Lumbar spinal stenosis: conservative or surgical management?: A prospective 10-year study. Clinical management of nonhealing periradicular pathosis. Surgery versus endodontic retreatment. Nonsurgical treatment of moderate and advanced periimplantitis lesions: a controlled clinical study. A randomized multicenter study to compare two treatment regimens of topical methyl aminolevulinate (Metvix)-PDT in actinic keratosis of the face and scalp. Treatment of vulvar intraepithelial neoplasia with topical imiquimod: seven years median follow-up of a randomized clinical trial. Modified lay-open (incision, curettage, partial lateral wall excision and marsupialization) versus total excision with primary closure in the treatment of chronic sacrococcygeal pilonidal sinus: a prospective, randomized clinical trial with a complete two-year follow-up. Treatment of chronic pilonidal sinus with local anaesthesia: a randomized trial of closed compared with open technique. Intraindividual, right-left comparison of topical methyl aminolaevulinate-photodynamic therapy and cryotherapy in subjects with actinic keratoses: a multicentre, randomized controlled study. Report of a controlled clinical trial comparing automated percutaneous lumbar discectomy and microdiscectomy in the treatment of contained lumbar disc herniation.
A cohort of 100 patients with symptomatic lumbar spinal stenosis, characterized in a previous article, were given surgical or conservative treatment and followed for 10 years.
                To identify the short- and long-term results after surgical and conservative treatment, and to determine whether clinical or radiologic predictors for the treatment result can be defined.
                Surgical decompression has been considered the rational treatment. However, clinical experience indicates that many patients do well with conservative treatment.
                In this study, 19 patients with severe symptoms were selected for surgical treatment and 50 patients with moderate symptoms for conservative treatment, whereas 31 patients were randomized between the conservative (n = 18) and surgical (n = 13) treatment groups. Pain was decisive for the choice of treatment group. All patients were observed for 10 years by clinical evaluation and questionnaires. The results, evaluated by patient and physician, were rated as excellent, fair, unchanged, or worse.
                After a period of 3 months, relief of pain had occurred in most patients. Some had relief earlier, whereas for others it took 1 year. After a period of 4 years, excellent or fair results were found in half of the patients selected for conservative treatment, and in four fifths of the patients selected for surgery. Patients with an unsatisfactory result from conservative treatment were offered delayed surgery after 3 to 27 months (median, 3.5 months). The treatment result of delayed surgery was essentially similar to that of the initial group. The treatment result for the patients randomized for surgical treatment was considerably better than for the patients randomized for conservative treatment. Clinically significant deterioration of symptoms during the final 6 years of the follow-up period was not observed. Patients with multilevel afflictions, surgically treated or not, did not have a poorer outcome than those with single-level afflictions. Clinical or radiologic predictors for the final outcome were not found. There were no dropouts, except for 14 deaths.
                The outcome was most favorable for surgical treatment. However, an initial conservative approach seems advisable for many patients because those with an unsatisfactory result can be treated surgically later with a good outcome. This prospective randomized study compared the outcome of retreatment and surgical intervention in root canal treated teeth with nonhealing periradicular pathosis.
                One such tooth from each of 38 patients was randomly allotted to retreatment or root-end resection and root-end filling. Treatment outcome after 1 year was evaluated and compared clinically and radiographically.
                The success rate for surgery was higher than for conventional retreatment, but the difference was not statistically significant.
