bluuebunny/crossref_metadata_2025 huggingface dataset:
Proton magnetic resonance spectroscopy to evaluate spinal cord axonal injury in cervical spondylotic myelopathy
Authors: Holly Langston T. , Freitas Bonnie , McArthur David L. , Salamon Noriko
Published: February 2011

Object

Magnetic resonance spectroscopy is commonly used to provide cellular and metabolic information in the management of a variety of pathological processes that affect the brain, and its application recently has been expanded to the cervical spine. The majority of radiographic investigations into the pathophysiology of cervical spondylotic myelopathy (CSM) have been focused on the spinal cord macrostructure. The authors sought to determine the feasibility of using MR spectroscopy to analyze spinal cord biochemical function in patients with CSM.

Methods

Twenty-one patients with clinical and radiographic evidence of CSM were prospectively enrolled in this study. The patients underwent preoperative neurological examination, functional assessment, and cervical spine MR spectroscopy. Voxels were placed at the C-2 level, and the MR spectroscopy spectra peaks for N-acetylaspartate (NAA), choline, lactate (Lac), and creatine (Cr) were measured. Thirteen age-matched healthy volunteers served as controls.

Results

The NAA/Cr ratio was significantly lower in patients with CSM than in controls (1.27 vs 1.83, respectively, p < 0.0001). The choline/Cr ratio was not significantly different between the 2 groups. Seven of the patients with CSM had a Lac peak, whereas no peaks were noted in the control group (p < 0.05). There was no correlation between the severity of myelopathy and the NAA/Cr ratio in the CSM cohort.

Conclusions

Data in this study demonstrated the feasibility of using MR spectroscopy to evaluate the cellular biochemistry of the spinal cord in patients with CSM. Patients with CSM had a significantly lower NAA/Cr ratio than healthy controls, likely because of axonal and neuronal loss. The presence of Lac peaks in one-third of the patients in the CSM cohort further supports the role of ischemia in the pathophysiology of CSM.
Diagnosis and management of sacral tumors
Authors: Sciubba Daniel M. , Petteys Rory J. , Garces-Ambrossi Giannina L. , Noggle Joseph C. , McGirt Matthew J. , Wolinsky Jean-Paul , Witham Timothy F. , Gokaslan Ziya L.
Published: February 2011

Sacral tumors pose significant challenges to the managing physician from diagnostic and therapeutic perspectives. Although these tumors are often diagnosed at an advanced stage, patients may benefit from good clinical outcomes if an aggressive multidisciplinary approach is used. In this review, the epidemiology, clinical presentation, imaging characteristics, treatment options, and published outcomes are discussed. Special attention is given to the specific anatomical constraints that make tumors in this region of the spine more difficult to effectively manage than those in the mobile portions of the spine.
Spinal cord herniation after multilevel anterior cervical corpectomy and fusion for ossification of the posterior longitudinal ligament of the cervical spine
Authors: Min Jun-Hong , Jung Byung-Joo , Jang Jee-Soo , Kim Seok-Kang , Jung Dae-Jin , Lee Sang-Ho
Published: February 2011

The authors report the case of a 52-year-old man who had undergone resection of an ossified posterior longitudinal ligament via the anterior approach. The patient experienced postoperative neurological deterioration that may have been caused by a massive cord herniation associated with a dural defect at the corpectomy site.

Spinal cord herniation may develop as a complication of anterior cervical decompression. Surgeons should be alert to this condition when planning to treat cervical ossification of the ossified posterior longitudinal ligament via the anterior approach.
Reversal of longstanding musculoskeletal changes in basilar invagination after surgical decompression and stabilization
Authors: Goel Atul , Shah Abhidha
Published: February 2011

Object

The authors investigated the changes in the bone architecture and the characteristics of the neck and craniovertebral region in selected cases of basilar invagination. The reversal in these changes that occurred after decompression and fixation are analyzed. The implications of such an analysis in understanding the pathogenesis of a number of features that are characteristically associated with basilar invagination are evaluated.

Methods

One hundred and seventy selected patients with basilar invagination who underwent atlantoaxial joint distraction-fixation surgery at the authors' institution between 1999 and April 2008 were reviewed. The study was prospective after June 2006. A variety of parameters were used for radiological and physical assessments. The evaluation was done on the basis of pre- and postoperative imaging studies and clinical photographs. In the 41 prospective cases, additional direct physical measurements of the neck were performed.

Results

Prior to surgery there were several physical changes such as reduced neck length, torticollis, exaggerated lordosis of the cervical spine, and reduced craniospinal angulation. Other findings included reduced discspace height, significant posterior cervical osteophyte formation, assimilation of atlas (72%), single-level (29%) or multiple-level (3%) cervical fusions, and an increase in the spinal subarachnoid space both above and below the level of maximum neural compression at the tip of the odontoid process. After surgical decompression of the region, there was remarkable recovery in craniovertebral alignments, and an increase in neck length (maximum up to 42 mm) was obvious on physical and radiological examination in 85% of patients. The disc-space height increased and there was a reversal of altered cervical lordosis, craniospinal angulation (maximum up to 36°), and torticollis.

