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Onder participatieve re-integratie wordt verstaan: een stapsgewijs protocol voor leidinggevenden en medewerkers voor het identificeren en gezamenlijk oplossen van barriиres voor terugkeer naar werk of het aanpakken van risicofactoren voor toekomstig verzuim mood dysregulation disorder dsm 5 buy bupropion 150mg. Ook voor ketenzorg (samenwerking tussen stakeholders anxiety job interview safe 150mg bupropion, bijvoorbeeld de bedrijfsarts anxiety cures 150 mg bupropion, verzekeringsarts depression unemployed buy 150mg bupropion, huisarts enerzijds en werkgever, werknemer anderzijds) komt steeds meer aandacht. Resultaten literatuurstudie In dit hoofdstuk worden interventies uit de recente literatuur beschreven die specifiek met het werk the maken hadden, de werkgerelateerde interventies. Dit in tegenstelling tot het hoofdstuk Interventies gericht op de aandoening, waar de interventies primair een relatie hebben met de aandoening, bijvoorbeeld pijnvermindering, herstel van (spier)functie, kracht of uithoudingsvermogen. Met werkgerelateerd wordt bedoeld dat de interventie geheel of gedeeltelijk plaatsvond op de werkplek van de werknemer, of de interventie behelsde direct contact met de werkgever of een vertegenwoordiger van de werkgever (leidinggevende of bedrijfsgeneeskundige). Werkgerelateerde interventies zijn gericht op, en hebben het primaire doel, de verbetering van het vermogen om the werken en dit the vertalen naar daadwerkelijk werken. Dit kan in de tweede plaats, op de langere termijn, leiden tot verbeterde symptomen. In de overgebleven 11 systematische literatuurstudies over de periode van 2005-2015 is specifiek gerapporteerd over de effectiviteit van werkgerelateerde interventies. Daarna volgt een overzicht van een aantal gerandomiseerde studies (n=12) waarin een werkgerelateerde interventie is vergeleken met een controlegroep bestaande uit standaardzorg of een andere interventie. Zij concludeerden dat de beste interventies voor terugkeer naar werk multidisciplinair zijn, niet noodzakelijkerwijs intensief en dat deze een biopsychosociale benadering hebben. Langdurige arbeidsongeschiktheid wordt niet langer alleen gezien als het gevolg van een bijzondere stoornis, maar eerder als gevolg van interacties tussen de werknemer en drie belangrijke systemen: de gezondheidszorg, de werkomgeving en het systeem van financiлle compensatie. In een systematisch literatuuronderzoek werd het lange termijn effect van multidisciplinaire rugtraining op de arbeidsparticipatie van patiлnten met aspecifieke chronische lage rugpijn onderzocht (Van Geen. Multidisciplinaire rugtraining heeft op de lange termijn een positief effect op de arbeidsparticipatie en de kwaliteit van leven van patiлnten met aspecifieke chronische lage rugpijn. Dit effect werd niet gevonden voor pijnvermindering en functioneren in algemeen dagelijks leven. Arbeidsrevalidatie heeft betrekking op het identificeren en aanpakken van de gezondheidsgerelateerde, persoonlijke/psychologische en sociale/beroepsmatige obstakels voor terugkeer naar werk. Arbeidsrevalidatie is doelgericht, met als centrale doelstelling het herstellen van de capaciteit voor het werk en dit om the zetten in daadwerkelijke participatie. De auteurs concluderen dat er sterk wetenschappelijk bewijs is voor de effectiviteit van arbeidsrevalidatie bij aspecifieke lage rugpijn. Arbeidsrevalidatie is niet een kwestie van gezondheidszorg alleen, het blijkt dat behandelingen op zich weinig invloed hebben op werk uitkomsten. Werkgevers hebben ook een belangrijke rol, er zijn sterke aanwijzingen dat bedrijven met een proactieve benadering van ziekte, in combinatie met het tijdelijk aanbieden van aangepast werk, effectief en rendabel zijn. Effectieve arbeidsrevalidatie is afhankelijk van de communicatie en coцrdinatie tussen de belangrijkste spelers, in het bijzonder het individu, de gezondheidszorg en de werkplek. Zij concludeerden dat het sterkste bewijs werd gevonden voor de effectiviteit van zowel klinische interventies gecombineerd met werkgerelateerde interventies als interventies gericht op vroege werkhervatting en werkaanpassingen met als gevolg snellere werkhervatting, vermindering van pijn en beperkingen en het verkleinen van het percentage werkgerelateerde rugklachten. Daarnaast werd gevonden dat ergonomische interventies ook effectieve werkplek-interventies zijn (Williams. Het mediane relatieve risico voor vermindering van ziekteverzuim was 1,11 dag/maand. Geen enkele interventie was duidelijk beter dan anderen, hoewel inspanning-intensieve interventies minder effectief waren dan eenvoudige interventies. De meeste interventies schenen effectief, hoewel studies van betere kwaliteit en grotere studies minder effect rapporteerden, wat publicatiebias suggereert. De auteurs stellen dat gezien het feit dat de effecten, met name in de studies van hogere kwaliteit, over het algemeen klein zijn en de kosteneffectiviteit twijfelachtig, er geen duidelijke aanbevelingen kunnen worden gedaan voor werkgevers bij de keuze van een interventie. Voor sommige werkgevers zullen eenvoudige interventies aantrekkelijk zijn als ze haalbaar zijn, goedkoop, veilig en met een potentieel gunstig effect (Palmer. In een Nederlands systematisch literatuuronderzoek werd de effectiviteit onderzocht van (fysieke) conditieverbetering als onderdeel van een terugkeer naar werk strategie om ziekteverzuim the verminderen voor werknemers met rugklachten (Schaafsma. Er is tegenstrijdig bewijs met betrekking tot het terugdringen van de verzuimduur met intense conditietraining versus de gebruikelijke zorg voor werknemers met subacute rugpijn. Voor chronische rugpijn werd bewijs van lage kwaliteit gevonden dat fysieke conditietraining als onderdeel van geпntegreerde zorg als aanvulling op de gebruikelijke zorg het aantal verzuimdagen kan verminderen in vergelijking met de gebruikelijke zorg na 12 maanden follow-up.

