained group had a 10% rate of reherniation and a 5% rate of reoperation. Patients in the Fragment-Defect group, who had extruded fragments and massive posterior anular loss, had a 27% rate of reherniation and a 21% rate of reoperation. Patients in the No Fragment-Contained group did poorly: 38% had recurrent or persistent sciatica, and the standard outcomes scores were less improved compared with those in the other groups (p < 0.001).
Intraoperative findings, as described, were more clearly associated with outcomes than were demographic, socioeconomic, or clinical variables. The degree of anular competence after discectomy and the type of herniation appear to have value for the prediction of the recurrence of sciatica, reoperation, and clinical outcome following lumbar discectomy 10).
Clinical features
A recurrent lumbar disc herniation (RLDH) is the most prevalent cause for new radicular pain after surgery for disc herniation-induced sciatica.
Differential diagnosis
Normal postdiscectomy appearances can be mistaken for recurrent or retained disc. In the early (0 to 6–month) postoperative period, MR imaging reveals an interspace high signal intensity band extending from the nucleus pulposus to the site of anular disruption (especially noticeable at 0–2 months). The anulus is typically hyperintense and the nucleus hypointense. There is loss of disc space height. The endplates and marrow can exhibit changes as well, often low signal on T1 -weighted and high signal on T2 -weighted images suggesting inflammation and edema. The anterior epidural space initially reveals an increase in soft-tissue mass, evidence of tissue disruption, edema, and hemorrhage, with the appearance of mass effect 11).
Nerve root enhancement with Gd is normal, reflect- ing breakdown of the blood–nerve barrier, but should resolve by 6 months. Adhesions within the thecal sac at the operative level usually resolve within several weeks. Postoperative changes at the laminectomy site depend on the extent of surgery, ligamentum flavum removal, and whether fat graft was placed in the epidural space. Facet joint enhancement occurs as a local response to dissection and persists long ( 6 months) after surgery in more than half of the patients in whom imaging is performed12) 13) 14).
Nerve root enhancement with Gd is normal, reflect- ing breakdown of the blood–nerve barrier, but should resolve by 6 months. Adhesions within the thecal sac at the operative level usually resolve within several weeks. Postoperative changes at the laminectomy site depend on the extent of surgery, ligamentum flavum removal, and whether fat graft was placed in the epidural space. Facet joint enhancement occurs as a local response to dissection and persists long ( 6 months) after surgery in more than half of the patients in whom imaging is performed12) 13) 14).
Diagnosis
http://www.elsevier.es/imatges/419/419v55n01/grande/419v55n01-90195107fig12.jpg
Persistent/recurrent disc herniation. 48-Year-old female who underwent laminectomy and L5-S1 discectomy. Follow-up MRI was performed 20 days after surgery due to persistent lumbar pain radiating to the left lower extremity. The axial T2-weighted image (A) shows persistent-recurrent left parasagittal DH connected to the left S1 nerve root at the lateral recess level (arrow). Unenhanced and contrast-enhanced axial T1-weighted image (B and C) shows peripheral enhancement of the herniated material.
Guidelines
Currently, there aren’t any guidelines to assist surgeons in determining which approach is most appropriate to treat rDH. A recent survey showed significant heterogeneity among surgeons regarding treatment options for rDH. It remains unclear which methods lead to better outcomes, as there are no comparative studies with a sufficient level of evidence.
In a study Drazin et al aimed to perform a systematic review to compare treatment options for rDH and determine if one intervention provides better outcomes than the other; more specifically, whether outcome differences exist between discectomy alone and discectomy with fusion.