Conclusions

It appears that a number of physical spinal changes characteristically associated with basilar invagination such as a short neck, exaggerated neck lordosis, torticollis, cervical spondylotic changes and fusions are potentially reversible after decompression and stabilization of the craniovertebral junction.
Introduction and methodology: guidelines for the surgical management of cervical degenerative disease
Authors: Matz Paul G. , Anderson Paul A. , Kaiser Michael G. , Holly Langston T. , Groff Michael W. , Heary Robert F. , Mummaneni Praveen V. , Ryken Timothy C. , Choudhri Tanvir F. , Vresilovic Edward J. , Resnick Daniel K.
Published: February 2011

In March 2006, the Joint Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons and Congress of Neurological Surgeons compiled an expert group to perform an evidence-based review of the clinical literature on management of cervical degenerative spine disease. This process culminated in the formation of the Guidelines for the Surgical Management of Cervical Degenerative Disease. The purpose of the Guidelines was to address questions regarding the therapy, diagnosis, and prognosis of cervical degenerative disease using an evidence-based approach. Development of an evidence-based review and recommendations is a multitiered process. Typical guideline development consists of 5 processes: 1) collection and selection of the evidence; 2) assessment of the quality and strength of the evidence; 3) analysis of the evidentiary data; 4) formulation of recommendations; and 5) guideline validation. This manuscript details the methodology in compiling the Guidelines for the Surgical Management of Cervical Degenerative Disease.
Clinical prognostic indicators of surgical outcome in cervical spondylotic myelopathy
Authors: Holly Langston T. , Matz Paul G. , Anderson Paul A. , Groff Michael W. , Heary Robert F. , Kaiser Michael G. , Mummaneni Praveen V. , Ryken Timothy C. , Choudhri Tanvir F. , Vresilovic Edward J. , Resnick Daniel K.
Published: February 2011

Object

The objective of this systematic review was to use evidence-based medicine to assess whether clinical factors predict surgical outcomes in patients undergoing cervical surgery.

Methods

The National Library of Medicine and Cochrane Database were queried using MeSH headings and keywords relevant to clinical preoperative factors. Abstracts were reviewed, and studies that met the inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I–III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons.

Results

Preoperative sensory-evoked potentials may aid in providing prognostic information in selected patients in whom clinical factors do not provide clear guidance (Class II). Age, duration of symptoms, and preoperative neurological function may commonly affect outcome (Class III).

Conclusions

Age, duration of symptoms, and preoperative neurological function should be discussed with patients when surgical intervention for cervical spondylotic myelopathy is considered. Preoperative sensory-evoked potentials may be considered for patients in whom clinical factors do not provide clear guidance if such information would potentially change therapeutic decisions.
Cervical laminectomy for the treatment of cervical degenerative myelopathy
Authors: Ryken Timothy C. , Heary Robert F. , Matz Paul G. , Anderson Paul A. , Groff Michael W. , Holly Langston T. , Kaiser Michael G. , Mummaneni Praveen V. , Choudhri Tanvir F. , Vresilovic Edward J. , Resnick Daniel K.
Published: February 2011

Object

The objective of this systematic review was to use evidence-based medicine to examine the efficacy of cervical laminectomy for the treatment of cervical spondylotic myelopathy (CSM).

Methods

The National Library of Medicine and Cochrane Database were queried using MeSH headings and keywords relevant to cervical laminectomy and CSM. Abstracts were reviewed after which studies meeting inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I–III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons.

Results

Laminectomy has improved functional outcome for symptomatic cervical myelopathy (Class III). The limitations of the technique are an increased risk of postoperative kyphosis compared to anterior techniques or laminoplasty or laminectomy with fusion (Class III). However, the development of kyphosis may not necessarily to diminish the clinical outcome (Class III).

Conclusions

Laminectomy is an acceptable therapy for near-term functional improvement of CSM (Class III). It is associated with development of kyphosis, however.
Cervical laminoplasty for the treatment of cervical degenerative myelopathy
Authors: Matz Paul G. , Anderson Paul A. , Groff Michael W. , Heary Robert F. , Holly Langston T. , Kaiser Michael G. , Mummaneni Praveen V. , Ryken Timothy C. , Choudhri Tanvir F. , Vresilovic Edward J. , Resnick Daniel K.
Published: February 2011

Object

The objective of this systematic review was to use evidence-based medicine to examine the efficacy of cervical laminoplasty in the treatment of cervical spondylotic myelopathy (CSM).

Methods

The National Library of Medicine and Cochrane Database were queried using MeSH headings and keywords relevant to cervical laminoplasty and CSM. Abstracts were reviewed and studies meeting the inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I–III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons and Congress of Neurological Surgeons.