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Besides the treatment of the fracture depression symptoms self help trusted 150mg bupropion, patients should be evaluated by an osteologist with regard to a formal assessment of bone metabolism and adequate medical treatment vertical depression definition cheap 150 mg bupropion. Treatment of osteoporosis focuses on agents that:) prevent bone loss) increase bone mass the main goal of conservative treatment is to reduce the number of fragility fractures anxiety free buy bupropion 150 mg. Osteoporosis mood disorder related to medical condition proven 150mg bupropion, however, is a multifactorial disease, and skeletal fragility results from various factors. Thus, achievement of optimal bone metabolism should be the aim throughout life, by age-specific non-pharmacological intervention first and adequate medication where needed. In the past 10 years, large double-blind placebo-controlled trials have been performed to assess the efficacy of medical treatment in postmenopausal women with incident vertebral and non-vertebral fractures as a primary endpoint (Table 5). The treatment focuses on:) restoration/maintenance of calcium and vitamin D metabolism) inhibition of bone resorption by biphosphonates the relative fracture risk is reduced 30 ­ 60 % by these drugs. The absolute risk reduction is 6 %, and the relative risk reduction is 60 out of 150 (40 %) [20] (Table 6). Furthermore there is a considerable number of non-responders and non-compliant patients [20, 24, 58, 83]. Medical treatment includes (Tables 4, 5):) calcium) vitamin D) bisphosphonates) raloxifene) hormone replacement) parathormone A calcium intake of at least 1 g per day should be achieved and is supplemented if dietary intake is not sufficient. However, about one-third of vertebral fractures become chronically painful [16] and 10 % need hospital admission [92]. The possibility of percutaneous cement injection into the vertebral body offers a new and extremely efficient treatment option. Following the technical recommendations (Tables 8, 9), the procedure can be performed safely. In this group of patients, percutaneous reinforcement provides a major pain improvement in more than 80 % of cases and prevents the further vertebral col- Table 8. Key points of surgical technique) high quality C-arm) guidewire) large diameter cannulas (8G)) direct cement application with small syringes (1 cc, 2 cc)) cement with high radiopacity) Cement with high/adapted viscosity Table 9. Indications for vertebroplasty) ongoing pain for more than 2 weeks after occurrence of a new fracture) severe pain; patients remain bedridden for more than 4 days) progressive compression fractures of one or multiple vertebrae with subsequent loss of posture) non-union with persisting instability (Kummel-Verneuil disease)) combined procedures with internal fixation in severe osteoporosis Table 11. Contraindications for vertebroplasty) pain unlikely to be related to a fracture) infection) blood clotting disorders) neurological compromise) impaired visibility during surgery) poor general state of patient, unable to stand in prone position) if an open procedure appears more appropriate Osteoporotic Spine Fractures Chapter 32 939 Table 12. In patients with severe osteoporosis and rapidly developing fractures, the reinforcement of multiple levels is an efficient means to preserve posture and prevent further collapse. Several prospective case series have been published and confirm a rapid and lasting pain relief in 80 ­ 90 % of patients (Table 11) [4, 23, 36 ­ 38, 77]. But also in older lesions the treatment can be effective in as many as 80 % of patients (Table 12) [9, 48]. This is applicable in non-unions, which can occur in up to 40 % [66] just by placing the patient in hyperextension. Pitfalls of Cement Reinforcement Vertebroplasty improves pain in about 80 ­ 90 % of patients the scientific evidence for the superiority of vertebroplasty compared to non-operative care is still lacking Complications (Table 13) related to percutaneous cement reinforcement may occur due to:) Positioning of the patient (fragility fractures of the rib, prone position alone) 940 Section Fractures Table 13. Furthermore systemic reactions during cement injection can occur which might be related to the leaking of the toxic cement monomer in the blood circulation. In the literature many reports of complications can be found [7, 32, 75, 81, 86, 90, 97, 99, 103]. The frequency of local cement leakage in vertebroplasty is reported to be between 3 % and 75 % [80]. In order to minimize the extravasation risk, it is strongly advocated to respect strictly the following recommendations:) use of large diameter cannulas) inject cement with enhanced radiopacity) be aware of the key factor cement viscosity [8] the surgical guidelines must be strictly respected Cement leakage into the spinal canal is the most serious complication Pulmonary cement embolism is a potentially lethal complication the use of small syringes allows direct control of the cement flow [3]. Any suspicious cement flow behavior must lead to immediate discontinuation of injection. The filling behavior is changing with increasing viscosity ­ if the cement flow does not behave as expected, one should pause for 45 s and reinject a small amount of cement. The fatty bone marrow is expelled into the circulation and is cleared in the lungs [94]. Therefore the maximal amount of cement that is injected per session is restricted to 25 cc; in other words not more than six levels should be reinforced per session [36]. Osteoporotic Spine Fractures Chapter 32 941 Risk of Adjacent Vertebral Fractures the risk of a fracture in the adjacent levels seems to be increased after cement reinforcement [6, 30, 50, 98]. Therefore patients and their post-treatment doctors should be informed about controlling the situation if new pain does appear.

