Barrett Woods

Cervical radiculopathy: epidemiology, etiology, diagnosis, and treatment.

Cervical radiculopathy is a relatively common neurological disorder resulting from nerve root dysfunction, which is often due to mechanical compression; however, inflammatory cytokines released from damaged intervertebral disks can also result in symptoms. Cervical radiculopathy can often be diagnosed with a thorough history and physical examination, but an magnetic resonance imaging or computed tomographic myelogram should be used to confirm the diagnosis. Because of the ubiquity of degenerative changes found on these imaging modalities, the patients symptoms must correlate with pathology for a successful diagnosis. In the absence of myelopathy or significant muscle weakness all patients should be treated conservatively for at least 6 weeks. Conservative treatments consist of immobilization, anti-inflammatory medications, physical therapy, cervical traction, and epidural steroid injections. Cervical radiculopathy typically is self-limiting with 75%-90% of patients achieving symptomatic improvement with nonoperative care. For patients who are persistently symptomatic despite conservative treatment, or those who have a significant functional deficit surgical treatment is appropriate. Surgical options include anterior cervical decompression and fusion, cervical disk arthroplasty, and posterior foraminotomy. Patient selection is critical to optimize outcome.

Bias in cervical total disc replacement trials

Purpose of reviewCervical disc replacement (CDR) has emerged as a motion-preserving alternative to anterior cervical discectomy and fusion in selected cases. Despite favorable literature, CDR is not universally accepted because of concerns regarding bias in the existing literature. The purpose of this review is to identify the possible biases in the disc replacement literature.Recent findingsRecent studies that compare CDR and ACDF have demonstrated equivalent or superior outcomes, lower rates of secondary surgery, and equivalent safety at medium- and long-term follow-up. In our review, we identified four types of bias that may affect the CDR literature: publication bias, external validity, confounding bias, and financial conflicts of interest.SummaryBias, whether intentional or unintentional, can impact the interpretation and outcome of CDR studies. Recognition of this issue is critical when utilizing the existing literature to determine the efficacy of CDR and designing future studies.

Is It Necessary to Extend a Multilevel Posterior Cervical Decompression and Fusion to the Upper Thoracic Spine

Study Design. A retrospective cohort analysis. Objective. The aim of this study was to determine if there is a difference in the revision rate in patients who undergo a multilevel posterior cervical fusions ending at C7, T1, or T2-T4. Summary of Background Data. Multilevel posterior cervical decompression and fusion is a common procedure for patients with cervical spondylotic myelopathy, but there is little literature available to help guide the surgeon in choosing the caudal level of a multilevel posterior cervical fusion. Methods. Patients who underwent a three or more level posterior cervical fusion with at least 1 year of clinical follow-up were identified. Patients were separated into three groups on the basis of the caudal level of the fusion, C7, T1, or T2-T4, and the revision rate was determined. In addition, the C2-C7 lordosis and the C2-C7 sagittal vertical axis (SVA) was recorded for patients with adequate radiographic follow-up at 1 year. Results. The overall revision rate was 27.8% (61/219 patients); a significant difference in the revision rates was identified between fusions terminating at C7, T1, and T2-T4 (35.3%, 18.3%, and 40.0%, P = 0.008). When additional variables were taken into account utilizing multivariate linear regression modeling, patients whose construct terminated at C7 were 2.29 (1.16–4.61) times more likely to require a revision than patients whose construct terminated at T1 (P = 0.02), but no difference between stopping at T1 and T2-T4 was identified. Conclusion. Multilevel posterior cervical fusions should be extended to T1, as stopping a long construct at C7 increases the rate of revision. Level of Evidence: 3

Safety of thromboembolic chemoprophylaxis in spinal trauma patients requiring surgical stabilization.