Results

Cervical laminoplasty has improved functional outcome in the setting of CSM or ossification of the posterior longitudinal ligament. Using the Japanese Orthopaedic Association scale score, ~ 55–60% average recovery rate has been observed (Class III). The functional improvement observed after laminoplasty may be limited by duration of symptoms, severity of stenosis, severity of myelopathy, and poorly controlled diabetes as negative risk factors (Class II). There is conflicting evidence regarding age, with 1 study citing it as a negative risk factor, and another not demonstrating this result.

Conclusions

Cervical laminoplasty is recommended for the treatment of CSM or ossification of the posterior longitudinal ligament (Class III).
An alternate method for placement of C-1 screws
Authors: Thomas J. Alex , Tredway Trent , Fessler Richard G. , Sandhu Faheem A.
Published: February 2011

Object

Several techniques for the surgical stabilization of the atlas and the axis have been described. Placement of C-1 lateral mass screws is one of the latest technical advances, and has gained popularity due to its efficacy and biomechanical advantages. However, the technique for placement of C-1 lateral mass screws, as first described by Harms, can cause excessive bleeding or irritation of the C-2 nerve. An alternative technique is available for the placement of C-1 lateral mass screws that completely avoids the C-2 nerve/ganglion and its associated venous plexus. This new technique mitigates some of the risk associated with the Harms techniques and eliminates the need to use specialized screws (that is, smooth shanks).

Methods

Twenty-six patients underwent atlantoaxial or occipitocervical fusions incorporating the alternative technique of C-1 screw placement. Three surgeons at 3 different institutions performed the surgeries. Standard lateral fluoroscopy and fully threaded polyaxial screws were used in each case.

Results

Forty-nine screws were placed in C-1 lateral masses by using the new technique. Solid arthrodesis was achieved in all cases, with a mean follow-up period of 30 months. There were no cases of CSF leakage, new neurological deficit, injury to the C-2 ganglion, vertebral artery injury, or hardware failures.

Conclusions

The technique is a safe and effective way to fixate C-1 while avoiding the C-2 nerve/ganglion and venous plexus. The results indicate that excellent clinical and radiographic outcomes can be achieved with this new technique.
Effects of age on perioperative complications of extensive multilevel thoracolumbar spinal fusion surgery
Authors: Cloyd Jordan M. , Acosta Frank L. , Cloyd Colleen , Ames Christopher P.
Published: February 2011

Object

The elderly compose a substantial proportion of patients presenting with complex spinal pathology. Several recent studies have suggested that fusion of 4 or more levels increases the risk of perioperative complications in elderly patients. Therefore, the purpose of this study was to analyze the effects of age in persons undergoing multilevel (≥ 5 levels) thoracolumbar fusion surgery.

Methods

A retrospective review of all hospital records, operative reports, and clinic notes was conducted for 124 consecutive patients who underwent surgery between 2000 and 2007 with an average follow-up of 3.5 years and a minimum follow-up of 1.2 years. The most frequent preoperative diagnoses included scoliosis, tumor, osteomyelitis, vertebral fracture, and degenerative disc disease with stenosis. Complications were classified as intraoperative and major and minor postoperative as well as the need for revision surgery. Multivariate logistic regression analysis was used to determine the effects of age and other potentially prognostic factors.

Results

After controlling for other factors, increasing age was associated with an elevated risk for major postoperative complications (OR 1.04, 95% CI 1.00–1.10) as were increasing levels of fusion (OR 1.5, 95% CI 1.1–2.1) and male sex (OR 4.6, 95% CI 1.3–16.2). In patients 65 years of age or older, rates of intraoperative complications, major and minor postoperative complications, and reoperation were 14.1, 23.4, 29.7, and 26.6%, respectively. The number of comorbidities was associated with a greater risk for perioperative complications in elderly patients (OR 1.8, 95% CI 1.1–2.8).

Conclusions

Age is a positive risk factor for major postoperative complications in extensive thoracolumbar spinal fusion surgery. Complication rates in the elderly are high, and good clinical judgment and careful patient selection are needed before performing extensive thoracolumbar reconstruction in older persons.
Using magnetic resonance imaging to accurately assess injury to the posterior ligamentous complex of the spine: a prospective comparison of the surgeon and radiologist
Authors: Rihn Jeffrey A. , Yang Nuo , Fisher Charles , Saravanja Davor , Smith Harvey , Morrison William B. , Harrop James , Vacaro Alexander R.
Published: February 2011

Object

Magnetic resonance imaging has been proposed as a powerful technique for assessing the integrity of the posterior ligamentous complex (PLC) in spinal trauma. Because MR imaging is often used to determine appropriate treatment, it is important to determine the accuracy and reliability of MR imaging in diagnosing PLC disruption. The purpose of this study is to compare the ability of the radiologist and surgeon to assess disruption of the PLC in the setting of acute cervical and thoracolumbar trauma using MR imaging.

