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Price B.B.,Professional Association | Amini S.B.,George Washington University | Kappeler K.,NeuroTexas Institute
Medicine and Science in Sports and Exercise

OBJECTIVE: A prospective randomized controlled trial was designed to assess the benefits and possible risks of aerobic exercise during pregnancy, using a fitness regimen based on the 2002 American College of Obstetricians and Gynecologists guidelines for exercise during pregnancy. METHODS: Inactive women were randomized at 12-14 wk gestation to a group that remained sedentary or to a group that performed moderate aerobic exercise 45-60 min, 4 d•wk, through 36 wk gestation. Thirty-one subjects in each group completed the study. RESULTS: Compared with women who remained sedentary, active women improved aerobic fitness (P < 0.05) and muscular strength (P < 0.01), delivered comparable size infants with significantly fewer cesarean deliveries (P < 0.01), and recovered faster postpartum (P < 0.05), at least related to the lower incidence of cesarean section. Active women developed no gestational hypertension (P = 0.16 compared with controls) and reported no injuries related to the exercise regimen. In the active group, there was one premature birth at 33 wk by a woman with a history of premature delivery of twins at 34 wk. There were no differences between groups in the incidence of gestational diabetes, musculoskeletal pains during pregnancy, flexibility on sit-and-reach test, mean length of pregnancy, neonatal Apgar scores, placenta weights, overall length of labor, weight gain during pregnancy, or weight retention postpartum. CONCLUSION: Previously sedentary women who began exercising at 12-14 wk improved fitness and delivery outcomes. Copyright © 2012 by the American College of Sports Medicine. Source

Wait S.D.,Barrow Neurological Institute | Fox Jr. D.J.,NeuroTexas Institute | Kenny K.J.,Barrow Neurological Institute | Dickman C.A.,Barrow Neurological Institute

Study Design: Retrospective review of a prospectively maintained surgical database. Objective: To report the indications, surgical procedures performed, and outcomes from the largest series of thoracoscopically treated herniated thoracic discs (HTDs). We also compared approach-related complications with an unmatched cohort undergoing thoracotomy for HTD. Summary of Background Data: Symptomatic HTDs are rare, and their surgical management is technically challenging. Methods: A prospectively maintained surgical database of all patients undergoing surgery for symptomatic HTDs by the senior author (blinded for review) was reviewed. As needed, the database was supplemented with hospital and clinic charts and telephone conversations with patients. A triportal method of thoracoscopic discectomy was performed in all cases. Results: Between 1994 and 2008, 121 patients underwent 125 thoracoscopic-assisted operations for 139 HTDs. Their mean age at surgery was 46.6 years. Indications for thoracoscopic resection currently include small symptomatic disc, anterior location, nonmorbidly obese patient, favorable chest anatomy, and T4-T11 location. Symptom duration averaged 32 months. Radiculopathy was the most common presentation, followed by myelopathy and pain (radiculopathic or back). The mean hospital stay was 4.8 days. Chest tubes remained in place for a mean of 3.2 days. At a mean follow-up of 2.4 years, myelopathy, radiculopathy, and back pain had resolved or improved at a rate of 91.1%, 97.6%, and 86.5%, respectively. Patients reported worsening in 0%, 1.2%, and 0% of cases, respectively. Most patients (97.4%) would be willing to undergo the operation again. The complication rate was acceptable. Patients undergoing thoracoscopic excision had less approach-related morbidity than an unmatched cohort undergoing excision using thoracotomy. Conclusion: Thoracoscopic-assisted microsurgical resection is a safe, effective, and minimally invasive method of treating symptomatic HTDs in appropriately selected patients. The symptoms of most patients improve or resolve with minimal morbidity. Source

Burnett M.G.,NeuroTexas Institute | Stein S.C.,University of Pennsylvania | Bartels R.H.M.A.,Radboud University Nijmegen
Journal of Neurosurgery: Spine

Object. Standard treatment options for patients with lumbar spinal stenosis include nonoperative therapies as well as decompressive laminectomy. The introduction of interspinous decompression devices such as the X-STOP has broadened treatment options, but data comparing these treatment strategies are lacking. The object of this study was to provide a cost-effectiveness analysis of laminectomy, interspinous decompression, and nonoperative treatment for patients with lumbar stenosis. Methods. The authors performed a structured literature review of lumbar stenosis and constructed a cost-effectiveness model. Using conservative treatment, decompressive laminectomy, and placement of X-STOP as the treatment arms, their primary analysis evaluated the optimal treatment strategy for a patient with lumbar stenosis at a 2-year time horizon. Secondary analyses were done to compare cases in which patients required single-level procedures with those in which multilevel procedures were required as well as to examine the outcomes for a 4-year time horizon. Outcomes were calculated using quality-adjusted life years and costs were considered from the perspective of society. Results. Laminectomy was found to be the most effective treatment strategy, followed by X-STOP and then conservative treatment at a 2-year time horizon. Both surgical procedures were more costly than conservative treatment. Because laminectomy was both more effective and less costly than X-STOP, it is said to dominate overall. When single level procedures were considered alone, laminectomy was more effective but also more costly than X-STOP. Conclusions. Lumbar laminectomy appears to be the most cost-effective treatment strategy for patients with symptomatic lumbar spinal stenosis. Source

