Category: Spine

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Outcome After Surgical Treatment for Lumbar Spinal Stenosis. The Lumbar Extension Test Is Not a Predictive Factor

Spine 2009;34:E930–E935

Study Design. A prospective clinical study.

Objectives. To investigate the predictive value of the lumbar extension test for outcome after surgical treatment of lumbar spinal stenosis (LSS).

Summary of Background Data. Studies have indicated that aggravation of the symptoms from LSS by extension of the lumbar spine has predictive value for the outcome after decompression. The aim of this study was to investigate this theory in a larger group of patients.

Methods. One hundred forty-six consecutive patients surgically treated for LSS were included in the study. The clinical condition was recorded before surgery and at 3, 6, 12, and 24 months after surgery using 3 different scoring systems: Swiss Spinal Stenosis Questionnaire, Neurogenic Claudication Outcome Score, and Oswestry Disability Index. The group of patients with preoperative aggravation of the symptoms by the lumbar extension test, (positive extension test), was compared with the group of patients without aggravation by the test, (negative extension test).

Results. Before surgery, patients with a positive extension test scored significantly worse on all disability scoring systems than patients with a negative test. However, the extension test itself had no prognostic value for the overall outcome after lumbar decompression. Using regression models with the 2-year Oswestry Disability Index as dependent variable, only before surgery self-reported health and age were found to have prognostic significance.

Conclusion. The lumbar extension test has no predictive value for the outcome after surgical treatment of LSS

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Aceclofenac–tizanidine in the treatment of acute low back pain: a double-blind, double-dummy, randomized, multicentric, comparative study against aceclofenac alone

Eur Spine J (2009) 18:1836–1842DOI 10.1007/s00586-009-1019-4

Tizanidine and aceclofenac individually have shown efficacy in the treatment of low back pain. The efficacy and tolerability of the combination have not yet been established.

The objective of the study was to evaluate the efficacy and safety of aceclofenac-tizanidine fixed dose combination against aceclofenac alone in patients with acute low back pain.

This double-blind, double-dummy, randomized, comparative, multicentric, parallel group study enrolled 197 patients of either sex in the age range of 18–70 years with acute low back pain. The patients were randomized to receive either aceclofenac (100 mg)–tizanidine (2 mg) b.i.d or aceclofenac (100 mg) alone b.i.d for 7 days. The primary efficacy outcomes were pain intensity (on movement, at rest and at night; on VAS scale) and pain relief (on a 5-point verbal rating scale). The secondary efficacy outcomes measures included functional impairment (modified Schober’s test and lateral body bending test) and patient’s and investigator’s global efficacy assessment.

Aceclofenac–tizanidine was significantly superior to aceclofenac for pain intensity (on movement, at rest and at night; P < 0.05) and pain relief (P = 0.00) on days 3 and 7. There was significant increase in spinal flexion in both the groups from baseline on days 3 and 7 with significant difference in favour of the combination group (P < 0.05). There were significantly more number of patients with excellent to good response for the aceclofenac–tizanidine treatment as compared to aceclofenac alone (P = 0.00). Both the treatments were well tolerated.

In this study, aceclofenac–tizanidine combination was more effective than aceclofenac alone and had a favourable safety profile in the treatment of acute low back pain.

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The Efficacy of Plate Construct Augmentation Versus Cage Alone in Anterior Cervical Fusion