Methods

The components of the PLC in 89 consecutive patients with cervical or thoracolumbar fractures following acute spinal trauma were evaluated using MR imaging by both a musculoskeletal radiologist and an independent spine surgeon and assessed intraoperatively under direct visualization by the treating surgeon. The MR imaging interpretations of the musculoskeletal radiologist and surgeon were compared with the intraoperative report for accuracy, sensitivity, specificity, and positive and negative predictive values. A comparison between the radiologist's and spine surgeon's accuracy of MR imaging interpretation was performed.

Results

The agreement between both the spine surgeon's and radiologist's MR imaging interpretation and the actual intraoperative findings was moderate for most components of the PLC. Overall, the MR imaging interpretation of the surgeon was more accurate than that of the radiologist. The interpretation of MR imaging by the surgeon had negative predictive value and sensitivity of up to 100%. However, the specificity of MR imaging for both the surgeon and radiologist was lower, ranging from 51.5 to 80.5%.

Conclusions

Comparison of the MR imaging interpretations between surgeon and radiologist indicates that the surgeon was more accurate for some PLC components. The relatively low positive predictive value and specificity for MR imaging in assessing PLC integrity suggests that both the surgeon and radiologist tend to overdiagnose PLC injury using MR imaging. This can lead to unnecessary surgeries if only MR imaging is used for treatment decision making.
Extreme-lateral, minimally invasive, transpsoas approach for the treatment of far-lateral lumbar disc herniation
Authors: Madhok Ricky , Kanter Adam S.
Published: February 2011

The authors present 2 cases of far-lateral lumbar disc herniations treated surgically via an extreme-lateral transpsoas approach. The procedure was performed using the MaXcess minimally invasive retractor system to access and successfully remove the disc fragments without complication. To the authors' knowledge, these are the first reported cases of using a minimally invasive retroperitoneal approach for the treatment of far-lateral disc herniations.
Setup accuracy of spine radiosurgery using cone beam computed tomography image guidance in patients with spinal implants
Authors: Gerszten Peter C. , Monaco Edward A. , Quader Mubina , Novotny Josef , Kim Jong Oh , Flickinger John C. , Huq M. Saiful
Published: February 2011

Object

Cone beam computed tomography (CBCT) image guidance technology has been adopted for use in spine radiosurgery. There is concern regarding the ability to safely and accurately perform spine radiosurgery without the use of implanted fiducials for image guidance in postsurgical cases in which titanium instrumentation and/or methylmethacrylate (MMA) has been implanted. In this study the authors prospectively evaluated the accuracy of the patient setup for spine radiosurgery by using CBCT image guidance in the context of orthopedic hardware at the site of disease.

Methods

The positioning deviations of 31 single-fraction spine radiosurgery treatments in patients with spinal implants were prospectively evaluated using the Elekta Synergy S 6-MV linear accelerator with a beam modulator and CBCT image guidance combined with a robotic couch that allows positioning correction in 3 translational and 3 rotational directions. To measure patient movement, 3 quality-assurance CBCT studies were performed and recorded: before, halfway through, and after radiosurgical treatment. The positioning data and fused images of planning CTs and CBCTs from the treatments were analyzed to determine intrafractional patient movements. From each of 3 CBCTs, 3 translational and 3 rotational coordinates were obtained.

Results

The prescribed dose to the gross tumor volume for the cohort was 12–18 Gy (mean 14 Gy) utilizing 9–14 coplanar intensity-modulated radiation therapy (IMRT) beams (mean 10 beams). At the halfway point of the radiosurgery, the translational variations and standard deviations were 0.6 ± 0.6, 0.4 ± 0.4, and 0.5 ± 0.5 mm in the lateral (X), longitudinal (Y), and anteroposterior (Z) directions, respectively. The magnitude of the 3D vector (X,Y,Z) was 1.1 ± 0.7 mm. Similarly, the variations immediately after treatment were 0.5 ± 0.3, 0.4 ± 0.4, and 0.5 ± 0.6 mm along the X, Y, and Z directions, respectively. The 3D vector was 1.0 ± 0.6 mm. The mean rotational angles were 0.3 ± 0.4, 0.5 ± 0.6, and 0.3 ± 0.4° along yaw, roll, and pitch, respectively, at the halfway point and 0.3 ± 0.4, 0.6 ± 0.6, and 0.4 ± 0.5° immediately after treatment.

Conclusions

Cone beam CT image guidance used for patient setup for spine radiosurgery was highly accurate despite the presence of spinal instrumentation and/or MMA at the level of the target volume. The presence of such spinal implants does not preclude safe treatment via spine radiosurgery in these patients.
Biomechanics of a lumbar interspinous anchor with anterior lumbar interbody fusion
Authors: Karahalios Dean G. , Kaibara Taro , Porter Randall W. , Kakarla Udaya K. , Reyes Phillip M. , Baaj Ali A. , Yaqoobi Ali S. , Crawford Neil R.
Published: February 2011

Object

An interspinous anchor (ISA) provides fixation to the lumbar spine to facilitate fusion. The biomechanical stability provided by the Aspen ISA was studied in applications utilizing an anterior lumbar interbody fusion (ALIF) construct.