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If combined anterior and posterior surgery is required depression symptoms quiz test trusted 150 mg bupropion, the ideal timing of the anterior surgery is still controversial [10] depression definition government cheap bupropion 150mg. Anterior surgery can be done on the same day or staged with a period of halo traction anxiety over ebola buy 150 mg bupropion, achieving some gradual correction over time depression test for 16 year olds buy bupropion 150 mg. Gravity halo traction [5] and intraoperative halo femoral traction [17] are options. Irrespective of the type of traction, close neurological examination including cranial nerve testing, muscle strength in the upper and lower extremities, sensory examination and long tract signs is mandatory to avoid injury to the spinal cord. Complications in staged surgery have been found to be higher and some advocate same day front and back surgery [10]. Severe Rigid Spinal Deformities Single anterior only surgery is indicated only in minor curves without the need for sacropelvic fixation Some of the neuromuscular spinal deformities can be severe, and particularly rigid spinal osteotomies, vertebrectomies, or even kyphectomies may be required to rebalance patients. When one needs to proceed to a kyphectomy, the neuromuscular kyphoscoliosis has reached its end stage disease and is an exam- 688 Section Spinal Deformities and Malformations Rigid S shape kyphosis requires spinal column resection Apical vertebral resection is technically very demanding and associated with significant blood loss ple of what can happen with neuromuscular curves. The severe spinal deformity can lead has led to significant loss of spinal column height, resulting in significant disability and morbidity. The problem is that kyphosis will always progress in this population and that the complexity of the case will only increase. The more classic collapsing C shape type kyphosis that can be addressed by pedicle subtraction type osteotomies [27] is classically performed in the newborn and young infant by removing the ossific nuclei. The second type is described as a so-called rigid S shape kyphosis [21] due to the associated thoracic lordosis above the lumbar kyphosis. When planning a spinal resection, one must achieve solid fixation above and below the resection. Distal fixation can be problematic if distal vertebrae have been resected, thus keeping as many distal spinal vertebrae as possible, to maximize distal spinal anchorage points. Pelvic/sacral fixation is best achieved with a modified Dunn-McCarthy presacral rod [28] augmented with pedicle screws in the most distal vertebral bodies. The entry points for these screws tend to be much more lateral (in the remnant pedicle) and must converge much more than the usual pedicle screws. As the Dunn-McCarthy rods are anterior to the sacrum and sacral alae, one is able to exert a significant corrective force across an osteoporotic pelvis and sacrum. With such a construction one is able to flex in a cantilever fashion the distal spine and pelvis, thus correcting the deformity. If it poses a physical barrier to our dissection, we ligate the sac and transect the cord; however, we prefer to spare it by mobilizing it and then transecting the roots. We then proceed in an extraperiosteal dissection just as one would do a classic anterior approach. We identify the disc levels, then, by using a blunt dissection we reflect the great vessel and the peritoneum off of the spine from either side. We then ligate the segmental vessels, and reflect anteriorly the peritoneum and the abdominal contents. Once the vertebrae identified have been circumferentially dissected, we place blunt retractors around the spine and proceed to cut the vertebra at a bony surface with an oscillating saw above and below the planned resected spine, thus providing bony apposition. As one does this, significant blood loss is encountered, and it persists until the two ends of the vertebrectomy are reapproximated. Therefore the spinal anchorage points must already be in place and the actual kyphectomy is done last (Case Study 4). In such situations we tend to keep all our instruments sterile on the back table until well after the surgery has ended and until the patient has moved all limbs. If there is a problem then we do not need to wait for the resterilization of the instruments and proceed to immediate hardware removal or decrease the amount of correction. In general, the greater the neuromuscular involvement, the greater the likelihood of having a spinal deformity and the greater the deformity will be. On taking the history one needs to find clues, which may confirm the presence of neuromuscular scoliosis. Clues suggestive of neuromuscular scoliosis are birth anoxia, delayed developmental milestone, acquired or familial neuropathies and/or myopathies, spinal deformity before the age of 7 years, or a painful scoliosis. A systemic examination is mandatory of head to toes and further clues can be found confirming the presence of neuromuscular spinal deformity. Neurocutaneous skin markings such as hairy patches or midline nevi (or vascular lesion) can be superficial clues to intradural pathologies.