                For management of nonhealing periradicular pathosis associated with root canal treated teeth, surgical intervention should be considered as an alternative to retreatment. In cases with a similar prognosis for both modes of treatment, the choice should be governed by consideration of intrinsic and extrinsic factors. The aim of this controlled, parallel design clinical study was to evaluate the effectiveness of an Er:YAG (erbium-doped:yttrium, aluminum, and garnet) laser for nonsurgical treatment of periimplantitis lesions. Twenty patients, each of whom displayed at least one implant with (a) moderate and (b) advanced periimplantitis (n=40 implants; IMZ, ITI, Spline Twist, ZL-Duraplant, Camlog), were randomly instrumented nonsurgically using either (1) an Er:YAG laser (100 mJ/pulse, 10 Hz) device (LAS) or (2) mechanical debridement using plastic curettes and antiseptic therapy with chlorhexidine digluconate (0.2%) (C). The following clinical parameters were measured at baseline, 3, 6, and 12 months after treatment: plaque index, bleeding on probing (BOP), probing depth, gingival recession, and clinical attachment level (CAL). Mean BOP improved significantly in both groups at 3, 6, and 12 months (a- lesions: P<0.001 and b- lesions: P<0.01, respectively). After 3 and 6 months, the mean reduction of BOP was significantly higher in the LAS group when compared to the C group (a- and b- lesions: P<0.01 and P<0.05, respectively). At 3 and 6 months, both groups revealed significant CAL gains at a- and b- lesions (P<0.01, respectively). In both groups, however, the mean CAL at a- and b- lesions was not significantly different from the respective baseline values at 12 months (P>0.05, respectively). Although treatment of periimplantitis lesions with LAS resulted in a significantly higher BOP reduction than C, its effectiveness seemed to be limited to a period of 6 months, particularly at b- lesions. Photodynamic therapy (PDT) with topical methyl aminolevulinate (MAL) administered in two treatment sessions separated by 1 week is an effective treatment for actinic keratoses. This open prospective study compared the efficacy and safety of MAL-PDT given as a single treatment with two treatments of MAL-PDT 1 week apart. Two hundred and eleven patients with 413 thin to moderately thick actinic keratoses were randomized to either a single treatment with PDT using topical MAL (regimen I; n=105) or two treatments 1 week apart (regimen II; n=106). Each treatment involved surface debridement, application of Metvix cream (160 mg/g) for 3 h, followed by illumination with red light using a light-emitting diode system (peak wavelength 634+/-3 nm, light dose 37 J/cm2). Thirty-seven lesions (19%) with a non-complete response 3 months after a single treatment were re-treated. All patients were followed up 3 months after the last treatment. A total of 400 lesions, 198 initially treated once and 202 treated twice, were evaluable. Complete response rate for thin lesions after a single treatment was 93% (95% CI=87-97%), which was similar to 89% (82-96%) after repeated treatment. Response rates were lower after single treatment of thicker lesions (70% (60-78%) vs 84% (77-91%)), but improved after repeated treatment (88% (82-94%)). The conclusion of this study is that single treatment with topical MAL-PDT is effective for thin actinic keratosis lesions; however, repeated treatment is recommended for thicker or non-responding lesions. Recently we reported on the efficacy of imiquimod for treating vulvar intraepithelial neoplasia (VIN) in a placebo-controlled, double-blinded randomized clinical trial (RCT). Four weeks after treatment, a complete response was observed in 35% of patients and a partial response in 46%. All complete responders remained disease-free at 12 months follow-up. In the current investigations, we assessed long-term follow-up at least 5 years after the initial RCT.
                Twenty-four of 26 imiquimod-treated patients who had participated in the initial RCT were seen for follow-up. Primary endpoint was durability of clinical response to imiquimod assessed by naked eye vulvar examination and histology. Long-term clinical response was correlated to lesion size before start of the initial RCT. Secondary endpoints were mental health, global quality of life, body image and sexual function in relation with long-term clinical response.
                Median follow-up period was 7.2 years (range 5.6-8.3 years). VIN recurred in one of nine complete responders. Of the initial partial responders, two became disease-free after additional imiquimod treatment. In the other partial responders, VIN recurred at least once after the initial RCT. In long-term complete responders, lesion size at study entry was smaller and these patients had a significantly better global quality of life at follow-up than patients with residual disease and/or recurrence after imiquimod treatment.
                In case of a complete response, imiquimod is effective in the long-term. Furthermore, patients with a long-term complete response had a significantly better global quality of life than patients who recurred after imiquimod treatment.
                Copyright © 2010 Elsevier Inc. All rights reserved. The best surgical technique for treating pilonidal sinus disease is controversial. The aim of this study is to compare the modified lay-open technique with primary closure following excision with respect to operating time, healing time, time before return to work, morbidity rate, and recurrence rate.
                After a pre-study power analysis, 142 patients with chronic sacrococcygeal pilonidal sinus were prospectively and randomly allocated, either to the modified lay-open group (Group A, n=73) or the primary closure group (Group B, n=69). In the former, incision, curettage, partial lateral wall excision, and marsupialization were performed. Single doses of cefazoline (1 g) and metronidazole (500 mg) were given intravenously 15 min before surgery to all patients.
                There were no differences with respect to gender, age, body mass index, and mean operating time between the groups. In Group A, healing failure and early bridging occurred in one patient each. In Group B, wound infection occurred in four patients, wound breakdown in three, one healing failure and hematoma in one patient each. Morbidity and recurrence rates were significantly lower in Group A (2.7 vs. 13%, P=0.028 and 1.4 vs. 17.4%, P<0.001 respectively). The median time before return to work in Group A was significantly shorter than in Group B (3 [range 2--8] vs. 21 [range 14--63] days, P<0.001). The median healing time in Group A was significantly longer than in Group B (7 [range 3--16] weeks vs. 2 [range 2--9] weeks; P<0.001).