Methods

Seven human cadaveric L3–S1 specimens were tested in the following states: 1) intact; 2) after placing an ISA at L4–5; 3) after ALIF with an ISA; 4) after ALIF with an ISA and anterior screw/plate fixation system; 5) after removing the ISA (ALIF with plate only); 6) after removing the plate (ALIF only); and 7) after applying bilateral pedicle screws and rods. Pure moments (7.5 Nm maximum) were applied in flexion and extension, lateral bending, and axial rotation while recording angular motion optoelectronically. Changes in angulation as well as foraminal height were also measured.

Results

All instrumentation variances except ALIF alone reduced angular range of motion (ROM) significantly from normal in all directions of loading. The ISA was most effective in limiting flexion and extension (25% of normal) and less effective in reducing lateral bending (71% of normal) and axial rotation (71% of normal). Overall, ALIF with an ISA provided stability that was statistically equivalent to ALIF with bilateral pedicle screws and rods. An ISA-augmented ALIF allowed less ROM than plate-augmented ALIF during flexion, extension, and lateral bending. Use of the ISA resulted in flexion at the index level, with a resultant increase in foraminal height. Compensatory extension at the adjacent levels prevented any significant change in overall sagittal balance.

Conclusions

When used with ALIF at L4–5, the ISA provides immediate rigid immobilization of the lumbar spine, allowing equivalent ROM to that of a pedicle screw/rod system, and smaller ROM than an anterior plate. When used with ALIF, the ISA may offer an alternative to anterior plate fixation or bilateral pedicle screw/rod constructs.
Atypical spine involvement of Erdheim-Chester disease in an elderly male
Authors: Allmendinger Andrew M. , Krauthamer Alan V. , Spektor Vadim , Aziz Mohamed S. , Zablow Bruce
Published: February 2011

Erdheim-Chester disease is a rare form of non-Langerhans histiocytosis presenting in the 5th through 7th decades of life. Osseous manifestations include symmetrical sclerosis of the long bones and, rarely, the spine. Central nervous system disease commonly affects the white matter tracts as well as the orbits, but epidural disease is rare. To the best of the authors' knowledge, simultaneous epidural and skeletal spine disease has not been reported. The MR imaging characteristics of skeletal spine disease have also not been reported. The authors describe the case of an 87-year-old man with both epidural and skeletal spine disease. The clinical characteristics, imaging manifestations, and the histological features are discussed.
The anatomy, spatial relationships, and role of uncovertebral articulations as the source of posterolateral cervical cartilage sequestrations
Authors: Browne Kenneth M.
Published: February 2011

Object

The aim of this study was to investigate the spatial relationships of the uncovertebral articulations (UAs) with the dural origins of the C-5, C-6, and C-7 nerve roots.

Methods

The C3–7 segment of the cervical spine was removed from 18 embalmed cadavers. Spatial relationships between the C-5, C-6, and C-7 nerve roots and the UAs were examined using combinations of standard surgical approaches together with cross-sections at the level of the dural origins of the nerve roots and exposures of the floor of the spinal canal.

Results

The cartilaginous interspace that underlies the dural origin of a nerve root is the interspace of a UA. It is interposed between the central core cartilage of the disc and the dural origin of a nerve root. Cervical nerve roots do not come in contact with the interspace of an intervertebral disc at any site from their dural origin to their exit from the spinal canal. A cartilage fragment that originates from the central core cartilage of the disc may compress the intradural segment of the nerve root by migrating to that site within the epidural space, but it is blocked from reaching the dural origin of a nerve root by the interspace of a UA that is filled with fibrocartilage.

Conclusions

Anatomical considerations indicate that the source of posterolateral cervical cartilage sequestrations is the cartilaginous interspace of a UA rather than that of an intervertebral disc.
Image-guided, endoscopic, transcervical resection of cervical chordoma
Authors: Hsu Wesley , Kosztowski Thomas A. , Zaidi Hasan A. , Gokaslan Ziya L. , Wolinsky Jean-Paul
Published: February 2011

Chordomas are rare tumors that arise from the sacrum, spine, and skull base. Surgical management of these tumors can be difficult, given their locally destructive behavior and predilection for growing near delicate and critical structures. En bloc resection with negative margins can be difficult to perform without damaging adjacent structures and causing significant clinical morbidity. For chordomas of the upper cervical spine, surgical options traditionally involve transoral or submandibular approaches. The authors report the use of the image-guided, endoscopic, transcervical approach to the upper cervical spine as an alternative to traditional techniques for addressing upper cervical spine tumors, particularly for tumors where gross-total resection is not feasible.
Functional outcome after resection of spinal cord hemangioblastomas associated with von Hippel-Lindau disease
Authors: Mehta Gautam U. , Asthagiri Ashok R. , Bakhtian Kamran D. , Auh Sungyoung , Oldfield Edward H. , Lonser Russell R.
Published: February 2011

Object

Spinal cord hemangioblastomas are a common protean manifestation of von Hippel-Lindau (VHL) disease and can be associated with significant morbidity. To better define expected outcome and optimal management of these tumors in the context of this neoplasia syndrome, the authors analyzed the findings from patients with VHL disease who underwent resection of spinal cord hemangioblastomas.