They applied the PICOS (participants, intervention, comparison, outcome, study design) format to develop this systematic review through PubMed. Twenty-seven papers from 1978-2014 met our inclusion criteria and were included in the analysis. Nine papers reported outcomes after discectomy and seven of them showed good or excellent outcomes (70.60%-89%). Ten papers reported on minimally invasive discectomy. The percent change in visual analog scale (VAS) ranged from -50.77% to -86.57%, indicating an overall pain reduction. Four studies out of the ten reported good or excellent outcomes (81% to 90.2%). Three studies looked at posterolateral fusion. Three studies analyzed posterior lumbar interbody fusion. For one study, we found the VAS percentage change to be -46.02%. All reported good to excellent outcomes. Six studies evaluated the transforaminal lumbar interbody fusion. All reported improvement in pain. Four used VAS, and we found the percent change to be -54% to -86.5%. The other two used the Japanese Orthopedic Association (JOA) score, and we found the percent change to be 68.3% to 93.3%. We did not find enough evidence to support any significant difference in outcomes between discectomy alone and discectomy with fusion. The limitation of the study includes the lack of standardized outcomes reporting in the literature. However, reviewing the selected articles shows that fusion may have a greater improvement in pain compared to reoperation without fusion. Nonetheless, the study shows that further and more in-depth investigation is needed on the of treatment of rDH 15).
In a study Drazin et al aimed to perform a systematic review to compare treatment options for rDH and determine if one intervention provides better outcomes than the other; more specifically, whether outcome differences exist between discectomy alone and discectomy with fusion.
They applied the PICOS (participants, intervention, comparison, outcome, study design) format to develop this systematic review through PubMed. Twenty-seven papers from 1978-2014 met our inclusion criteria and were included in the analysis. Nine papers reported outcomes after discectomy and seven of them showed good or excellent outcomes (70.60%-89%). Ten papers reported on minimally invasive discectomy. The percent change in visual analog scale (VAS) ranged from -50.77% to -86.57%, indicating an overall pain reduction. Four studies out of the ten reported good or excellent outcomes (81% to 90.2%). Three studies looked at posterolateral fusion. Three studies analyzed posterior lumbar interbody fusion. For one study, we found the VAS percentage change to be -46.02%. All reported good to excellent outcomes. Six studies evaluated the transforaminal lumbar interbody fusion. All reported improvement in pain. Four used VAS, and we found the percent change to be -54% to -86.5%. The other two used the Japanese Orthopedic Association (JOA) score, and we found the percent change to be 68.3% to 93.3%. We did not find enough evidence to support any significant difference in outcomes between discectomy alone and discectomy with fusion. The limitation of the study includes the lack of standardized outcomes reporting in the literature. However, reviewing the selected articles shows that fusion may have a greater improvement in pain compared to reoperation without fusion. Nonetheless, the study shows that further and more in-depth investigation is needed on the of treatment of rDH 15).
Treatment
While repeat discectomy is often successful in treating these patients, concern over repeat RLDH may lead surgeons to advocate instrumented fusion even in the absence of instability.
Surgical choices for disc recurrent herniations are limited by multiple factors, require longer operative time, and are associated with higher rate of complications, treatment seems to be associated with a similar chance of good outcome.
Surgical choices for disc recurrent herniations are limited by multiple factors, require longer operative time, and are associated with higher rate of complications, treatment seems to be associated with a similar chance of good outcome.
Outcome
rLDH patients do not only present higher postoperative VAS scores, compared to fLHD patients, but also that these scores are correlated with increased inflammation and may contribute to pain chronicity 16).
Case series
2017
Guan et al., used the National Neurosurgery Quality and Outcomes Database (N2QOD) to assess outcomes of patients who underwent repeat discectomy versus instrumented fusion at a single institution from 2012 to 2015. Primary outcomes included Oswestry Disability Index (ODI) score, visual analog scale (VAS) score, and quality-adjusted life year (QALY) measures. Secondary outcomes included hospital length of stay, discharge status, and hospital charges.
The authors identified 25 repeat discectomy and 12 instrumented fusion patients with 3- and 12-month follow-up records. The groups had similar ODI and VAS scores and QALY measurements at 3 and 12 months. Patients in the instrumented fusion group had significantly longer hospitalizations (3.7 days vs 1.0 days, p < 0.001) and operative times (229.6 minutes vs 82.7 minutes, p < 0.001). They were also more likely to be female (p = 0.020) and to be discharged to inpatient rehabilitation instead of home (p = 0.036). Hospital charges for the instrumented fusion group were also significantly higher ($54,458.29 vs $11,567.05, p < 0.001). Rates of reoperation were higher in the repeat discectomy group (12% vs 0%), but the difference was not statistically significant (p = 0.211).