                The results of the present study suggest that modified lay-open is superior to excision with primary closure for the surgical treatment of chronic sacrococcygeal pilonidal sinus with regard to morbidity and recurrence rates, and time before return to work, although healing time is longer. To compare open with closed treatment of chronic pilonidal sinus.
                From 1993 to 1996, 100 patients were submitted to excision of chronic pilonidal sinus, with local anaesthesia and were randomized in two groups: group A in which open treatment and group B in which direct suture were performed. The follow-up, ranging from 37 to 89 months, was performed by outpatient visits or by phone.
                Short-term results showed 6 (12.0%) post-operative complications in group A vs 10 (20.0%) in group B. Long-term results showed 9 (18.0%) complications in group A vs 7 (14.0%) in group B. Mean wound healing was 58 days (range: 29-93) in group A vs 12 (range: 9-61) in group B. The return to normal activity was 25.7 (range: 11-77) vs 10.4 (range: 5-32). Wound healing and the return to normal activity were the only statistically significant differences.
                Regarding morbidity neither technique has particular advantages over the other. The closed technique produced quicker wound healing and a quicker return to normal activity. Actinic keratosis (AK), the most common premalignant skin condition, can represent a management challenge. Treatment should not only be effective, but also well tolerated and allow for good cosmesis on typical sun-exposed highly visible body sites.
                The primary objective was to compare the lesion response and subject preference for topical methyl aminolaevulinate (MAL)-photodynamic therapy (PDT) vs. cryotherapy for the treatment of AK.
                In this 24-week, multicentre, randomized, intraindividual (right-left) study, subjects received both one treatment session of MAL-PDT and a double freeze-thaw cryotherapy; the treatments were randomly allocated to either side of the face/scalp. Lesions with a noncomplete response were retreated after 12 weeks. The primary assessments were the subject's overall preference and lesion response at week 24. Secondary assessments included lesion response at week 12, cosmetic outcome, subject and investigator cosmetic outcome preference at week 24, and investigator overall preference at week 24. Skin discomfort and adverse events were also evaluated.
                In total, 119 subjects with 1,501 lesions were included in the study. At week 12, treatment with MAL-PDT resulted in a significantly larger rate of cured lesions relative to cryotherapy (percentage lesion reduction from baseline: 86.9% vs. 76.2%; P < 0.001). At week 24, both treatment groups showed a high rate of cured lesions (89.1% for MAL-PDT vs. 86.1% for cryotherapy; P = 0.20; 95% confidence interval: -1.62 to 7.67). Results for subject and investigator preferences as well as cosmetic outcome favoured MAL-PDT. Both treatment regimens were safe and well tolerated.
                The present study shows that, when treated with both MAL-PDT and cryotherapy, subjects significantly prefer MAL-PDT treatment for AK. MAL-PDT is an attractive treatment option for AK, with comparable efficacy and superior cosmetic outcomes compared with double freeze-thaw cryotherapy. The results of a randomized controlled trial comparing automated percutaneous lumbar discectomy (APLD) with lumbar microdiscectomy for the treatment of small contained lumbar discal herniations are reported. All patients gave full informed consent and were assessed by an independent observer. Seventy-one patients with radiologically confirmed small contained lumbar disc herniations were randomly assigned to undergo either APLD or lumbar microdiscectomy. All patients were formally assessed by the independent assessor using the Macnab outcome classification at 3 weeks, 2 months, and 6 months after the procedure with follow-up being continued for the duration of the study.
                The objective was to complete the first randomized and blinded study with sufficient numbers to provide a valid statistical evaluation of these procedures.
                No previous randomized controlled study comparing these methods has been previously reported.
                Each procedure was performed by the same surgeon using standard techniques. Statistical analysis was by the chi-square method.
                In the APLD group only 9 of 31 (29%) had satisfactory outcomes as compared to 32 of 40 (80%) for the microdiscectomy group. Of those patients in the APLD group who had an unsatisfactory outcome and who then opted to undergo surgery (20 of 22 patients), the final success rate was only 65%. Thus, the cumulative success rate of the group initially randomized to APLD including those undergoing either APLD alone or APLD and microdiscectomy after unsuccessful APLD was 22 of 31 (71%).
                In this group of patients, APLD is seen to be ineffective in the treatment of contained lumbar disc herniation.
The finding that healing rates can be higher for cases treated surgically as compared to those treated non-surgically, at least in the short term, is based on two RCTs only. A single RCT reported that in the medium to long term healing rates for the two procedures are very similar. There is currently scarce evidence for a sound decision making process among alternative treatments for the re-treatment of a periradicular pathosis. More well-designed RCTs should be performed with follow up of at least 4 years, and with a consistent sample size, to detect a true difference in the long term between the outcomes of the two alternative treatments, if any exist.