Methods

Consecutive patients with VHL disease who underwent surgery for spinal cord hemangioblastomas with > 6 months follow-up were included in the study. Serial clinical examinations, functional scores, imaging findings, and operative records were analyzed.

Results

One hundred eight patients (57 male, 51 female) underwent 156 operations for resection of 218 spinal cord hemangioblastomas. One hundred forty-six operations (94%) were performed for symptom-producing tumors. The most common presenting symptoms included hypesthesia (64% of resections), hyperreflexia (57%), dysesthesia (43%), and weakness (36%). Mean follow-up was 7.0 ± 5.0 years (range 0.5–20.9 years). Complete resection was achieved for 217 tumors (99.5%). At 6-months follow-up, patients were stable or improved after 149 operations (96%) and worse after 7 operations (4%). Ventral tumors (OR 15.66, 95% CI 2.54–96.45; p = 0.003) or completely intramedullary tumors (OR 10.74, 95% CI 2.07–55.66; p = 0.005) were associated with an increased risk of postoperative worsening. The proportion of patients remaining functionally stable at 2, 5, 10, and 15 years' follow-up was 93, 86, 78, and 78%. Long-term functional decline was caused by extensive VHL-associated CNS disease (6 patients), VHL-associated visceral disease (1 patient), or non-VHL disease (2 patients).

Conclusions

Resection of symptomatic spinal cord hemangioblastomas is a safe and effective means of preserving neurological function in patients with VHL disease. Tumor location (ventral or completely intramedullary) can be used to assess functional risk associated with surgery. Long-term decline in neurological function is usually caused by VHL-associated disease progression.
Cervical spondylotic myelopathy associated with kyphosis or sagittal sigmoid alignment: outcome after anterior or posterior decompression
Authors: Uchida Kenzo , Nakajima Hideaki , Sato Ryuichiro , Yayama Takafumi , Mwaka Erisa S. , Kobayashi Shigeru , Baba Hisatoshi
Published: February 2011

Object

The effects of sagittal kyphotic deformities or mechanical stress on the development of cervical spondylotic myelopathy, or the reduction and fusion of kyphotic sagittal alignment have not been consistently documented. The aim in this study was to determine the effects of kyphotic sagittal alignment of the cervical spine in terms of neurological morbidity and outcome after 2 types of surgical intervention.

Methods

The authors retrospectively reviewed the records of 476 patients who underwent cervical spine surgeries for spondylotic myelopathy between 1993 and 2006 at their university medical center. Among these were identified 43 patients—30 men and 13 women, with a mean age of 58.8 years—who had cervical kyphosis exceeding 10° on preoperative sagittal lateral radiographs obtained in the neutral position, and their cases were analyzed in this study. Anterior decompression with interbody fusion was conducted in 28 patients, and en bloc open-door C3–7 laminoplasty in 15 patients. Both pre- and postoperative neurological, radiographic, and MR imaging findings were assessed in both surgical groups.

Results

The mean preoperative kyphotic angle in all 43 patients was 15.9 ± 5.9° in the neutral position. Segmental instability was noted in 26 patients (61%) and reversed dynamic spinal canal stenosis at the level above the local kyphosis in 22 (51%). Preoperative T2-weighted MR images showed high-intensity signal within the cord at and around the level of maximal compression or segmental instability in 28 patients (65%). The mean kyphotic angle in both the neutral and flexion positions was significantly smaller at 4–6 weeks after surgery in the anterior spondylectomy group than in the laminoplasty group (p < 0.001). Furthermore, the angle in the neutral position was significantly smaller on follow-up in the anterior spondylectomy group than in the laminoplasty group (p = 0.034). The transverse area of the spinal cord was significantly larger in the anterior spondylectomy group than in the laminoplasty group on follow-up (p = 0.037). Preoperative neurological scores (assessed using the Japanese Orthopaedic Association scale) and improvement on follow-up ≥ 2 years after treatment (average 3.3 years) were not significantly different between the 2 groups; however, there was a significant difference in Japanese Orthopaedic Association score at 4–6 weeks postoperatively (p = 0.047).

Conclusions

Kyphotic deformity and mechanical stress in the cervical spine may play an important role in neurological dysfunction. In a select group of patients with kyphotic deformity ≥ 10°, adequate correction of local sagittal alignment may help to maximize the chance of neurological improvement.
Functional outcomes assessment for cervical degenerative disease
Authors: Holly Langston T. , Matz Paul G. , Anderson Paul A. , Groff Michael W. , Heary Robert F. , Kaiser Michael G. , Mummaneni Praveen V. , Ryken Timothy C. , Choudhri Tanvir F. , Vresilovic Edward J. , Resnick Daniel K.
Published: February 2011

Object

The objective of this systematic review was to use evidence-based medicine to identify valid, reliable, and responsive measures of functional outcome after treatment for cervical degenerative disease.

