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James J. Brennan and Christopher M. Loftus

The study of carotid artery occlusive disease interventions can be divided clinically into the treatment of asymptomatic and symptomatic diseases. Clinical trials that have studied or are currently studying asymptomatic disease include: the Carotid Artery Stenosis with Asymptomatic Narrowing Operation Versus Aspirin study; the Mayo Asymptomatic Carotid Endarterectomy trial; Veterans Administration Cooperative Trial on Asymptomatic Carotid Stenosis; and the Asymptomatic Carotid Atherosclerosis Study. Trials for the treatment of symptomatic disease include: the North American Symptomatic Carotid Endarterectomy Trial; the European Carotid Surgery Trial; and the Veterans Administration Cooperative Study.

In the earliest trials conducted to study asymptomatic disease medical therapy was slightly favored; on close scrutiny these studies were flawed and the findings appeared to be equivocal. The more scientific and appropriate trial, which was ended due to ethical concerns, revealed a clear advantage in patients who underwent surgery for greater than 60% stenosis and when the surgical center demonstrated less than 3% surgical risks.

All trials studying symptomatic disease found a significant decrease in subsequent stroke when surgical intervention was performed. It is now judged that patients with greater than 50% stenosis receive significant benefit.

In this paper the authors review the data from all of these studies. They also review data for special circumstances, such as critical stenosis and patients with symptomatic and asymptomatic Hollenhorst plaques. It is their opinion that these data have allowed surgeons to make much more educated decisions when considering the treatment of patients with carotid artery occlusive disease.

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Dennis J. Rivet, David Jeck, James Brennan, Adrian Epstein and Carl Lauryssen

Object. The authors conducted a prospective study to evaluate the clinical and radiological outcomes and complications associated with uni- and bilateral transforaminal lumbar interbody fusion (TLIF) performed using carbon fiber Brantigan I/F Cages and pedicle screw fixation.

Methods. Forty-two consecutive patients who had undergone uni- or bilateral TLIF between February 1999 and July 2000 were prospectively evaluated. Clinical outcome was graded using a modified Prolo Scale, the McGill Pain Index Scale, a follow-up questionnaire, and charts. An independent radiologist assessed radiological outcomes. All patients were followed for at least 1 year.

Based on Prolo Scale scores, an excellent or good 1-year outcome was achieved in 73% of patients; 90% of patients responded that they would undergo the procedure again. At 1 year, radiographic fusion was demonstrated in 74% and was statistically related to clinical outcome (p < 0.05).

There were no deaths or major hardware failures. Complications requiring repeated surgery included one case of cerebrospinal fluid (CSF) leakage and one case in which the hemovac drain was retained. There were four cases involving minor wound infections, eight involving CSF leaks, and none requiring repeated surgery. On routine follow-up radiography one pedicle screw was found to be broken; the patient remained asymptomatic and fusion occurred.

Conclusions. Unilateral and bilateral TLIF involving placement of carbon fiber cages and pedicle screw fixation are effective treatment options in patients with indications for lumbar arthrodesis. The procedures result in acceptable rates of fusion and clinical success, and a minimal incidence of morbidity when performed by an experienced surgeon.