Spine 2009 Dec 15;34(26):2886-92.DOI: 10.1097/BRS.0b013e3181b64f2c

Study Design. Retrospective study.
Objective. To compare the efficacy of anterior cervical discectomy and fusion with cage alone (ACDF-CA) with cage and plate construct (ACDF-CPC) in regards to fusion rate, radiologic and clinical outcomes.
Summary of Background Data. ACDF-CA has shown good results; however, debate exists regarding the high rate of complications such as pseudarthrosis, subsidence, and local kyphosis. In an attempt to avoid these complications, the authors have performed ACDF with cage and plate construct (ACDF-CPC).
Methods. A total of 78 consecutive patients who underwent 1- or 2-level ACDF-CA or ACDF-CPC suffering from cervical radiculopathy were divided into 2 groups; Group A (n = 38) underwent ACDF-CA; Group B (n = 40) underwent ACDF-CPC. Fusion rate, segmental kyphosis, disc height, and subsidence rate were assessed by radiographs. Clinical outcomes were assessed using Robinson criteria.
Results. Solid fusion was achieved in 78.9% (30/38) of subjects in group A compared to 97.5% (39/40) of subjects in group B (P = 0.01). Segmental kyphosis was noted in 42.1% (16/38) in group A compared with 10% (4/40) in group B (P < 0.01). There was a significant decrease in disc height in group A compared to group B (P < 0.05). Subsidence occurred in 32.3% (19/59 levels) of group A compared with 9.7% (6/62 levels) of group B (P < 0.01). Clinical outcomes were similar for both treatment groups. The pseudarthrosis rate in group A was higher than that in group B (P = 0.01). Revision surgery was required in 10.5% (4/38) of group A, whereas none of group B required reoperation (P < 0.01).
Conclusion. The use of cage and plate construct in 1- or 2-level ACDF results in a more lordotic alignment, an increased disc height, a higher fusion rate, a lower subsidence rate, and a lower complication rate than that of cage alone; however, there is no significant difference in clinical outcome between groups

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Understanding inconsistencies in patient-reported outcomes after spine treatment: response shift phenomena

Not uncommonly, spine surgeons and physiatrists note a mismatch between patient-reported outcome measures, where one measure might indicate a good outcome and another indicates an inferior outcome after spine treatment. This may be the result of patient characteristics that lead to changes in internal standards, values, and conceptualization of their own health-related quality of life. This can result in a ‘‘moving goal post’’ when a self-report outcome measure is used for prepost comparisons. These ‘‘response shifts’’ may obfuscate relevant changes of interest to clinicians and are meaningful and worthy of study in and of themselves.

PURPOSE: To provide a background on response shift with an emphasis on distinctions relevant to spinal interventions, both surgical and nonsurgical. To describe current methods for detecting and investigating response shift phenomena, and to propose specific hypotheses that can be tested in collaborative research. METHODS AND RESULTS: Two types of methods will be briefly described: methods that require new data collection; and methods that use recent statistical and technical advances to implement secondary analysis of existing data. Two specific testable hypotheses for spinal disorders are suggested along with suggested methods for testing these hypotheses. CONCLUSIONS: A response shift will cause the patient to use the same functional outcome report measure differently pre- and posttreatment. Response shift phenomena are likely to affect the measurement properties of standard spine outcome measures and to obfuscate differences between treatments in clinical trials and cost-effectiveness studies. They point to a need for developing strategies in clinical practice to manage response shifts so that they enhance patient well-being.

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Effective lordosis: analysis of sagittal spinal canal alignment in cervical spondylotic myelopathy

J Neurosurg Spine 11:667–672, 2009. (DOI: 10.3171/2009.7.SPINE08656)

Object. Analysis of cervical sagittal deformity in patients with cervical spondylotic myelopathy (CSM) requires a thorough clinical and radiographic evaluation to select the most appropriate surgical approach. Angular radiographic measurements, which are commonly used to define sagittal deformity, may not be the most appropriate to use for surgical planning. The authors present a simple straight-line method to measure effective spinal canal lordosis and analyze its reliability. Furthermore, comparisons of this measurement to traditional angular measurements of sagittal cervical alignment are made in regards to surgical planning in patients with CSM.

Methods. Twenty preoperative lateral cervical digital radiographs of patients with CSM were analyzed by 3 independent observers on 3 separate occasions using a software measurement program. Sagittal measurements included C2–7 angles utilizing the Cobb and posterior tangent methods, as well as a straight-line method to measure effective spinal canal lordosis from the dorsal-caudal aspect of the C2–7 vertebral bodies. Analysis of variance for repeated measures or Cohen 3-way (kappa) correlation coefficient analysis was performed as appropriate to calculate the intra and interobserver reliability for each parameter. Discrepancies in angular and effective lordosis measurements were analyzed.

Results. Intra and interobserver reliability was excellent (intraclass coefficient > 0.75, kappa > 0.90) utilizing all 3 techniques. Four discrepancies between angular and effective lordotic measurements occurred in which images with a lordotic angular measurement did not have lordosis within the ventral spinal canal. These discrepancies were caused by either spondylolisthesis or dorsally projecting osteophytes in all cases.