Methods

The National Library of Medicine and Cochrane Database were queried using MeSH headings and key words relevant to functional outcomes. Abstracts were reviewed after which studies meeting inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I–III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons.

Results

Myelopathy Disability Index, Japanese Orthopaedic Association scale, 36-Item Short Form Health Survey, and gait analysis were found to be valid and reliable measures (Class II) for assessing cervical spondylotic myelopathy. The Patient-Specific Functional Scale, the North American Spine Society scale, and the Neck Disability Index were found to be reliable, valid, and responsive (Class II) for assessing radiculopathy for nonoperative therapy. The Cervical Spine Outcomes Questionnaire was a reliable and valid method (Class II) to assess operative therapy for cervical radiculopathy.

Conclusions

Several functional outcome measures are available to assess cervical spondylotic myelopathy and cervical radiculopathy.
Laminectomy and fusion for the treatment of cervical degenerative myelopathy
Authors: Anderson Paul A. , Matz Paul G. , Groff Michael W. , Heary Robert F. , Holly Langston T. , Kaiser Michael G. , Mummaneni Praveen V. , Ryken Timothy C. , Choudhri Tanvir F. , Vresilovic Edward J. , Resnick Daniel K.
Published: February 2011

Object

The objective of this systematic review was to use evidence-based medicine to examine the efficacy of cervical laminectomy and fusion for the treatment of cervical spondylotic myelopathy (CSM).

Methods

The National Library of Medicine and Cochrane Database were queried using MeSH headings and keywords relevant to cervical laminectomy, fusion, and CSM. Abstracts were reviewed, after which studies that met the inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Class I–III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations which contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer-review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons.

Results

Cervical laminectomy with fusion (arthrodesis) improves functional outcome in patients with CSM and ossification of the posterior longitudinal ligament (OPLL). Functional improvement is similar to laminectomy or laminoplasty for patients with CSM and OPLL. In contrast to laminectomy, cervical laminectomy with fusion it is not associated with late deformity (Class III).

Conclusions

Laminectomy with fusion (arthrodesis) is an effective strategy to improve functional outcome in CSM and OPLL.
Electrophysiological monitoring during surgery for cervical degenerative myelopathy and radiculopathy
Authors: Resnick Daniel K. , Anderson Paul A. , Kaiser Michael G. , Groff Michael W. , Heary Robert F. , Holly Langston T. , Mummaneni Praveen V. , Ryken Timothy C. , Choudhri Tanvir F. , Vresilovic Edward J. , Matz Paul G.
Published: February 2011

Object

The objective of this systematic review was to use evidence-based medicine to examine the diagnostic and therapeutic utility of intraoperative electrophysiological (EP) monitoring in the surgical treatment of cervical degenerative disease.

Methods

The National Library of Medicine and Cochrane Database were queried using MeSH headings and key words relevant to cervical spine surgery and EP monitoring. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I–III). The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons.

Results

The reliance on changes in EP monitoring as an indication to alter a surgical plan or administer steroids has not been observed to reduce the incidence of neurological injury during routine surgery for cervical spondylotic myelopathy or cervical radiculopathy (Class III). However, there is an absence of study data examining the benefit of altering a surgical plan due to EP changes.

Conclusions

Although the use of EP monitoring may serve as a sensitive means to diagnose potential neurological injury during anterior spinal surgery for cervical spondylotic myelopathy, the practitioner must understand that intraoperative EP worsening is not specific—it may not represent clinical worsening and its recognition does not necessarily prevent neurological injury, nor does it result in improved outcome (Class II). Intraoperative improvement in EP parameters/indices does not appear to forecast outcome with reliability (conflicting Class I data).
Thoracolumbar spinal deformity: Part I. A historical passage to 1990
Authors: Kanter Adam S. , Bradford David S. , Okonkwo David O. , Rengachary Setti S. , Mummaneni Praveen V.
Published: February 2011

Seven millennia of anthropological artifacts and historical tales reference human spinal deformity, its diagnosis, and treatment—many of the latter of which turned out to be worse than the deformity itself. From Hippocrates to Harrington to the 21st century, the literature base has expanded in exponential fashion to yield an imperfect but constantly improving body of evidence, experience, and understanding of this challenging disease phenomenon. This review details the pre-1990 innovations, whose failures and successes have equally contributed to the advancement and dissemination of the increasingly evidence-based field of spinal deformity.
Preoperative patient selection with magnetic resonance imaging, computed tomography, and electroencephalography: does the test predict outcome after cervical surgery?
Authors: Mummaneni Praveen V. , Kaiser Michael G. , Matz Paul G. , Anderson Paul A. , Groff Michael , Heary Robert , Holly Langston , Ryken Timothy , Choudhri Tanvir , Vresilovic Edward , Resnick Daniel
Published: February 2011

Object

The objective of this systematic review was to use evidence-based medicine to assess whether preoperative imaging or electromyography (EMG) predicts surgical outcomes in patients undergoing cervical surgery.