Study Design. Retrospective review. Objective. To determine the incidence of thromboembolic events, bleeding complications such as epidural hematomas, and wound complications in patients with spinal trauma requiring surgical stabilization. Summary of Background Data. Literature addressing the safety and efficacy of chemoprophylactic agents in postoperative patients with spinal trauma is sparse. As a result, significant variability exists regarding administration of thromboembolic chemoprophylaxis in this population. The risk of bleeding complications is particularly concerning. Methods. Patients with spinal trauma who underwent surgical stabilization in 2009 and 2010 at a single level 1 trauma center were retrospectively reviewed. Exclusion criteria included patients who underwent solely decompressive procedures, noninstrumented fusions, kyphoplasty, or had incomplete medical records. Patients who received chemoprophylaxis were compared with patients who did not. Demographical information and injury data were collected. Primary outcome measures were prevalence of thromboembolic events, epidural hematomas, and persistent wound drainage requiring irrigation and debridement. Results. Two hundred twenty-seven of 373 patients were included (56 in the untreated group, 171 in the treated group). Eight patients in the untreated group (14.3%) and 12 patients in the treated group (7%) developed postoperative thromboembolism (P = 0.096). There was 1 pulmonary embolism in the untreated group (1.8%), and 4 pulmonary embolisms in the treated group (2.3%). Surgical irrigation and debridement for wound drainage was required for 1.8% of patients in the untreated group and for 5.3% of patients in the treated group. No epidural hematomas were noted in either group. The treated group had more spinal levels fused (P = 0.46), higher injury severity scores (0.001), and longer hospitalizations (0.018). Patients who developed postoperative thromboembolism had significantly higher body mass indexes (P = 0.01), injury severity scores (0.001), number of spinal levels fused (P = 0.004), incidence of neurological deficits (0.001), and longer hospitalizations (0.16) compared with those who did not. Conclusion. The use of chemoprophylaxis appears to be safe in at-risk patients in the immediate postoperative period after spinal trauma surgery. No epidural hematomas occurred, and the risk of wound drainage is small. Body mass index, injury severity score, presence of neurological deficits, and number of spinal levels fused should be considered when determining which patients should receive chemoprophylaxis after surgical stabilization. Level of Evidence: 3

Feasibility of Endoscopic Inspection of Pedicle Wall Integrity in a Live Surgery Model

ABSTRACT Background: Perforations of the pedicle wall during cannulation can occur with experienced surgeons. Direct endoscopic visualization has not been used to inspect pedicles previously due to bone bleeding obscuring the camera visualization. The hypothesis of this study was that endoscopic visualization of pedicle wall integrity was technically feasible and would enable identification of clinically significant pedicle breaches. Methods: A live porcine model was used. Eight lumbar pedicles were cannulated. Clinically significant breaches were created. An endoscope was introduced and was used to inspect the pedicles. Results: All lumbar pedicles were endoscopically visible at a systolic pressure of 100 mm Hg. Clinically relevant anatomic structures and iatrogenic pathology, such as medial, lateral, and anterior breaches, were identified. There were no untoward events resulting from endoscopic inspection of the pedicle endosteal canal. Conclusions: Endoscopic inspection of lumbar pedicles was safe and effective. The findings on endoscopic inspection corresponded with the ball-tip probe palpation techniques. Additional techniques, such as selection between 2 tracts, was possible with the endoscopic technique.

Does Resection of the Posterior Longitudinal Ligament Impact the Incidence of C5 Palsy after Cervical Corpectomy Procedures

Study Design. Retrospective review. Objective. To evaluate key risk factors for the development of C5 palsy after cervical corpectomy, including resection of the posterior longitudinal ligament (PLL). Summary of Background Data. Postoperative C5 palsy is a well-known complication after cervical spine surgery. It is unknown whether resection of the PLL affects the incidence of C5 palsy. Methods. We performed a retrospective review of 459 consecutive patients undergoing anterior cervical corpectomies over a 15-year period. Medical records were reviewed to gather demographic data, operative details, and the incidence of C5 palsy. We performed regression analyses to identify variables that predicted the development of C5 palsy. Results. Our final analysis included 397 patients (females 51.4%, mean age 55.6 ± 11.6 yrs). Anterior corpectomy alone was performed in 255 (64.2%) patients, and combined anterior and posterior fusion was performed in 142 (35.8%) patients. Twenty-four patients (6.0%) developed C5 nerve palsy. Univariable regression demonstrated age greater than 65 (odds ratio, OR 2.7, 95% confidence interval, CI 1.2 to 6.3), corpectomy of three or more levels (OR 6.3, 95% CI 2.1 to 18.9), presence of ossification of the PLL (OR 4.3, 95% CI 1.6 to 11.7), and complete or partial resection of the PLL (OR 2.6, 95% CI 1.0 to 6.7) predicted development of C5 palsy. Multivariable regression demonstrated that the odds of getting C5 palsy with complete or partial resection of the PLL is 4.0 times (95% CI 1.5 to 10.5) higher compared with patients with an intact PLL. There were no significant differences in C5 palsy rates based on surgical approach (anterior vs. anterior plus posterior), sex, smoking status, or diabetes. Conclusion. Age greater than 65 years, corpectomy of three or more levels, presence of ossification of the PLL, and complete or partial resection of the PLL significantly predicted the development of C5 palsy. Level of Evidence: 4

C1 Lateral Mass Screw Migration Causing a Delayed Unilateral Hypoglossal Nerve Lesion

Case:We present the case of a fifty-eight-year-old woman who was initially treated with a C1 to C7 anterior-posterior cervical decompression and fusion for an epidural abscess and returned two years postoperatively with four days of progressive dysphagia and tongue deviation. She was diagnosed with a unilateral hypoglossal nerve (cranial nerve XII) palsy secondary to compression from a C1 lateral mass screw. Conclusion:This is the first reported case that we are aware of describing a delayed cranial nerve palsy secondary to cutout and cephalad migration of a C1 lateral mass screw resulting in a neurologic deficit due to impingement on the hypoglossal nerve.