Conclusions. Although they are reliable, traditional methods used to make angular measurements of sagittal cervical spine alignment do not take into account ventral obstructions to the spinal cord. The effective lordosis measurement method provides a simple and reliable means of determining clinically significant lordosis because it accounts for both overall alignment of the cervical spine as well as impinging structures ventral to the spinal cord. This method should be considered for use in the treatment of patients with CSM.


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No effect of traction in patients with low back pain: a single centre, single blind, randomized controlled trial of Intervertebral Differential Dynamics Therapy

Eur Spine J (2009) 18:1843–1850 DOI 10.1007/s00586-009-1044-3

Low back pain (LBP) poses a significant problem to society. Although initial conservative therapy may be beneficial, persisting chronic LBP still frequently leads to expensive invasive intervention. A novel non- invasive therapy that focuses on discogenic LBP is Intervertebral Differential Dynamics Therapy (IDD Therapy, North American Medical Corp. Reg U.S.). IDD Therapy consists of intermittent traction sessions in the Accu-SPINA device (Steadfast Corporation Ltd, Essex, UK), an FDA approved, class II medical device. The intervertebral disc and facet joints are unloaded through axial distraction, positioning and relaxation cycles. The purpose of this study is to investigate the effect of IDD Therapy when added to a standard graded activity program for chronic LBP patients. In a single blind, single centre, randomized controlled trial; 60 consecutive patients were assigned to either the SHAM or the IDD Therapy. All subjects received the standard conservative therapeutic care (graded activity) and 20 sessions in the Accu-SPINA device. The traction weight in the IDD Therapy was systematically increased until 50% of a person’s body weight plus 4.45 kg (10 lb) was reached. The SHAM group received a non-therapeutic traction weight of 4.45 kg in all sessions. The main outcome was assessed using a 100-mm visual analogue scale (VAS) for LBP. Secondary outcomes were VAS scores for leg pain, Oswestry Disability Index (ODI), Short-Form 36 (SF-36). All parameters were measured before and 2, 6 and 14 weeks after start of the treatment. Fear of (re)injury due to movement or activities (Tampa Scale for Kinesiophobia), coping strategies (Utrecht Coping List) and use of pain medication were recorded before and at 14 weeks. A repeated measures analysis was performed. The two groups were comparable at baseline in terms of demographic, clinical and psychological characteristics, indicating that the random allocation had succeeded. VAS low back pain improved significantly from 61 (±25) to 32 (±27) with the IDD protocol and 53 (±26) to 36 (±27) in the SHAM protocol. Moreover, leg pain, ODI and SF-36 scores improved significantly but in both groups. The use of pain medication decreased significantly, whereas scores for kinesiophobia and coping remained at the same non-pathological level. None of the parameters showed a difference between both protocols. Both treatment regimes had a significant beneficial effect on LBP, leg pain, functional status and quality of life after 14 weeks. The added axial, intermittent, mechanical traction of IDD Therapy to a standard graded activity program has been shown not to be effective.

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Risk factors for adjacent segment disease after lumbar fusion

Eur Spine J (2009) 18:1637–1643 DOI 10.1007/s00586-009-1060-3

The incidence of adjacent segment problems after lumbar fusion has been found to vary, and risk factors for these problems have not been precisely verified, espe- cially based on structural changes determined by magnetic resonance imaging.

The purpose of this retrospective clinical study was to describe the incidence and clinical features of adjacent segment disease (ASD) after lumbar fusion and to determine its risk factors.

We assessed the incidence of ASD in patients who underwent lumbar or lumbosacral fusions for degenerative conditions between August 1995 and March 2006 with at least a 1-year follow- up. Patients less than 35 years of age at the index spinal fusion, patients with uninstrumented fusion, and patients who had not achieved successful union were excluded.

Of the 1069 patients who underwent fusions, 28 (2.62%) needed secondary operations because of ASD and were included in this study. In order to identify the risk factors, we matched a disease group and a control group. The disease group consisted of 26 of the 28 patients with ASD, excluding the 2 patients for whom we did not have initial MRI data. Each patient in the disease group was matched by age, sex, fusion level and follow-up period with a control patient. The assumed risk factors included disc and facet degeneration, instability, listhesis, rotational defor- mity, and disc wedging. The mean age of the 28 patients with ASD requiring surgical treatment was 58.4 years, which did not differ significantly from that of the population in which ASD did not develop (58.2years, p = 0.894). Of the 21 patients who underwent floating fusion, only 1 developed distal ASD. Facet degeneration was a significant risk factor (p<0.01) on logistic regression analysis. The incidence of distal ASD was much lower than that of proximal ASD. Pre-existing facet degeneration may be associated with a high risk of adjacent segment problems following lumbar fusion procedures.