Lewis D.J.,University of Pennsylvania | Lewis D.J.,Baylor College of Medicine | Attiah M.A.,University of Pennsylvania | Malhotra N.R.,University of Pennsylvania | And 2 more authors.

STUDY DESIGN. Cost-effectiveness analysis with decision analysis and meta-analysis. OBJECTIVE. To determine the relative cost-effectiveness of anterior cervical discectomy with fusion (with autograft, allograft, or spacers), anterior cervical discectomy without fusion (ACD), and cervical disc replacement (CDR) for the treatment of 1-level cervical disc disease. SUMMARY OF BACKGROUND DATA. There is debate as to the optimal anterior surgical strategy to treat single-level cervical disc disease. Surgical strategies include 3 techniques of anterior cervical discectomy with fusion (autograft, allograft, or spacer-assisted fusion), ACD, and CDR. Several controlled trials have compared these treatments but have yielded mixed results. Decision analysis provides a structure for making a quantitative comparison of the costs and outcomes of each treatment. METHODS. A literature search was performed and yielded 156 case series that fulfilled our search criteria describing nearly 17,000 cases. Data were abstracted from these publications and pooled meta-analytically to estimate the incidence of various outcomes, including index-level and adjacent-level reoperation. A decision analytic model calculated the expected costs in US dollars and outcomes in quality-adjusted life years for a typical adult patient with 1-level cervical radiculopathy subjected to each of the 5 approaches. RESULTS. At 5 years postoperatively, patients who had undergone ACD alone had significantly (P < 0.001) more quality-adjusted life years (4.885 ± 0.041) than those receiving other treatments. Patients with ACD also exhibited highly significant (P < 0.001) differences in costs, incurring the lowest societal costs ($16,558 ± $539). Follow-up data were inadequate for comparison beyond 5 years. CONCLUSION. The results of our decision analytic model indicate advantages for ACD, both in effectiveness and costs, over other strategies. Thus, ACD is a cost-effective alternative to anterior cervical discectomy with fusion and CDR in patients with single-level cervical disc disease. Definitive conclusions about degenerative changes after ACD and adjacent-level disease after CDR await longer follow-up. Level of Evidence: 4. © 2014 by Lippincott Williams & Wilkins. Source

Cowperthwaite M.C.,NeuroTexas Institute | Cowperthwaite M.C.,University of Texas at Austin | Van Den Hout W.B.,Leiden University | Webb K.M.,NeuroTexas Institute
Journal of Neurosurgery: Spine

Object. The authors comprehensively studied the recovery of individual patients undergoing treatment for lumbar disc herniation. The primary goal was to gain insight into the variability of individual patient utility scores within a treatment cohort. The secondary goal was to determine how the rates and variability of patient recovery over time, represented by improvement in utility scores, affected long-term patient outcomes. Methods. EuroQol Group-5 Dimension (EQ-5D) scores were obtained at baseline and at 2, 4, 8, 12, 26, 38, and 52 weeks for 93 patients treated under a prolonged conservative care protocol for lumbar disc herniation. Gaussian kernel densities were used to estimate the distribution of utility scores at each time point. Logistic regression and multistate Markov models were used to characterize individual patient improvement over time. Fisher exact tests were used to compare the distribution of EQ-5D domain scores. Results. The distribution of utility scores was bimodal at 1 year and effectively sorted patients into a "higher" utility group (EQ-5D = 1; 43% of cohort) and a "lower" utility group (EQ-5D < 0.86; 57% of cohort). Fisher exact tests revealed that pain/discomfort, mobility, and usual activities significantly differed between the 2 utility groups (p << 0.001). The utility groups emerged at 8 weeks and were stable for the remainder of the treatment period. Using utility scores from 8 weeks, regression models predicted 1-year outcomes with 62% accuracy. Conclusions. This study is the first to comprehensively consider the utility recovery of individual patients within a treatment cohort for lumbar disc herniation. The results suggest that most utility is recovered during the early treatment period. Moreover, the findings suggest that initial improvement is critical to a patient's long-term outcome: patients who do not experience significant initial recovery appear unlikely to do so at a later time under the same treatment protocol. © AANS, 2013. Source

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