Repeat discectomy and instrumented fusion result in similar clinical outcomes at short-term follow-up. Patients undergoing repeat discectomy had significantly shorter operative times and length of stay, and they incurred dramatically lower hospital charges. They were also less likely to require acute rehabilitation postoperatively. Further research is needed to compare these two management strategies 17).
The authors identified 25 repeat discectomy and 12 instrumented fusion patients with 3- and 12-month follow-up records. The groups had similar ODI and VAS scores and QALY measurements at 3 and 12 months. Patients in the instrumented fusion group had significantly longer hospitalizations (3.7 days vs 1.0 days, p < 0.001) and operative times (229.6 minutes vs 82.7 minutes, p < 0.001). They were also more likely to be female (p = 0.020) and to be discharged to inpatient rehabilitation instead of home (p = 0.036). Hospital charges for the instrumented fusion group were also significantly higher ($54,458.29 vs $11,567.05, p < 0.001). Rates of reoperation were higher in the repeat discectomy group (12% vs 0%), but the difference was not statistically significant (p = 0.211).
Repeat discectomy and instrumented fusion result in similar clinical outcomes at short-term follow-up. Patients undergoing repeat discectomy had significantly shorter operative times and length of stay, and they incurred dramatically lower hospital charges. They were also less likely to require acute rehabilitation postoperatively. Further research is needed to compare these two management strategies 17).
2016
A total of 163 patients who underwent Microendoscopic diskectomy (MED) for LDH and could be followed for a minimum of 1 year after surgery were enrolled in this study (follow-up [FU] rate: 79.9%).
Ikuta et al., investigated the characteristics of LDH recurrence and conducted a comparative study between the patient groups with and without recurrence to identify the risk factors for the recurrence.
The recurrence of LDH was observed in 19 patients (11.7%) during a mean of 38 months FU. Although the mean length of time from MED to recurrence was 19.2 months, 36.8% of the LDH recurrence occurred in the first 3 months following MED. Eleven patients were treated successfully by conservative treatments, and the remaining eight patients had to undergo revision surgery (MED in five patients, microdiskectomy in one, and instrumented fusion in two). In the analysis of risk factors for the recurrence, the presence of diabetes mellitus (DM) was significantly correlated with the recurrence (p = 0.0027).
The recurrence rate following MED for LDH was equivalent to those of previous reports of conventional and microscopic diskectomy. However, a third of the LDH recurrences occurred in the first 3 months after MED. We should pay attention to LDH recurrence at an early phase following MED and recognize the presence of DM as a risk factor for LDH recurrence 18).
Ikuta et al., investigated the characteristics of LDH recurrence and conducted a comparative study between the patient groups with and without recurrence to identify the risk factors for the recurrence.
The recurrence of LDH was observed in 19 patients (11.7%) during a mean of 38 months FU. Although the mean length of time from MED to recurrence was 19.2 months, 36.8% of the LDH recurrence occurred in the first 3 months following MED. Eleven patients were treated successfully by conservative treatments, and the remaining eight patients had to undergo revision surgery (MED in five patients, microdiskectomy in one, and instrumented fusion in two). In the analysis of risk factors for the recurrence, the presence of diabetes mellitus (DM) was significantly correlated with the recurrence (p = 0.0027).
The recurrence rate following MED for LDH was equivalent to those of previous reports of conventional and microscopic diskectomy. However, a third of the LDH recurrences occurred in the first 3 months after MED. We should pay attention to LDH recurrence at an early phase following MED and recognize the presence of DM as a risk factor for LDH recurrence 18).
2013
A study included 344 patients who underwent MED (213 males and 131 females; mean age, 39.3 years; age range, 11-82 years; mean follow-up, 3.6 years; follow-up range, 2.0-6.5 years). The clinical outcomes were evaluated using the Japanese Orthopedic Association Score for Low Back Pain (JOA score). Recurrence factors investigated by logistic regression analysis included age; sex; level, laterality, and classified type of LDH; occupation; sports activity; and learning curve of the surgeon.