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Effect of spinal cord signal intensity changes on clinical outcome after surgery for cervical spondylotic myelopathy

J Neurosurg Spine 11:562–567, 2009.DOI: 10.3171/2009.6.SPINE091

The presence of intramedullary T2 high signal intensity changes in patients with cervical spondylotic myelopathy (CSM) indicates the existence of a chronic spinal cord compressive lesion. However, the prognostic significance of signal intensity changes remains controversial. The purpose of this study was to evaluate the effect of spinal cord T2 signal intensity changes on the outcome after surgery for CSM.

Method. In a prospective study, 64 patients with CSM who underwent surgical treatment between October 2006 and April 2008 using an anterior approach were included. Based on the clinical symptoms and signs present, the severity of neurological deficits of all patients was scored according to a modified Japanese Orthopaedic Association scale score for CSM just before the surgery and at 6 months follow-up. Recovery rates were calculated at 6 months.

Results. There were 22 patients who did not have spinal cord intensity changes on MR imaging and 44 who demonstrated high-intensity signal changes on T2-weighted images (focal or segmental). No statistically significant differences were found in recovery rates between cases with T2 signal intensity changes and those with no signal intensity changes. However, the postoperative modified Japanese Orthopaedic Association scale scores and the recovery rates were much lower in patients with multisegmental signal intensity changes compared with those without these changes or those with focal signal intensity change, and ANOVA demonstrated this difference to be statistically significant (p < 0.05).

Conclusion. Multisegmental spinal cord signal intensity changes on T2-weighted MR imaging are predictors of a poor outcome in terms of functional recovery rate in patients undergoing operations for CSM.

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The major complications of transpedicular vertebroplasty

J Neurosurg Spine 11:607–613, 2009. DOI: 10.3171/2009.4.SPINE08466

Vertebroplasty is a well-known technique used to treat pain associated with vertebral. Despite a success rate of up to 90% in different series, the procedure is often associated such as cord and root compression, epidural and subdural hematomas (SDHs), and other minor complications. In this study, the authors discuss the major complications of and their clinical implications during the postoperative course.

Methods. Vertebroplasty was performed in 12 vertebrae of 7 patients. Five patients had fractures, 1 had tumoral compression fractures, and 1 had a traumatic fracture. Two leakage, 1 had epidural leakage, 1 had subdural cement leakage, 2 had a spinal SDH, and after the procedure.

Results. Three patients had paraparesis (2 had SDHs and 1 had epidural cement leakage), 3 had root symptoms, and 1 had lower back pain. Two of the 3 patients with paraparesis recovered after evacuation of the SDH and subdural cement; however, 1 patient with paraparesis did not recover after epidural cement leakage, despite cement evacuation. Two patients with foraminal leakage and 1 with subdural cement leakage had root symptoms and recovered after evacuation and conservative treatment. The patient with the split fracture had no neurological symptoms and recovered with conservative treatment.

Conclusions. Transpedicular vertebroplasty may have major complications, such as a spinal SDH and/or cement leakage into the epidural and subdural spaces, even when performed by experienced spinal surgeons. Early diagnosis with CT and intervention may prevent worsening of these complications.

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Imaging correlation of the degree of degenerative L4–5 spondylolisthesis with the corresponding amount of facet fluid

J Neurosurg Spine 11:614–619, 2009. DOI: 10.3171/2009.6.SPINE08413

The aim of this study was to correlate the degree of L4–5 spondylolisthesis on plain flexion-extension radiographs with the corresponding amount of L4–5 facet fluid visible on MR images.

Methods. Patients underwent evaluation at the Neurosurgical Spine Clinics of Stanford University Medical Center and National Health Insurance Medical Center (Goyang, South Korea) between January 2006 and December 2007. Only patients who were diagnosed with L4–5 degenerative spondylolisthesis (DS) and who had both lumbosacral flexion-extension radiographs and MR images available for review were eligible for this study. Each patient’s dynamic motion index (DMI) was measured using the lateral lumbosacral plain radiograph and was the percentage of the degree of anterior slippage seen on flexion versus that seen on extension. Axial T2-weighted MR images of the L4–5 facet joints obtained in each patient was analyzed for the amount of facet fluid, using the image showing the widest portion of the facets. The facet fluid index was calculated from the ratio of the sum of the amounts of facet fluid found in the right plus left facets over the sum of the average widths of the right plus left facet joints.