Epidural Injections for Spinal Stenosis.

Epidural steroid injections (ESIs) are a common treatment for various types of lumbar spine pathology. Although ESI have been shown to contribute to successful nonoperative treatment in some patients with lumbar disk herniation, there is little evidence to suggest ESI alters the natural history of spinal stenosis or facilitates surgical avoidance.2 In this debate, we will argue that there is no role for ESI in the treatment of lumbar stenosis from a biological or clinical perspective. The biological rational for ESI in patients with chronic spinal stenosis is not concordant with the underlying pathophysiology of this disease process. Acute stenosis secondary to a disk herniation may have an inflammatory component that responds to ESI resulting in short-term benefit. This theory is supported by the SPORT subgroup analysis of lumbar disk herniation, which showed increased surgical avoidance in patients who received ESI but no difference in outcome measures between either group at 4 years.3 Unlike stenosis caused by disk herniation, biological mechanisms for resorption of osseous or ligamentous structures causing neural impingement do not exist. Chronic lumbar stenosis is likely symptomatic due to ischemic or vascular phenomena, not inflammation. Laboratory markers of inflammation are not uniformly elevated in patients with symptomatic lumbar stenosis either in the serum or in the epidural space. Prospective randomized control trials have shown no significant benefit of ESI over anesthetic or saline injections in patients with lumbar stenosis.4,5 Also there is concern regarding the potential deleterious systemic and local effect repetitive exposure to steroids can have on these patients, such as hyperglycemia, weight gain, epidural lipomatosis, or exacerbation of osteoporosis.6 Exposing the nerve roots of the cauda equina to epidural steroids in the setting of spinal stenosis may adversely affect neurological outcome. Radcliff et al,7 reported patients with lumbar spinal stenosis who received ESI had significantly less improvement at 4 years than patients without exposure to steroids in both the surgical and nonsurgical treatment groups. There is a growing body of clinical literature challenging the efficacy of ESI in patients with spinal stenosis. Despite this, ESIs are commonly administered to spinal stenosis patients and account for approximately 25% of all ESI in Medicare patients and 75% of patients who receive ESI in the Veterans Affairs system.8,9 The contention that ESI can facilitate surgical avoidance in patients with spinal stenosis is not supported clinically, as ESI are now often a prerequisite for surgical intervention. There is also a high correlation between ESI and increased rates of surgery for spinal stenosis in empirical databases.10 Finally, there is high-level data from a Level I study showing no difference between ESI and anesthetic injections in patients with spinal stenosis. Friedly et al published a multisite blinded prospective randomized control trial that evaluated if ESI and lidocaine provided any benefit over lidocaine alone at 6 weeks in patients with spinal stenosis. Four hundred patients were randomly assigned to either the treatment or placebo group, with the primary outcome measures at 6 weeks being average pain score and Roland Morris Disability Questionnaire (RMDQ). Although patients in the treatment group reported higher satisfaction scores, there was no statistically significant difference in any outcome measure between treatment and control groups at 6 weeks. Another doubleblind control trial randomized 100 patients with spinal stenosis into 1 of 2 groups receiving caudal injections with local anesthetic or local and steroid.12 There was no significant difference in outcome between the treatment and the control group with approximately 40% of patients in each group demonstrating clinical improvement at 2 years. In addition ESI are not benign, with complications such as cerebral spinal fluid leak, osteomyelitis, and epidural abscess reported in the literature. In review of the literature, it is hard to recommend ESI to patients with spinal stenosis. It should be noted that the randomized control trial conducted by Freidly and colleagues has been heavily criticized for flaws in the study design, methodology, and interpretation of results. There may be a role for ESI in patients with Received for publication March 22, 2015; accepted May 26, 2015. From the *Department of Orthopaedic Surgery, Thomas Jefferson University; and wDepartment of Orthopaedic Surgery, University of Pittsburgh Medical Center, Philadelphia, PA. The authors declare no conflict of interest. Reprints: Barrett I. Woods, MD, Thomas Jefferson University, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107 (e-mail: Barretti woodsmd@gmail.com). Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved. CONTROVERSIES IN SPINE SURGERY