LDH recurrence was observed in 37 patients (10.8%). It was observed at the same level in the ipsilateral side as the original LDH in 30 patients, in the contralateral side in three patients, and at a level adjacent to the original level in four patients. The mean time interval between MED and the recurrence was 16.6 months (range, 0.5-52 months). Twenty patients (54.1%) developed recurrence within 1 year after MED. Twenty-two patients (59.5%) were treated by revision surgery (MED in 20 patients and microdiscectomy in two patients), and 15 patients (40.5%) were treated conservatively. The mean JOA score of all the patients was 14.7 ± 3.5 before surgery and 26.5 ± 2.2 at the final follow-up, yielding an average recovery rate of 82.3 ± 15.7%. The recovery rate was 83.1 ± 14.8% in patients without recurrence and 75.7 ± 20.4% in patients with recurrence (p = 0.006). By logistic regression analysis, we identified migration of LDH as a significant factor related to recurrence. The patients with caudal migration of LDH had recurrence more frequently (19.0%) than those with rostral migration (12.5%) or without migration (10.2%) (p = 0.04; odds ratio, 2.0; 95% confidence interval, 1.0-3.8).
The recurrence rate and reoperation rate for LDH after MED were comparable to those of conventional discectomy. More than half of the cases of recurrence occurred at an early postoperative phase, and patients with caudally migrated LDH experienced recurrence significantly more often than those with rostrally migrated or nonmigrated LDH 19).
LDH recurrence was observed in 37 patients (10.8%). It was observed at the same level in the ipsilateral side as the original LDH in 30 patients, in the contralateral side in three patients, and at a level adjacent to the original level in four patients. The mean time interval between MED and the recurrence was 16.6 months (range, 0.5-52 months). Twenty patients (54.1%) developed recurrence within 1 year after MED. Twenty-two patients (59.5%) were treated by revision surgery (MED in 20 patients and microdiscectomy in two patients), and 15 patients (40.5%) were treated conservatively. The mean JOA score of all the patients was 14.7 ± 3.5 before surgery and 26.5 ± 2.2 at the final follow-up, yielding an average recovery rate of 82.3 ± 15.7%. The recovery rate was 83.1 ± 14.8% in patients without recurrence and 75.7 ± 20.4% in patients with recurrence (p = 0.006). By logistic regression analysis, we identified migration of LDH as a significant factor related to recurrence. The patients with caudal migration of LDH had recurrence more frequently (19.0%) than those with rostral migration (12.5%) or without migration (10.2%) (p = 0.04; odds ratio, 2.0; 95% confidence interval, 1.0-3.8).
The recurrence rate and reoperation rate for LDH after MED were comparable to those of conventional discectomy. More than half of the cases of recurrence occurred at an early postoperative phase, and patients with caudally migrated LDH experienced recurrence significantly more often than those with rostrally migrated or nonmigrated LDH 19).
1) Erbayraktar S, Acar F, Tekinsoy B, et al: Outcome analysis of reoperations after lumbar discectomies: a report of 22 patients. Kobe J Med Sci 48:33–41, 2002
2) , 11) Ross JS: MR imaging of the postoperative lumbar spine. Magn Reson Imaging Clin N Am 7:513–524, 1999
3) Mobbs RJ, Newcombe RL, Chandran KN: Lumbar discectomy and the diabetic patient: incidence and outcome. J Clin Neu- rosci 8:10–13, 2001
4) Suk KS, Lee HM, Moon SH, et al: Recurrent lumbar disc herniation: results of operative management. Spine 26:672–676, 2001
5) , 12) Babar S, Saifuddin A: MRI of the post-discectomy lumbar spine. Clin Radiol 57:969–981, 2002
6) , 10) Carragee EJ, Han MY, Suen PW, et al: Clinical outcomes after lumbar discectomy for sciatica: the effects of fragment type and anular competence. J Bone Joint Surg Am 85:102–108, 2003
7) Moliterno JA, Knopman J, Parikh K, Cohan JN, Huang QD, Aaker GD, Grivoyannis AD, Patel AR, Härtl R, Boockvar JA. Results and risk factors for recurrence following single-level tubular lumbar microdiscectomy. J Neurosurg Spine. 2010;12:680–686.