Results. Fifty-four patients with L4–5 DS were included in this study. Of these 54 patients, facet fluid was noted on MR images in 29 patients (53.7%), and their mean DMI was 6.349 ± 2.726. Patients who did not have facet fluid on MR imaging had a mean DMI of 1.542 ± 0.820; this difference was statistically significant (p < 0.001). There was a positive linear association between the facet fluid index and the DMI in the group of patients who exhibited facet fluid on MR images (Pearson correlation coefficient 0.560, p < 0.01). In the subgroup of 29 patients with L4–5 DS who showed facet fluid on MR images, flexion-extension plain radiographs in 10 (34.5%) showed marked anterolisthesis, while the corresponding MR images did not.

Conclusions. There is a linear correlation between the degree of segmental motion seen on flexion-extension plain radiography in patients with DS at L4–5 and the amount of L4–5 facet fluid on MR images. If L4–5 facet fluid in patients with DS is seen on MR images, a corresponding anterolisthesis on weight-bearing flexion-extension lateral radiographs should be anticipated. Obtaining plain radiographs will aid in the diagnosis of anterolisthesis caused by an L4–5 hypermobile segment, which may not always be evident on MR images obtained in supine patients.

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Cervical spondylotic myelopathy associated with kyphosis or sagittal sigmoid alignment: outcome after anterior or posterior decompression

J Neurosurg Spine 11:521–528, 2009. DOI: 10.3171/2009.2.SPINE08385

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. Seg- mental 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 lamino- plasty 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

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Surgical results of cervical myelopathy in patients older than 80 years of age

J Neurosurg Spine 11:421–426, 2009. DOI: 10.3171/2009.4.SPINE08584

In this prospective analysis the authors describe the clinical results of surgical treatment in patients > 80 years of age in whom spinal function was evaluated with motor evoked potential (MEPs) monitoring.

Methods. The authors included 57 patients > 80 years of age who were suspected of having cervical myelopathy. The mean age of the patients was 83.0 years (range 80–90 years). The central motor conduction time (CMCT) was calculated from the latencies of the MEPs following transcranial magnetic stimulation and from M and F waves fol- lowing peripheral nerve stimulation.

Results. Preoperative electrophysiological evaluation demonstrated significant elongation of CMCT or abnor- malities in MEP waveforms in 37 patients (65%), and 35 patients of these underwent laminoplasty. In 30 patients cervical spondylotic myelopathy was diagnosed and 5 patients ossification of the posterior longitudinal ligament was diagnosed. The preoperative mean Japanese Orthopaedic Association Scale score was 8.6 (range 3–12.5) and the mean postoperative score was 12.6 (range 6–14.5) with an average recovery rate of 45% (range −21 to 100%). There were no major complications in any of the patients during the operative period and there were no cases of death resulting from operative intervention.

Conclusions. Sufficient clinical results are expected even in patients with myelopathy who are older than 80 years of age, provided the patients are correctly selected by electrophysiological evaluation with MEPs and CMCT.


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Cross-sectional magnetic resonance imaging study of lumbar disc degeneration in 200 healthy individuals

J Neurosurg Spine 11:501–507, 2009. (DOI: 10.3171/2009.5.SPINE08675)

Object. The current cross-sectional observational MR imaging study aimed to investigate the prevalence and risk factors of lumbar disc degeneration in a healthy population and to establish the baseline data for a prospective longitudinal study.

Methods. Two hundred healthy volunteers participated in this study after providing informed consent. The status of lumbar disc degeneration was assessed by 3 independent observers, who used sagittal T2-weighted MR imaging. Demographic data collected included age, sex, body mass index, episode(s) of low-back pain, smoking status, hours of standing and sitting, and Roland-Morris Disability Questionnaire scores. There were 68 men and 132 women whose mean age was 39.7 years (range 30–55 years). Eighty-two individuals (41%) were smokers, and the Roland- Morris Disability Questionnaire scores were averaged to 0.6/24.