Methods

The National Library of Medicine and Cochrane Database were queried using MeSH headings and keywords relevant to the preoperative imaging and EMG. Abstracts were reviewed after which studies meeting inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I–III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons.

Results

Preoperative MR imaging and CT myelography are successful in confirming clinical radiculopathy (Class II). Multilevel T2 hyperintensity, T1 focal hypointensity combined with T2 focal hyperintensity, and spinal cord atrophy each convey a poor prognosis (Class III). There is conflicting data concerning whether focal T2 hyperintensity or cervical stenosis are associated with a worse outcome. Electromyography has mixed utility in predicting outcome (Class III).

Conclusions

Magnetic resonance imaging or CT myelography are important for preoperative assessment. Magnetic resonance imaging may be helpful in assessing prognosis, whereas EMG has mixed utility in assessing outcome.
Anterior cervical surgery for the treatment of cervical degenerative myelopathy
Authors: Matz Paul G. , Holly Langston T. , Mummaneni Praveen V. , Anderson Paul A. , Groff Michael W. , Heary Robert F. , Kaiser Michael G. , Ryken Timothy C. , Choudhri Tanvir F. , Vresilovic Edward J. , Resnick Daniel K.
Published: February 2011

Object

The objective of this systematic review was to use evidence-based medicine to examine the efficacy of anterior cervical surgery for the treatment of cervical spondylotic myelopathy (CSM).

Methods

The National Library of Medicine and Cochrane Database were queried using MeSH headings and key words relevant to anterior cervical surgery and CSM. Abstracts were reviewed, and studies meeting inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I–III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons.

Results

Mild CSM (modified Japanese Orthopaedic Association [mJOA] scale scores > 12) responds in the short term (3 years) to either surgical decompression or nonoperative therapy (prolonged immobilization in a stiff cervical collar, “low-risk” activity modification or bed rest, and antiinflammatory medications) (Class II). More severe CSM responds to surgical decompression with benefits being maintained a minimum of 5 years and as long as 15 years postoperatively (Class III).

Conclusions

Treatment of mild CSM may involve surgical decompression or nonoperative therapy for the first 3 years after diagnosis. More severe CSM (mJOA scale score ≤ 12) should be considered for surgery depending upon the individual case. The shortcomings of this systematic review are that the group was not able to determine whether an mJOA scale score of 12 was indicative of a more severe CSM disease course, and whether patients who received nonsurgical treatment for 3 years had a significant probability for clinical deterioration after that time point.
Cervical surgical techniques for the treatment of cervical spondylotic myelopathy
Authors: Mummaneni Praveen V. , Kaiser Michael G. , Matz Paul G. , Anderson Paul A. , Groff Michael W. , Heary Robert F. , Holly Langston T. , Ryken Timothy C. , Choudhri Tanvir F. , Vresilovic Edward J. , Resnick Daniel K.
Published: February 2011

Object

The objective of this systematic review was to use evidence-based medicine to compare the efficacy of different surgical techniques for the treatment of cervical spondylotic myelopathy (CSM).

Methods

The National Library of Medicine and Cochrane Database were queried using MeSH headings and keywords relevant to anterior and posterior cervical spine surgery and CSM. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I–III). The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons.

Results

A variety of techniques have improved functional outcome after surgical treatment for CSM, including anterior cervical discectomy with fusion (ACDF), anterior cervical corpectomy with fusion (ACCF), laminoplasty, laminectomy, and laminectomy with fusion (Class III). Anterior cervical discectomy with fusion and ACCF appear to yield similar results in multilevel spine decompression for lesions at the disc level. The use of anterior plating allows for equivalent fusion rates between these techniques (Class III). If anterior fixation is not used, ACCF may provide a higher fusion rate than multilevel ACDF but also a higher graft failure rate than multilevel ACDF (Class III). Anterior cervical discectomy with fusion, ACCF, laminectomy, laminoplasty, and laminectomy with arthrodesis all provide near-term functional improvement for CSM. However, laminectomy is associated with late deterioration compared with the other types of anterior and posterior surgeries (Class III).

Conclusions

Multiple approaches exist with similar near-term improvements; however, laminectomy appears to have a late deterioration rate that may need to be considered when appropriate.
Iatrogenic intradural spinal arachnoid cyst as a complication of lumbar spine surgery
Authors: Nottmeier Eric W. , Wharen Robert E. , Patel Naresh P.
Published: February 2011

Iatrogenic spinal arachnoid cysts are rare, but have been described as a complication of spinal injection and lumbar puncture procedures. The authors describe 2 cases of iatrogenic spinal arachnoid cyst formation that occurred after incidental durotomy during lumbar spine surgery. In both cases, postoperative MR imaging revealed compression of the cauda equina by an intradural arachnoid cyst. Intradural exploration and fenestration of the arachnoid cyst was accomplished in each case. This entity should be considered in the differential diagnosis of a patient experiencing symptoms of neurological compression after a lumbar surgery complicated by incidental durotomy.