8) Yurac R, Zamorano JJ, Lira F, Valiente D, Ballesteros V, Urzúa A. Risk factors for the need of surgical treatment of a first recurrent lumbar disc herniation. Eur Spine J. 2015 Oct 15. [Epub ahead of print] PubMed PMID: 26471389.
9) Chang HK, Chang HC, Wu JC, Tu TH, Fay LY, Chang PY, Wu CL, Huang WC, Cheng H. Scoliosis may increase the risk of recurrence of lumbar disc herniation after microdiscectomy. J Neurosurg Spine. 2016 Apr;24(4):586-91. doi: 10.3171/2015.7.SPINE15133. Epub 2015 Dec 11. PubMed PMID: 26654337.
13) Boden SD, Davis DO, Dina TS, et al: Contrast-enhanced MR imaging performed after successful lumbar disk surgery: pro- spective study. Radiology 182:59–64, 1992
14) Van de Kelft EJ, van Goethem JW, de La Porte C, et al: Early postoperative gadolinium-DTPA-enhanced MR imaging after successful lumbar discectomy. Br J Neurosurg 10:41–49, 1996
15) Drazin D, Ugiliweneza B, Al-Khouja L, Yang D, Johnson P, Kim T, Boakye M. Treatment of Recurrent Disc Herniation: A Systematic Review. Cureus. 2016 May 23;8(5):e622. doi: 10.7759/cureus.622. PubMed PMID: 27382530.
16) Andrade P, Hoogland G, Teernstra OP, van Aalst J, van Maren E, Daemen MA, Visser-Vandewalle V. Elevated levels of TNF-α and TNFR1 in recurrent herniated lumbar discs correlate with chronicity of postoperative sciatic pain. Spine J. 2015 Oct 30. pii: S1529-9430(15)01623-X. doi: 10.1016/j.spinee.2015.10.038. [Epub ahead of print] PubMed PMID: 26523959.
17) Guan J, Ravindra VM, Schmidt MH, Dailey AT, Hood RS, Bisson EF. Comparing clinical outcomes of repeat discectomy versus fusion for recurrent disc herniation utilizing the N(2)QOD. J Neurosurg Spine. 2017 Jan;26(1):39-44. doi: 10.3171/2016.5.SPINE1616. PubMed PMID: 27517528.
18) Ikuta K, Tarukado K, Masuda K. Characterization and Risk Factor Analysis for Recurrence Following Microendoscopic Diskectomy for Lumbar Disk Herniation. J Neurol Surg A Cent Eur Neurosurg. 2016 Sep 22. [Epub ahead of print] PubMed PMID: 27657858.
19) Matsumoto M, Watanabe K, Hosogane N, Tsuji T, Ishii K, Nakamura M, Chiba K, Toyama Y. Recurrence of lumbar disc herniation after microendoscopic discectomy. J Neurol Surg A Cent Eur Neurosurg. 2013 Jul;74(4):222-7. doi: 10.1055/s-0032-1320031. Epub 2012 Dec 18. PubMed PMID: 23250873.
Clinical neurology and neurosurgery December 2016
Description of the anterior cerebral artery and its cortical branches: Variation in presence, origin, and size
Possible common neurological breakdowns for alexithymia and humour appreciation deficit: A case study
Severe bilateral subdural hematomas as a complication of diagnostic lumbar puncture for possible Alzheimer’s disease
Spinal sagittal balance and spinopelvic parameters in patients with degenerative lumbar spinal stenosis; a comparative study
The effect of renal dysfunction on short-term outcomes after lumbar fusion
Thrombolytic treatment to stroke mimic patients via telestroke
Toxoplasmosis versus lymphoma: Cerebral lesion characterization using DSC-MRI revisited
Today: New Generation Neuroendoscopy Clinical Observer Course
New Generation Neuroendoscopy Clinical Observer Course
December 8 — December 9
Zurich, Switzerland
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The two course directors, Professor Nikolai Hopf and Professor Robert Reisch have been pupils of Professor Axel Perneczky, pioneer of endoscopic and minimal invasive neurosurgery, and have been using endoscopic techniques since their very beginning of neurosurgical training. They have conducted 29 international courses only within the last seven years, teaching more than 500 international participants. They understand very well that integration of minimally invasive concepts into the daily surgical routine is not simple and requires a strong and stable strategy.