Results. The prevalence of disc degeneration was 7.0% in L1–2, 12.0% in L2–3, 15.5% in L3–4, 49.5% in L4–5, and 53.0% in L5–S1. A herniated disc was observed at the corresponding levels in 0.5, 3.5, 6.5, 25.0, and 35.0% of cases respectively. Spondylolisthesis was observed in < 3% of this population. Multiple logistic regression analysis demonstrated that age and hours sitting were significantly related to L4–5 disc herniation. Episode of low-back pain, smoking status, body mass index, and hours standing did not affect the prevalence of disc degeneration.

Conclusions. The current study established the baseline data of lumbar disc degeneration in a 30- to 55-year-old healthy population for a prospective longitudinal study. Hours spent sitting significantly increased the prevalence of disc herniation, but episode of low-back pain, smoking status, obesity, and standing hours were not significant risk factors.

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Primary Intramedullary Tumors of the Spinal Cord

SPINE Volume 34, Number 22S, pp S69 –S77, 2009

Study Design. Clinically based systematic review.

Objective. To define optimal clinical care for primary intramedullary spinal cord tumors using a systematic re- view with expert opinion.

Methods. Focused questions on the treatment of primary intramedullary spinal cord tumors were refined by a panel of spine oncology surgeons, medical and radiation oncologist. Keyword were searched through Medline database and pertinent abstracts and manuscripts obtained. The quality of literature was rated as high, moderate, low, or very low. Using the GRADE evidence based review system the proposed questions were answered using the literature review and expert opinion. These treatment recommendations were then rated as either strong or weak based on the quality of evidence and clinical expertise.

Results. The literature searches revealed low and very low quality evidence with no prospective or randomized studies. The MEDLINE search engine returned 9000 articles which was restricted to articles about human subjects and written in the English language. The subsequent search resulted in a return of: “spinal cord tumor” (5053), “ependymoma” (580), “astrocytoma” (420), and “glioma” (235) articles. Seventeen articles referenced timing of surgical intervention and symptomatology for intramedullary spinal cord tumors. One hundred fifty-eight chemotherapy and 183 radiation therapy articles for intramedullary spinal cord tumors were reviewed.

Conclusion. The most important factor in determining the IMSCT patient’s long-term neurologic and functional outcome after surgery is the patient’s preoperative neurologic status. However, this must be taken in the context of the underlying tumor histology. Therefore, resection is reserved for progressive neurologic decline and serial monitoring for asymptomatic individuals. Adjuvant therapy is an option for high grade astrocytomas (WHO grades 3–4).


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Removal of giant extraforaminal dumbbell tumors of cervical spine

The Spine Journal 9 (2009) 822–829. doi:10.1016/j.spinee.2009.06.023

Removal of cervical dumbbell tumors can be particularly challenging because of unique exposure requirements and proximity of the vertebral artery (VA). There are no reports describing the treatment of giant cervical spine dumbbell tumors (CSDTs).

PURPOSE: To introduce an extensive posterolateral approach to CSDTs involving total lateral mass resection and laminectomy.

STUDY DESIGN: Prospective study of all the patients with multilevel CSDTs treated by  this new procedure between December 2002 and March 2006.

PATIENT SAMPLE: Sixteen patients (3 men and 13 women) with CSDTs underwent the procedure we describe. The follow-up periods ranged from 9 to 51 months (average 9 months). Average age at surgery was 45 years (range 23–68 years).

OUTCOME MEASURES: Axial symptoms and Japanese Orthopedic Association scores were recorded. Pre- and postoperative ranges of neck motion were measured on lateral flexion and extension radiographs.

METHODS: After making a midline incision, we preferred exposing the extraforaminal component of the tumor before performing a semilaminectomy and lateral mass resection. Any lateral extensión of a tumor can be attained by detachment of the adjacent three or more segments of the lateral mass muscle insertion. The most lateral portion can be separated beneath the tumor’s superficial muscle flap, and then when the tumor is retracted medially, the whole portion of the lateral component can be totally exposed. We then performed total lateral mass resection and laminectomy to expose the tumor at the foramina and cervical canal.

RESULTS: We were able to completely resect the tumors in every patient. The average duration of surgery was 150 minutes. Blood loss was minimal (average 400 mL). All patients were monitores for a minimum of 9 months (range 9–51 months; mean 28 months). The follow-up period was uneventful, and no patients developed spinal instability.