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Spinal instrumentation and the stabilized spine segment form a system which shares loads and moments anxiety 8 months pregnant generic bupropion 150mg. In-vivo telemetric measures have given valuable insight into device loading patterns depression rehab centers order 150mg bupropion. It has been shown that rod/pedicle screw implants are mainly loaded with compression forces and bending moments depression world history definition quality 150mg bupropion. Load sharing between the implant and bone graft is mandatory for successful bone healing depression synonym effective 150 mg bupropion. Pedicle screw/rod instrumentation has been well established for the surgical treatment of almost all spinal disorders. Unless there is a substantial incompetence of the anterior column, pedicle screw systems provide excellent stability in mono- and multisegmental applications. Choosing convergent screw trajectories and cross-linked rods may enhance stability. The translaminar route should be favored over the direct transarticular trajectory in degenerative disorders and in conjunction with anterior interbody fusion. Lateral mass screws, transarticular screws (C1­C2) and pedicle screws provide increased stability compared to laminar hooks and wires. Lumbar interbody cages are designed to provide sufficient strength to keep disc space height without the necessity for using structural bone grafts. Originally implanted as stand-alone cages, which led to noticeable pseudarthrosis rates, they are nowadays routinely combined with additional instrumentation (pedicle screws/translaminar screws or anterior tension band) due to the poor control of extension/distraction and rotation. In the cervical spine, however, after single level discectomy and "stand-alone" cage implantation near 100 % fusion rates are achieved. Spinal instability after corpectomy or after vertebrectomy in the lumbar spine often requires complex reconstructive procedures. The type and degree of instrumentation depend strongly on the number of involved levels and the retained functioning stabilizing structures. Generally, after corpectomy anterior support is mandatory and long-term stability cannot be achieved with rod/pedicle screw instrumentation alone. Furthermore, the combination with an anterior tension band device still exhibits a certain instability in extension and rotation. Therefore, from the biomechanical perspective, substantial anterior instability requires "front and back" instrumentation. In the cervical spine, however, single-level cage stabilization is sufficiently supported by an anterior tension band device. Multiple-level cervical corpectomies are particularly unstable and anterior plating may be insufficient; consequently additional pedicle/lateral mass screw devices must be considered. Anterior rods/ plates act as tension bands in extension and function as buttress plates in flexion. For the cervical spine, the latest generation of "semi-constrained/ dynamic" plates allow locked angle-stable monocortical screw fixation while axial compression of the graft is permitted. This offers increased stability combined with a minimized risk of stress-shielding. In the lumbar spine, anterior rod/double-rod instrumentation increases anterior stability after cage or graft implantation especially in extension. However, it is still unclear if adjacent segment degeneration after spinal fusion is resulting from the changed biomechanics or exhibits simply the progression of the natural history. Disc arthroplasty offers several advantages such as preservation of segmental motion, potential absence of adjacent segment degeneration and no need for harvesting autologous bone graft. Current prostheses differ in bearing materials (metal or polyethylene) and kinematics principles. Constrained prostheses have a fixed center of rotation whereas unconstrained devices allow translational movement and thus respect the physiological helical axis of motion. Kinematics studies have shown that both types successfully reestablish almost the physiological range of motion. Improving primary or iatrogenic spinal instability while "unloading/protecting" certain spine elements without performing a spinal fusion are the objectives of posterior dynamic implants.

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