Therefore, in this course you will:
hear conceptual lectures on modern endoscopic & minimally invasive neurosurgery
learn practical hints to set up and perform complex procedures
see how to avoid and handle complications
experience extensive case discussions
enjoy complex endoscopic procedures in the OR
discuss every operating step with the surgeon on-site
HIGHLIGHTS
didactic experience with more than 500 international trainees
small group (max. 8 neurosurgeons) guaranteeing intensive education
extensive discussion of complex cases
possibility to discuss your own cases with us
close-up observation of various complex live-surgeries
The curriculum consists of dissection courses in Berlin/Germany, advanced dissection courses in Budapest/Hungary, clinical observer (master) courses in Zurich/Switzerland and an international fellowship up to six months.
NEW GENERATION means the new generation of trainees, having the opportunity to grow up with these techniques, as well as the new education concept, providing a stepwise, comprehensive and practically oriented training in cranial Neurosurgery. All events are approved by the Neuroendoscopy Committee of the World Federation of Neurosurgical Societies (WFNS).
The clinical observer course in Zurich is designed for neurosurgeons with considerable experience in endoscopic and minimal invasive Neurosurgery. You will observe various complex endoscopic and minimal invasive surgeries within the operating theatre, seeing every little detail of setting up and performing such surgeries and handling unforeseen situations. This will certainly shorten your personal learning curve and help you to avoid unnecessary complications.
As an interesting option, you can book a one-day visit of Karl Storz Endoscopy in Tuttlingen/Germany, around 1h apart from the course venue, looking behind the scenes of the head quarter and the factory.
Tuebingen Online Course on Clinical Neurosurgery
Tuebingen Online Course on Clinical Neurosurgery
December 3
13h CET
Online
Posterior & Anterior Fossa Lesions
with Marcos Tatagiba
This is an online attend. Attend via live streaming video and get answers to your questions via live chat with the speaker.
Flyer.
Website: http://www.tvmedlive.com/tatagiba/
with Marcos Tatagiba
This is an online attend. Attend via live streaming video and get answers to your questions via live chat with the speaker.
Flyer.
Website: http://www.tvmedlive.com/tatagiba/
The Comprehensive Clinical Neurosurgery Review
The Comprehensive Clinical Neurosurgery Review
November 28 — December 2
Krakow, Poland
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The targeted audience for this medical event basically for Neurosurgeons.
This course is mainly designed for Established Neurosurgeons and Senior Trainees. Seasoned neurosurgeons and Junior trainees will find this course as an excellent refresher and a practical review of neurosurgery.
The course aims to help participants focus on examination relevant topics, while deepening their understanding of materials through lectures, discussions and critique. It will provide an excellent preparation for challenging oral board exams such as the Royal College (British,Canadian), EANS and the American board exams or oral boards in your respective countries.
Today: Clinical Workshop of Endoscopic Neurosurgery
Clinical Workshop of Endoscopic Neurosurgery
03.11.2016 – 04.11.2016
Homburg-Saar, Germany
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Flyer
Clinical neurology and neurosurgery October 2016
Gamma knife radiosurgery for brainstem cavernous malformations.
IDH mutation and MGMT promoter methylation are associated with the pseudoprogression and improved prognosis of glioblastoma multiforme patients who have undergone concurrent and adjuvant temozolomide-based chemoradiotherapy.
Management of postoperative pain after Lumbar surgery-pregabalin for one day and 14 days-a randomized, triple-blinded, placebo-controlled study.
Neck range of motion following cervical spinal fusion: A comparison of patient-centered and objective assessments.
Optimal perioperative management of antithrombotic agents in patients with chronic subdural hematoma.
Profile of autonomic dysfunctions in patients with primary brain tumor and possible autoimmunity.
Tibialis anterior muscle herniation with superficial peroneal nerve involvement: Ultrasound role for diagnosis and treatment.