CONCLUSIONS: Extensive posterolateral exposure enables surgeons to reach the lateralmost portion of CSDTs and also facilitates septation of the VA and resection of vertebral body encroachment of the tumor.


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Radiologically documented adjacent-segment degeneration after cervical arthroplasty

Surgical Neurology 72 (2009) 325–329. doi:10.1016/j.surneu.2009.02.013

Background: The authors retrospectively studied the incidence and characteristics of radiologically documented adjacent-segment degeneration after single-level diskectomy and subsequent cervical arthroplasty using the Bryan (Medtronic Sofamor Danek; Memphis, TN) disk prosthesis.

Methods: Seventy-two patients with single-level arthroplasty using the Bryan cervical disk prosthesis were evaluated. Radiological evidence of adjacent-disk disease included new formation or enlargement of anterior osteophyte, new or increasing ALL calcification, or narrowing of disk space documented on serial plain radiographs. We reported the characteristics of adjacent-segment degeneration and reviewed all of the cases.

Results: Among the 72 patients, 9 patients (12.5%) showed radiological evidence of adjacentsegment degeneration. The mean age was 43.3 years old, with a male-female ratio 1:3. The mean follow-up period was 24.2 (12.1-35.9) months. The mean period of onset was 16.3 months. Uppersegment degeneration was documented in 4 cases (3 new osteophyte, 1 enlargement of osteophyte), whereas lower-segment degeneration was noted in 5 cases (1 new osteophyte, 3 enlargement of osteophyte, 1 decreased disk height). Among the degenerated cases, 4 cases (44.4%) also showed various degrees of HO.

Conclusions: The rate of adjacent-segment degeneration was higher than that observed in previous studies. Adjacent-segment degeneration documented a tendency toward HO. A longer follow-up period is necessary to investigate and document the different types of degeneration seen at levels adjacent to artificial Bryan cervical disk prostheses.

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Outcome After Anterior Cervical Discectomy and Arthrodesis A Clinical Study of 368 Patients

Neurosurg Q 2009;19:164–170

Aim: To define the predictors for the clinical outcome after anterior cervical discectomy and arthrodesis for patients with degenerative diseases of the cervical spine. Does the subsidence of the intervertebral spacer in the adjacent vertebral have a negative influence on the outcome?
Materials and Methods: In a prospective clinical study, 368 patients underwent anterior cervical discectomy and arthrodesis with degenerative disease of the cervical spine. The patients were treated between September 1997 and January 2005. All patients were followed up 1 year after surgery.
Results: Young age of the patient, mono-segmental anterior cervical discectomy and arthrodesis of the lower cervical spine are predictors of a satisfactory outcome. We did not find statistical differences in the outcome between male and female patients or between patients with or without subsidence of the cage.
Conclusions: Good results can be achieved by early operative therapy. The subsidence of the cage does not affect the outcome.

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Comparative study of anterior versus posterior decompression in elderly patients of cervical myelopathy with co-morbid conditions

Eur J Orthop Surg Traumatol (2009) 19:397–401 DOI 10.1007/s00590-009-0444-8

Study design: Prospective.

Objective: To assess the results of laminectomy in patients suffering from multilevel multidirectional compressive cervical myelopathy with co-morbid conditions and to compare results of anterior and laminectomy clinically, radiologically and functionally.

Summary of background data: Cervical myelopathy or myeloradiculopathy is a progressive degenerative disorder that usually starts in the middle age. It leads to circumferential cord compression leading to a constellation of signs and symptoms.

Methods: Prospective study of 30 cases in which we had compared the results of anterior and posterior decompression surgery. Our follow-up ranged from 18 to 60 months with an average follow-up of 31.8 months.

Results: Eighteen patients underwent laminectomy by posterior midline approach in which lamina and if required, medial one-third of the facet was also removed. Diskectomy and bone grafting was done in eight patients by standard anterior approach with removal of disc at two or three levels. Corpectomy and diskectomy above and below with bone grafting was done in four patients. Out of these two were fused with tricortical iliac crest and two with fibula.

Conclusion: Anterior decompression is the gold standard. However, in medically unfit patients with multi-level circumferential compression, laminectomy is an equally rewarding option.

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Posterior Lumbar Interbody Fusion: Comparison of Single Intervertebral Cage and Single Side Pedicle Screw Fixation versus Bilateral Cages and Screw Fixation

Minim Invas Neurosurg 2009; 52: 132 – 136. DOI 10.1055/s-0029-1224097

Introduction: The efficacy and economy of an alternative sparing method for posterior lumbar interbody fusion (PLIF) using a single cage fixed with pedicle screws placed on a single side (SS group, n = 22) was compared to that of a standard bilateral protocol using two cages and pedicle screws placed bilaterally (BL group, n = 15).

Methods: All PLIFs were non-compensation cases done at a single level by a single surgeon and were similar in most background characteristics. Significant differences were not found between the two groups in fusion rates, complications or in 2-year prospectively collected outcomes including percent improvement in back and leg pain (visual analog scales) and the Oswestry disability index.

Results: Perioperative results significantly favored the SS group: BL patients lost 81 % more blood, used 74 % more time for surgery, stayed in hospital 1.7 days longer, and the hospital-related cost per procedure was twice as high. Currently, the SS procedure typically averages less than 1 hand blood loss less than 50 mL. In summary, the BL and SS groups had similar outcomes while the SS procedure provided substantially superior efficiency and economy.

Conclusion: In conclusion, the results of this retrospective comparative level III study warrant further studies on the SS protocol which may lead to the adoption of this minimally invasive protocol in the standard practice of PLIF in selected cases.

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Minimally Invasive Lumbar Discectomy Had Worse Outcome than Conventional Open Microdiscectomy. A Randomized Controlled Trial

JAMA. 2009;302(2):149-158.

Context Conventional microdiskectomy is the most frequently performed surgery for patients with sciatica due to lumbar disk herniation. Transmuscular tubular diskectomy has been introduced to increase the rate of recovery, although evidence is lacking of its efficacy.

Objective To determine outcomes and time to recovery in patients treated with tubular diskectomy compared with conventional microdiskectomy.

Design, Setting, and Patients The Sciatica Micro-Endoscopic Diskectomy randomized controlled trial was conducted among 328 patients aged 18 to 70 years who had persistent leg pain (>8 weeks) due to lumbar disk herniations at 7 general hospitals in the Netherlands from January 2005 to October 2006. Patients and observers were blinded during the follow-up, which ended 1 year after final enrollment.

Interventions Tubular diskectomy (n = 167) vs conventional microdiskectomy (n = 161).

Main Outcome Measures The primary outcome was functional assessment on the Roland-Morris Disability Questionnaire (RDQ) for sciatica (score range: 0-23, with higher scores indicating worse functional status) at 8 weeks and 1 year after randomization. Secondary outcomes were scores on the visual analog scale for leg pain and back pain (score range: 0-100 mm) and patient’s self-report of recovery (measured on a Likert 7-point scale).

Results Based on intention-to-treat analysis, the mean RDQ score during the first year after surgery was 6.2 (95% confidence interval [CI], 5.6 to 6.8) for tubular diskectomy and 5.4 (95% CI, 4.6 to 6.2) for conventional microdiskectomy (between-group mean difference, 0.8; 95% CI, –0.2 to 1.7). At 8 weeks after surgery, the RDQ mean (SE) score was 5.8 (0.4) for tubular diskectomy and 4.9 (0.5) for conventional microdiskectomy (between-group mean difference, 0.8; 95% CI, –0.4 to 2.1). At 1 year, the RDQ mean (SE) score was 4.7 (0.5) for tubular diskectomy and 3.4 (0.5) for conventional microdiskectomy (between-group mean difference, 1.3; 95% CI, 0.03 to 2.6) in favor of conventional microdiskectomy. On the visual analog scale, the 1-year between-group mean difference in improvement was 4.2 mm (95% CI, 0.9 to 7.5 mm) for leg pain and 3.5 mm (95% CI, 0.1 to 6.9 mm) for back pain in favor of conventional microdiskectomy. At 1 year, 107 of 156 patients (69%) assigned to tubular diskectomy reported a good recovery vs 120 of 151 patients (79%) assigned to conventional microdiskectomy (odds ratio, 0.59 [95% CI, 0.35 to 0.99]; P = .05).

Conclusions Use of tubular diskectomy compared with conventional microdiskectomy did not result in a statistically significant improvement in the Roland-Morris Disability Questionnaire score. Tubular diskectomy resulted in less favorable results for patient self-reported leg pain, back pain, and recovery.

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