Seizures in Cerebrovascular Disorders: A Clinical Guide
Seizures in Cerebrovascular Disorders: A Clinical Guide
List Price:$159.00
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This comprehensive and practical book fills the current knowledge gap about the incidence and characteristics of seizures in all kinds of cerebrovascular disorders. Chapters are divided according to the nature of cerebrovascular diseases and highlight incidence, early versus late onset seizure types, pathophysiology, electro-clinical manifestations, treatment and prognosis. Authored by leaders in the field of epilepsy and stroke, Seizures in Cerebrovascular Disorders is an excellent resource for the daily management of patients suffering from this disease overlap.
Product Details
- Published on: 2016-10-09
- Original language: English
- Number of items: 1
- Dimensions: 9.25″ h x .35″ w x 6.10″ l,
- Binding: Paperback
- 134 pages
Editorial Reviews
From the Back Cover
This comprehensive and practical book fills the current knowledge gap about the incidence and characteristics of seizures in all kinds of cerebrovascular disorders. Chapters are divided according to the nature of cerebrovascular diseases and highlight incidence, early versus late onset seizure types, pathophysiology, electro-clinical manifestations, treatment and prognosis. Authored by leaders in the field of epilepsy and stroke, Seizures in Cerebrovascular Disorders is an excellent resource for the daily management of patients suffering from this disease overlap.
About the Author
Mohamad Z. Koubeissi, MD, FAAN, FANA
Associate Professor, Department of Neurology
Director, Epilepsy Center
George Washington University
MFA 2150
Pennsylvania Ave., NW; Suite 7-404
Washington DC, 20037
Amer Alshekhlee, MD, MSc
Vascular and Interventional Neurology
Director: DePaul Comprehensive Stroke Center-SSM Neuroscience Institutes
Associate Professor of Neurology, St. Louis University
12255 DePaul Drive, Suite 200
St. Louis, Missouri 63044
Prachi Mehndiratta, MD
Vascular Neurology Fellow, University of Virginia, Charlottesville
This comprehensive and practical book fills the current knowledge gap about the incidence and characteristics of seizures in all kinds of cerebrovascular disorders. Chapters are divided according to the nature of cerebrovascular diseases and highlight incidence, early versus late onset seizure types, pathophysiology, electro-clinical manifestations, treatment and prognosis. Authored by leaders in the field of epilepsy and stroke, Seizures in Cerebrovascular Disorders is an excellent resource for the daily management of patients suffering from this disease overlap.
About the Author
Mohamad Z. Koubeissi, MD, FAAN, FANA
Associate Professor, Department of Neurology
Director, Epilepsy Center
George Washington University
MFA 2150
Pennsylvania Ave., NW; Suite 7-404
Washington DC, 20037
Amer Alshekhlee, MD, MSc
Vascular and Interventional Neurology
Director: DePaul Comprehensive Stroke Center-SSM Neuroscience Institutes
Associate Professor of Neurology, St. Louis University
12255 DePaul Drive, Suite 200
St. Louis, Missouri 63044
Prachi Mehndiratta, MD
Vascular Neurology Fellow, University of Virginia, Charlottesville
Book: Essential Clinical Handbook for Neurosurgery (Essential Clinical Handbooks)
Essential Clinical Handbook for Neurosurgery (Essential Clinical Handbooks)
By Jon Sen
List Price:$79.99
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This is a neurosurgical text that is current, accessible, practical, insightful and authoritative, a companion guide that will act as a comprehensive resource for trainees at all levels, from junior specialty registrars sitting the MRCS to those undertaking their final exit exams (FRCS (SN). It includes clear signposting along the way indicating what objectives need to be met at each level. The content has been structured to provide a learner friendly approach to this complex subject matter. It adopts a step-by-step guide to progressively more complex neurosurgical procedures, as well as including the most up-to-date research that will impact on practice for years to come. This concise textbook distils everything a modern neurosurgery trainee needs to know. It is also suitable for those training in the United States, working towards their primary and final ABN exams. The book will also be of interest as a reference source for practicing neurologists, GP medical students and other healthcare professionals with an interest in this field.
Product Details
- Published on: 2016-09-30
- Original language: English
- Number of items: 1
- Dimensions: 8.27″ h x .87″ w x 5.91″ l, .0 pounds
- Binding: Paperback
- 200 pages